Initial evaluation of treatment-naïve adolescents with signs and symptoms suggestive of PCOS

COC: combination oral contraceptive; FSH: follicle-stimulating hormone; hCG: human chorionic gonadotropin; LH: luteinizing hormone; PCOS: polycystic ovary syndrome; SHBG: sex hormone-binding globulin; T: testosterone; TSH: thyroid-stimulating hormone.

* Hirsutism (an abnormal excess of sexual hair growth, as determined by Ferriman-Gallwey score) must be distinguished from normal-variant "patient-important hirsutism," localized areas of excessive sexual hair growth yet a normal hirsutism score (also termed "focal hirsutism"), which is a common cosmetic complaint, and from hypertrichosis, a generalized excess of vellus hair growth that is unrelated to androgen excess. Refer to UpToDate content on clinical features of PCOS in adolescents.

¶ Irregular menses are a common manifestation of the physiologic adolescent anovulation during the first few postmenarcheal years. Menstrual bleeding usually occurs at 21- to 45-day intervals even in the first postmenarcheal year, with increasing menstrual regularity developing over the first 6 postmenarcheal years. Bleeding more frequently than every 19 days or less frequently than every 90 days is always abnormal. A biochemical evaluation is indicated after 2 years of persistent menstrual abnormality, or after 1 year of menstrual abnormality if associated with other clinical evidence of a hyperandrogenic disorder. Refer to UpToDate content on clinical features of PCOS in adolescents.

Δ Drugs that cause hirsutism include anabolic or androgenic steroids (consider these in athletes and users of dietary body-building supplements) or valproic acid.

◊ Free testosterone is more sensitive than total testosterone for detecting hyperandrogenemia. However, free testosterone assays are less well standardized and are only reliable if they are calculated from total testosterone and the percent-free testosterone, as calculated from the SHBG concentration, or determined by equilibrium dialysis assays with well-defined reference intervals. A simultaneous assay of early morning 17-hydroxyprogesterone is indicated in subjects at increased risk for nonclassic congenital adrenal hyperplasia (eg, Ashkenazi Jews). Refer to UpToDate content on diagnostic evaluation of PCOS in adolescents.

§ Other clinical evidence of a hyperandrogenic endocrine disorder may include menstrual disorders, infertility, galactorrhea, Cushingoid features, sudden-onset rapidly progressive hirsutism, lowering of the voice, and clitoromegaly. PCOS is the most common hyperandrogenic endocrine disorder. Other disorders account for less than 15% of hyperandrogenism; the most important to consider are nonclassic congenital adrenal hyperplasia, hyperprolactinemia, Cushing syndrome, and ovarian or adrenal neoplasm.

¥ The chronic disease panel consists of complete blood count, erythrocyte sedimentation rate, and comprehensive metabolic profile.

‡ Women with hirsutism, normal total and free testosterone levels, normal menses, and no clinical evidence of other hyperandrogenic endocrine disorders likely have idiopathic hirsutism. Most comedonal or mild inflammatory acne during the early postmenarcheal years is physiologic. These individuals should be followed clinically. If hirsutism or acne progress, the patient should be re-evaluated for hyperandrogenemia. If infertility becomes an issue in adulthood, they may be further evaluated for the possibility of ovulatory PCOS, including ultrasonography to detect polycystic ovary morphology.

† Isolated menstrual symptoms (ie, in the absence of hirsutism or treatment-resistant acne) and normal total and free testosterone levels in an adolescent are most likely due to physiologic adolescent anovulation. This is common during the first few years after menarche. Patients with menstrual patterns that are abnormal (eg, periods at intervals less frequent than 45 days [fewer than 8 periods per year] by the third postmenarcheal year) should be re-evaluated. Refer to UpToDate content on definition of PCOS in adolescents.

** The combination of mild hirsutism and menstrual abnormality is a weak criterion for diagnosing PCOS in the absence of hyperandrogenemia, particularly in an adolescent where this is considered "provisional" PCOS. These adolescent patients should be considered at risk for the development of hyperandrogenemia and/or infertility and followed accordingly. Refer to UpToDate content on definition of PCOS in adolescents.

¶¶ For the laboratory work-up to determine the cause of hyperandrogenemia, refer to the UpToDate algorithms on the Initial evaluation of hyperandrogenemia and determining the source of androgen excess, and related text.