Endocrine Abstracts

PCOS typically presents in adolescence. Whilst early diagnosis is important, symptoms and signs (anovulatory cycles, menstrual irregularities, acne) reflect a continuum on a background genetic predisposition and can be difficult to distinguish at an early stage from normal adolescent maturation. Major clinical stigmata – persistent menstrual irregularities (oligo- and amenorrhoea) and hirsutism and acne due to hyperandrogenism – can be very distressing.

Overweight / obesity (increasingly prevalent in adolescents) amplifies symptoms by associated insulin resistance / hyperinsulinism (beyond that in normal puberty) which drives LH stimulation of ovarian androgen production and other deleterious metabolic / hormonal changes.

Of 5–10% of women are thought to have PCOS. The prevalence in adolescents is unknown although probably similar given its pathophysiology. In a peadiatric clinic there is ascertainment bias with PCOS diagnosed in obese peripubertal girls with moderate / severe insulin resistance or, sometimes, with acne / hirsutism. In an adolescent endocrinology / gynaecology clinic, presentation is typically with menstrual abnormalities with or without signs of hyperandrogenism.

Management is difficult. In the obese, weight loss (if achievable) is the strategy of choice, but changing adolescent eating, exercise and lifestyle is extremely difficult – no interventions have been shown to be effective. There are no published randomised control trials of insulin-lowering agents in adolescents. Metformin would theoretically be beneficial – there are small studies which show only short term efficacy (insulin sensitisation and falls in BMI). Anti-androgen treatment (symptomatic rather than curative) can be effective in improving acne / hirsutism and, in combination with oestrogen, restore normal menstrual regularity and improve prospects for future fertility treatment.

Persisting hypernadrognism and hyperinsulinism increase medium term cardiovascular and type 2 diabetes risk. With increasing obesity prevalence in adolescents, epidemiological as well as individual consequences of PCOS extend well beyond the cosmetic and gynaecological.