By: Gloria Singleton
Director’s Note: To conclude National Adolescent Health Month, Gloria Singleton, a former FACTS elective participant, summarized research on current criteria for polycystic ovary syndrome (PCOS). One of the criteria, anovulation, is common among adolescents, yet it is important to properly distinguish between normal physiology and teens suffering from undiagnosed PCOS. This study by Shah et al highlights several other criteria, including endometrial thickness and ovarian features noted on transabdominal ultrasound, which can be used to hasten the diagnosis and treatment of PCOS. Learning to chart using a fertility awareness-based method (FABM) is another important tool to monitor reproductive health. With the help of a FABM-trained physician or clinician, adolescents who track their cycles may be better able to identify signs and symptoms potentially indicative of PCOS.
Introduction
Polycystic ovary syndrome (PCOS) is diagnosed by the Rotterdam criteria. Patients must meet at least two of the three criteria of oligo/anovulation, hyperandrogenism as determined clinically or biochemically, and polycystic ovaries seen on ultrasound.[1] The diagnosis of PCOS by Rotterdam criteria in adolescents is challenging due to the anatomic and hormonal characteristics of adolescent females.
Utilization of the polycystic ovary criterion is challenging in adolescents for both physiologic and social reasons. Polycystic ovaries are not uncommon in ovulatory women (16-25%) and occur in even greater frequency in ovulatory teenagers (27-39%). Additionally, visualization of the ovaries is typically done via transvaginal ultrasound, an imaging modality that is rarely applied in the adolescent population.
Oligo/anovulation, another Rotterdam criterion, may represent normal physiology in adolescents. The two years post-menarche are often associated with some degree of anovulatory cycles, possibly up to half of the cycles during this time. Although physiologic, these anovulatory cycles are associated with hormonal imbalances which may present as clinical hyperandrogenism, the third Rotterdam criterion.
Despite these challenges to clearly define PCOS in adolescence, early diagnosis of PCOS is vital for patient health. Potential long-term health consequences of PCOS include metabolic conditions such as dyslipidemia and type 2 diabetes, infertility, and endometrial cancer. The objective of this 2010 study[2], by Shah et al, was to evaluate the uterine and ovarian morphology in adolescents with PCOS to gain an understanding of imaging findings that support a diagnosis of PCOS in this unique population.
“Potential long-term health consequences of PCOS include metabolic conditions such as dyslipidemia and type 2 diabetes, infertility, and endometrial cancer.”
Methodology
This study was a cross-sectional retrospective analysis. Patient medical records were reviewed, including history and physical exam findings, laboratory data, and ultrasonographic imaging collected from 1997 to 2008. The study sample consisted of 51 females 10 to 18 years old diagnosed with PCOS and followed by pediatric endocrinology at New York University Medical Center. For all patients, the revised 2003 Rotterdam criteria were utilized to diagnose PCOS and exclude possible confounding diagnoses, such as congenital adrenal hyperplasia, Cushing’s syndrome, and androgen-secreting tumors.
All ultrasonography was via transabdominal imaging. A pediatric radiologist reviewed the images to confirm measurements and comment on ovarian morphology. Ultrasonographic images of the uterus were utilized to determine endometrial thickness (ET) and morphology, uterine length, and uterine volume. Ovarian images were used to determine ovarian volume and morphology including follicle number and placement. Measurements were compared with normative data for the Tanner stage when relevant.
Results
The mean age of the patients was 15 years old, and patients represented diverse ethnic backgrounds (28 Hispanic, 8 Asian, 5 African American, and 10 Caucasian). A large proportion of the patients had a history of menstrual abnormalities including irregular menses (50.9%), secondary amenorrhea (29.4%), primary amenorrhea (7.9%), and menometrorrhagia (3.9%). The vast majority of patients also demonstrated clinical hyperandrogenism in the form of acne or hirsutism (88.2%).
Multiple follicles, defined as >10 per ovary, were found in 83% of patients, with 80% of the visualized follicles located peripherally. Enlarged ovarian volumes of >10cc were present in 43% of the adolescents. On uterine images, the endometrium of all patients was found to be homogeneous, with 31.4% of patients having an enlarged ET of >7mm. Enlarged ET was not found to be associated with time since the last menstruation, free testosterone, or LH/FSH ratio. The reduced uterine length was present in 43% of patients, while a normal-increased uterine volume was seen in all patients.
Discussion
Although establishing normative ovarian and uterine parameters for adolescents with PCOS is challenging, the study findings revealed some dominant findings in this population. In particular, the results suggest that the presence of ovaries with multiple follicles in a peripheral arrangement points to PCOS even without enlarged ovarian volume. Additionally, decreased uterine length and increased ET may indicate a diagnosis of PCOS. Overall, ovarian and uterine imaging findings should be interpreted in the context of each adolescent’s clinical picture.
“The results suggest that the presence of ovaries with multiple follicles in a peripheral arrangement points to PCOS even without enlarged ovarian volume.”
Interestingly, this study demonstrated multiple imaging findings that differ from those in adult women with PCOS. In terms of ovarian morphology, only 43% of adolescents in this study were found to have enlarged ovarian volumes compared with up to 70% of adult women with PCOS. Furthermore, while previous studies have shown adult women with PCOS have reduced uterine volume, adolescents in this study were all found to have normal-increased uterine volume. The uterine volume discrepancy is likely related to the changing uterine shape in the peripubertal period from a tubular to pear-shaped structure.
The findings related to endometrial thickness and morphology are also important, as they suggest adolescents with PCOS have a lower incidence of development of endometrial hyperplasia (EH) and endometrial cancer (EC) as compared with adult women. A minority (31.4%) of patients was found to have enlarged ET. Notably, ET was not associated with hormonal factors previously found to play a role in the development of EC, such as unopposed estrogen, hyperandrogenism, and elevated LH. The presence of homogeneous endometrium is also significant, as previous studies have found EH only in the setting of heterogeneous endometrium, and homogeneous morphology does not appear to increase the risk of EH.
This study has limitations, the most obvious being its small sample size and retrospective design. Imaging factors also pose limitations as there was no control of the timing of ultrasounds in relation to patients’ menstrual cycles and all imaging was done via transabdominal rather than transvaginal ultrasound. Further, endometrial evaluation was done via ultrasound without pathology correlation.
The diagnosis of PCOS in the adolescent population remains challenging and dependent on clinical judgment due to the unique reproductive physiology of the adolescent stage. Although this study was limited by size and design and did not establish normative ovarian or uterine parameters for adolescents with PCOS, the imaging findings from this study may aid in the diagnosis of adolescents with clinical features suggestive of PCOS. The study also suggests a low incidence of EH and EC in adolescents with PCOS, and this information can help inform treatment choices. In anovulatory patients of any age with PCOS, a role likely remains for interruption of unopposed estrogen with progestin-induced withdrawal bleeds or oral contraceptive pills.
“The diagnosis of PCOS in the adolescent population remains challenging and dependent on clinical judgment due to the unique reproductive physiology of the adolescent stage.”
It is essential for adolescents to have information about their reproductive health and for clinicians to have additional resources to diagnose and more accurately characterize PCOS in adolescents. Further studies, particularly with prospective designs and large sample sizes, are needed to move toward adolescent-specific diagnostic criteria for PCOS. Until these criteria are available, medical professionals must be both diligent and flexible in the diagnosis of PCOS in adolescents.
References
[1] El Hayek S, Bitar L, Hamdar LH, Mirza FG, Daoud G. Polycystic Ovarian Syndrome: An Updated Overview. Front Physiol. 2016;7:124. doi: 10.3389/fphys.2016.00124. PMID: 27092084; PMCID: PMC4820451.
[2] Shah B, Parnell L, Milla S, Kessler M, David R. Endometrial thickness, uterine, and ovarian ultrasonographic features in adolescents with polycystic ovarian syndrome. J Pediatr Adolesc Gynecol. 2010;23(3):146-152. doi:10.1016/j.jpag.2009.07.002.
ABOUT THE AUTHOR
Gloria Singleton
Gloria Singleton is a fourth-year medical student at the Renaissance School of Medicine at Stony Brook University. She obtained a BS in Chemical Engineering from Northeastern University and worked in biotech before entering medical school. She plans to complete residency in diagnostic radiology but maintains a deep interest in women’s health. She has pursued opportunities to fulfill this interest, such as enrolling in the FACTS elective and conducting breast imaging research.
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