Polycystic ovary syndrome (PCOS) in the adolescent patient: recommendations for practice.(Updates & Kidbits)

Polycystic ovary syndrome (PCOS) is an endocrine disorder affecting women across the lifespan. Originally thought only to impact women of child-bearing age because of the presence of infertility associated with the disease, health care professionals are now realizing that adolescent females are presenting with PCOS and the associated health concerns of menstrual irregularities, obesity, type 2 diabetes, and evidence of hyperandrogenism (hirsutism and acne) with increasing prevalence. In fact, there seems to be an over-representation of obesity-related type 2 diabetes in adolescents, especially in those females who present with signs of hyperandrogenism and menstrual irregularities (Lewy, Danadian, Witchel, & Arslanian, 2001).

PCOS often manifests around the time of menarche as irregular and often lengthened menstrual cycles (Richardson, 2003). Unfortunately, PCOS often goes unrecognized and undiagnosed at this time because most adolescents do not have regular menstrual cycles (Meisler, 2002). These young women also go undiagnosed because the prescribed treatment for irregular menstrual cycles is the use of oral contraceptive pills (OCPs). OCPs will regulate menstrual cycles and often times control acne and hirsutism. These girls often will not receive a diagnosis until much later, perhaps at the time when they seek treatment for infertility.

The main concerns in caring for the adolescent with PCOS are twofold. The first involves cyclic control of irregular menstruation cycles. By having predictable menstrual cycles, young females would avoid the embarrassment that is often associated with irregularity. Also, because of the irregular nature of the cycles seen in women with PCOS, leading to a span of time between periods of anywhere between 45 days and 365 days, the menstrual flow is heavier and the period is associated with significant cramping (Richardson, 2003). The second issue involves the avoidance of the long-term sequelae that are associated with obesity, insulin resistance, glucose intolerance, and type 2 diabetes. These conditions can result in subsequent lipid abnormalities and hypertension that are significant risk factors in the development of cardiovascular disease.

Because PCOS is a lifelong disorder with significant long-term health risks, nurses working with adolescent patients need to keep this endocrine/metabolic syndrome in mind, especially when a female presents with obesity, acne, hirsutism, and irregular menses. This article will address the following issues related to PCOS in the adolescent patient: (a) pathogenesis of the disorder; (b) recommendations for the diagnostic work-up in terms of history, physical exam, and laboratory testing; (c) recommendations for management strategies that can help alleviate the troubling signs and symptoms with which teens often present; and (d) resources that are available to teens to help them learn more about the disease and get needed psychosocial support. Early intervention through lifestyle modification and the use of various medications is essential to prevent the medical co-morbidities associated with PCOS.

Pathogenesis of PCOS

PCOS is a heterogeneous endocrine disorder diagnosed in 5%-10% of women in the U.S. (Markle, 2001; Tweedy, 2000). It is most likely a genetic disorder but can appear in girls with no prior identifiable family history. The most troubling outward signs of the disease involve those that occur as the result of hyperandrogenism. The hyperandrogenism occurs primarily because of an overproduction of testosterone from ovarian thecal cells and the adrenal gland. Hyperandrogenism manifests in females as hirsutism, acne, frontal and temporal balding, deepening voice, increased muscle mass, decreased breast size, and in severe cases, virilization involving clitoromegaly (Marshall, 2001).

The other prominent endocrine component involves the effects of insulin. Women with PCOS tend to be insulin resistant with accompanying hyperinsulinemia. Insulin resistance means that the body tissues do not respond to insulin. To overcome insulin resistance, the body secretes more insulin, thus causing a hyperinsulinemia state (Azziz, 2004). The endocrine problems found in adolescent girls with PCOS include reduced peripheral tissue insulin sensitivity, hepatic insulin resistance, and hyperinsulinemia; these are all predictive of type 2 diabetes (Lewy et al., 2001).

In addition to impacting glucose metabolism, insulin also affects circulating androgen levels. Increased circulating levels of testosterone are noted in women with insulin resistance and hyperinsulinemia. This occurs because high levels of insulin decrease circulating levels of sex hormone binding globulin (SHBG). This in turn leads to increasing levels of free testosterone and a worsening of the signs of hyperandrogenism (Azziz, 2004). These increased levels of androgens are not only responsible for hirsutism, acne, and male pattern baldness but also the development of central/android obesity as well. The presence of this central/android obesity only serves to aggravate insulin resistance, thereby worsening PCOS symptoms.

Obesity, insulin resistance, hyperinsulinemia, glucose intolerance, and type 2 diabetes have a great impact on overall health, particularly the development of heart disease. Women with PCOS who manifest these endocrine disturbances have been shown to have increased blood pressure, increased low-density lipoprotein (LDL) cholesterol, and decreased high-density lipoprotein (HDL) cholesterol (Sheehan, 2004). All of these are known to be significant risk factors for the development of cardiovascular disease.

The Diagnostic Work-Up

PCOS can be a challenge to diagnose because the…