By: Siva Kumaravelu, DO
Editor’s Note: Polycystic ovary syndrome (PCOS) is a common, multifactorial condition with significant implications for women’s health and fertility in adolescence and adulthood. This and other chronic conditions that impact a woman’s overall health are part of the curriculum for the FACTS online electives and CME courses. Dr. Siva Kumaravelu participated in the FACTS elective and summarized the article published in 2017 titled, “Polycystic ovary syndrome: Pelvic MRI as alternative to pelvic ultrasound for the diagnosis in overweight and obese adolescent girls.” [4] This study added to the limited literature suggesting pelvic MRI is a good alternative to pelvic ultrasound to diagnose PCOS in overweight and obese adolescent girls.
Introduction
Polycystic ovary syndrome (PCOS) is a common disorder that affects 5-10% of pre-menopausal women around the world. [1] The clinical manifestation of PCOS varies greatly based on genetics and environmental factors, including diet. [2] Symptoms commonly reported by patients include abnormal hair growth on various parts of the body, irregular menses, obesity, and infertility. [2] Our understanding of the underlying cause of PCOS remains largely unknown. [2] However, there is a strong correlation between the endocrine ovarian dysfunction seen in PCOS and irregularities in metabolism, resulting in obesity and insulin resistance. [1] [2]
Under the Endocrine Society’s guidelines, two of the following three qualities must be present in an adult patient to diagnose PCOS: (1) hyperandrogenism, (2) ovulatory dysfunction, and/or (3) polycystic ovaries. [3] Hyperandrogenism can be diagnosed either clinically by the presence of acne, alopecia, or hirsutism, or biochemically through elevated androgens. [3] Signs of oligomenorrhea (cycles > 35 days apart) or amenorrhea (the arrest of menses for at least 6 months) can be diagnosed as ovulatory dysfunction, satisfying the second criteria. [3] To satisfy the third criterion, an ultrasound of the ovary with at least 12 follicles and an ovarian volume > 10mL is often the preferred method for clinicians. [3] Other imaging modalities, such as a pelvic MRI, are rarely used.
“Under the Endocrine Society’s guidelines, two of the following three qualities must be present in an adult patient to diagnose PCOS: (1) hyperandrogenism, (2) ovulatory dysfunction, and/or (3) polycystic ovaries.”
To diagnose PCOS in the pediatric population, the American Academy of Family Physicians recommends that all three criteria are met after two years of oligomenorrhea, as anovulation is common in the first few years after menarche. [3] In terms of the first and second criteria, clinicians have difficulty diagnosing PCOS in adolescents as menstrual irregularities, acne, mild hirsutism, and physiologic insulin resistance are common during the peripubertal years. [2] Furthermore, it is difficult to satisfy the third criterion as imaging can prove difficult in adolescents; transvaginal ultrasounds are often inappropriate to use in children, especially virginal girls, and transabdominal ultrasounds can be limited by excess adipose tissue in obese or overweight children. [2][4]
“To diagnose PCOS in the pediatric population, the American Academy of Family Physicians recommends that all three criteria are met after two years of oligomenorrhea, as anovulation is common in the first few years after menarche.”
The study by Kayemba-Kay et al summarized below assessed whether MRI imaging can be used to diagnose PCOS in virginal obese or overweight adolescent girls. [4]
Methodology
Eight adolescent girls, mean age of 14.6, were recruited from an endocrinology clinic in Dreux, France. All participants had features of amenorrhea or oligomenorrhea for the past 2 years, and clinical hyperandrogenism such as acne or hirsutism. Adrenal hyperplasia and adrenal tumors were ruled out as potential causes of hyperandrogenism before starting the study. Laboratory testing for all participants included LH, FSH, fasting glucose, progesterone, lipids, insulin, prolactin, free T4, delta-4 androstenedione, dehydroepiandrosterone sulfate (DHEA-S), homeostasis model assessment of insulin resistance (HOMA-IR), and homeostasis model assessment of beta cell function (HOMA-B). Each participant had a pelvic MRI; although the study began with the intention to complete a pelvic ultrasound on all participants as well, this idea was abandoned during the study. The same radiologist interpreted all images. [4]
Results
Seven of the eight participants were obese and one was overweight. They all had menarche around 11 years of age except for one girl who had not yet reached menarche. Despite this, they were all at Tanner stage 5. They all had high plasma androgens, insulin resistance, low glucose/insulin ratio, and decreased sex hormone binding globulin (SHBG). [4]
Transabdominal ultrasound was attempted with one patient but the researchers were unable to obtain an accurate reading due to marked central adipose tissue. Transvaginal ultrasound was not attempted; instead, each participant had a pelvic MRI. [4]
On MRI, any ovary with more than 12 follicles and a volume > 10mL was considered polycystic. On average, the participants had high ovarian volume at 13.7mL with more than 12 follicles around the ovaries. The follicles were clearly delineated on MRI and had ovarian morphology typical of PCOS. [2][4]
Discussion
This study had many limitations. It had a very small population (n=8) and the participants were all from the same clinic in France, creating poor external validity. However, the researchers managed to screen out other causes of hyperandrogenism and were able to look at specific biomarkers associated with PCOS, such as testosterone. [4] This confirmed the participants met the criterion of hyperandrogenism associated with PCOS. The second criterion was also met, as the participants were either amenorrheic or oligomenorrheic. [4] The third criterion was the central concept explored in this study.
Despite its limitations, the study highlights the need for a discussion on how to diagnose PCOS in adolescents if all three criteria are to be satisfied. It is difficult to apply the criteria used for adult women in the pediatric population. Common clinical symptoms of PCOS seen in adult women, such as signs of hyperandrogenism or ovulatory dysfunction, are often considered normal during the peripubertal years. [2][3]
To satisfy the third criterion, ultrasound may not be the best modality for children despite being the gold standard for adult women. [2][3] Transvaginal ultrasound is seen as too invasive or inappropriate, especially in virginal or sexually abused adolescents, and transabdominal ultrasound can prove challenging in obese or overweight children, as seen in this study. [2][4] Thus, an alternative imaging modality such as MRI can aid in diagnosis. [4] Given the limited research to date on the use of MRI to diagnose PCOS, future studies should focus on this imaging modality.
“To satisfy the third criterion, ultrasound may not be the best modality for children … (as) transvaginal ultrasound is seen as too invasive or inappropriate… Thus, an alternative imaging modality such as MRI can aid in diagnosis.”
Mounting evidence suggests the clinical manifestations of PCOS often begin in the peripubertal years. [2] This leads to several questions:
- If PCOS is identified and non-pharmacological management is started in early puberty, will the risk of infertility [1] in adulthood diminish?
- Since PCOS is multifactorial, will lifestyle modifications through diet and exercise during adolescence minimize the risk of type 2 diabetes in adulthood? [2][3]
- Can we identify polycystic ovaries using MRI instead of transvaginal or pelvic ultrasound?
- How can physicians and other medical professionals use fertility awareness-based methods (FABMs) to diagnose and manage PCOS in adolescents?
Future research should focus on the benefits of diagnosing and treating PCOS in adolescence as well as identifying the most accurate, non-invasive way to diagnose PCOS in the pediatric population.
Editor’s Note: Charting the female cycle through the use of FABMs can lead to earlier diagnosis of PCOS and other conditions. Charting with FABMs can also be used to monitor response to therapy in non-invasive ways once treatment is started. Learn more about the clinical applications of FABMs in PCOS in the following articles or by enrolling in one of our live or online educational programs.
- Metabolic Implications & Nutritional Management of PCOS: A Review of Research
- Subclinical PCOS in Healthy Eumenorrheic Women? A Research Review
- Beyond Family Planning: Using FABMs for PCOS
- Fertility Awareness in PCOS: A Choice Aligned with Future Goals
References
[1] Bani Mohammad M, Majdi Seghinsara A. Polycystic Ovary Syndrome (PCOS), Diagnostic Criteria, and AMH. Asian Pac J Cancer Prev. 2017;18(1):17-21. Published 2017 Jan 1. doi:10.22034/APJCP.2017.18.1.17
[2] Bremer AA. Polycystic ovary syndrome in the pediatric population. Metab Syndr Relat Disord. 2010;8(5):375-394. doi:10.1089/met.2010.0039
[3] Williams T, Mortada R, Porter S. Diagnosis and Treatment of Polycystic Ovary Syndrome. Am Fam Physician. 2016;94(2):106-113.
[4] Kayemba-Kay’s S, Pambou A, Heron A, Benosman SM. Polycystic ovary syndrome: Pelvic MRI as alternative to pelvic ultrasound for the diagnosis in overweight and obese adolescent girls. Int J Pediatr Adolesc Med. 2017;4(4):147-152. doi:10.1016/j.ijpam.2017.09.002
ABOUT THE AUTHOR
Siva Kumaravelu, DO
Siva Kumaravelu, DO was a fourth-year medical student at Michigan State University College of Osteopathic Medicine when she wrote this review.
She plans to pursue a career in primary care with a focus on women’s health. Dr. Kumaravelu participated in the FACTS elective.
