Diagnosis of polycystic ovary syndrome (PCOS) is challenging, and there should be no rush to label an adolescent as having the condition before a thorough evaluation of symptoms, according to a leading endocrinologist who was speaking at the RCOG World Congress 2018 in Singapore.

“Common features of PCOS such as hirsutism, acne, and obesity are often present in otherwise ‘normal’ adolescents,” said Dr Veronique Celine Viardot-Foucault from the KK Women’s and Children’s Hospital, Singapore, adding that these features may not necessarily be indicative of PCOS.

Appropriate diagnosis of PCOS in adolescents should involve careful evaluation of symptoms such as menstrual irregularities, hyperandrogenism, and polycystic ovarian morphology, she said. Menstrual irregularities—including secondary amenorrhoea and oligomenorrhoea in girls beyond 2 years after menarche, or primary amenorrhoea in those who have completed puberty—may be indicative of androgen excess. [Horm Res Paediatr 2017;88:371-395]

As symptom such as acne is common in adolescence and usually transient, it may not be indicative of hyperandrogenism, said Viardot-Foucault. Also, isolated cases of acne and/or alopecia should not be considered as diagnostic criteria for PCOS in adolescence, but moderate or severe inflammatory acne that is unresponsive to topical therapy may require investigation of androgen excess. [Horm Res Paediatr 2017;88:371-395]

Another feature commonly seen with PCOS is hirsutism, which can be evaluated using the modified Ferriman–Gallwey (FG) scoring system. “However, the FG scoring system is not applicable to younger, perimenarchal patients [younger than 15 years old],” she advised, pointing out that biochemical evidence of hyperandrogenism is preferred in this group.

As there is no clear cut-off of testosterone levels for adolescents, biochemical hyperandrogenism should be defined based on the methodology used, informed Viardot-Foucault. “Ideally, to establish the existence of androgen excess, assaying for free testosterone levels is the gold standard as it is more sensitive than measuring the total testosterone levels,” she said. “But a downside of this is that it requires equilibrium dialysis techniques which are costly and not widely available.”

However, most commercial laboratories use direct analogue radio-immunoassay, which is notoriously inaccurate for measuring free testosterone, cautioned Viardot-Foucault. “If uncertain regarding the quality of the free testosterone assay, it is preferable to rely on calculated free testosterone, which has a good concordance and correlation with free testosterone levels measured by equilibrium dialysis methods,” she suggested. [J Clin Endocrinol Metab 1999;84:3666-3672]

Also, the value of measuring other androgens besides free testosterone in patients with PCOS is relatively low, although increased levels of dehydroepiandrosterone sulphate (DHEAS) have been observed in 30–35 percent of PCOS patients. [Ann N Y Acad Sci 2006;1092:130-137]

“Transabdominal pelvic ultrasound has a lower diagnostic accuracy,” said Viardot-Foucault. “The presence of polycystic ovarian morphology [on ultrasound] in an adolescent who does not have hyperandrogenism or oligo-anovulation does not indicate a diagnosis of PCOS.”

When menstrual irregularities are concerned, the first-line treatment should be cyclical progestogens when contraception is not required and there are no signs of hyperandrogenism, according to Viardot-Foucault. If there is clinical hyperandrogenism or a need for contraception in those sexually active, third-generation oral contraceptives such as ethinyl estradiol 30 µg can be considered.

“There is room for local treatment of hirsutism such as laser [hair removal, but only for patients beyond] 16 years old and [who are] at least 2 years post-menarche,” she said. “If there are metabolic complications, [patients should be referred] to the endocrinologist.”