Overview
Definition:
Hyperandrogenism in adolescent girls refers to a state of excessive androgen production or activity, leading to clinical signs and symptoms of masculinization
Polycystic Ovary Syndrome (PCOS) is the most common cause of hyperandrogenism in this age group, characterized by a combination of ovulatory dysfunction, hyperandrogenism, and polycystic ovarian morphology on ultrasound (though the latter is not essential for diagnosis in adolescents).
Epidemiology:
PCOS is estimated to affect 15-20% of reproductive-aged women, with onset often in adolescence
Studies suggest prevalence rates of 6-23% in adolescent girls, varying by diagnostic criteria used
It is a leading cause of menstrual irregularities and hyperandrogenic symptoms in this demographic.
Clinical Significance:
Undiagnosed or inadequately managed hyperandrogenism and PCOS in adolescents can lead to significant physical and psychological distress
Long-term consequences include metabolic syndrome, type 2 diabetes mellitus, cardiovascular disease, infertility, and impaired quality of life
Early and accurate evaluation is crucial for timely intervention and prevention of these sequelae.
Clinical Presentation
Symptoms:
Irregular menstrual cycles (oligomenorrhea, amenorrhea) usually starting within 1-2 years of menarche
Hirsutism, characterized by excessive hair growth in a male-like pattern (e.g., face, chest, abdomen)
Acne vulgaris, often severe or persistent beyond typical adolescent acne
Androgenic alopecia (hair thinning on the scalp)
Weight gain or obesity, particularly central obesity
Acanthosis nigricans, indicative of insulin resistance
Mood disturbances, anxiety, and depression.
Signs:
Evidence of hirsutism on physical examination, often graded using the Ferriman-Gallwey score
Moderate to severe acne vulgaris
Evidence of alopecia
Clinical signs of obesity or excess central adiposity
Acanthosis nigricans on neck, axillae, or other friction areas
Clitoromegaly (rare, suggestive of more severe hyperandrogenism or an androgen-secreting tumor).
Diagnostic Criteria:
The Rotterdam criteria are commonly used, requiring at least two of the following three features for diagnosis: 1
Oligo- and/or anovulation
2
Clinical and/or biochemical evidence of hyperandrogenism
3
Polycystic ovaries on transvaginal ultrasound (at least 12 follicles measuring 2-9 mm in diameter in each ovary and/or ovarian volume > 10 mL)
In adolescents, diagnosis requires the exclusion of other androgen excess disorders, and ultrasound findings may be less specific due to normal physiological changes
The presence of oligo-anovulation and hyperandrogenism, with exclusion of other etiologies, is often sufficient for diagnosis in this age group.
Diagnostic Approach
History Taking:
Detailed menstrual history, including age of menarche, cycle regularity, duration, and flow
Onset and progression of hyperandrogenic symptoms (hirsutism, acne, hair loss)
History of obesity or rapid weight gain
Family history of PCOS, diabetes, or cardiovascular disease
Medications that can cause hyperandrogenic symptoms (e.g., certain anticonvulsants, anabolic steroids)
Symptoms suggestive of adrenal or pituitary disorders (e.g., rapid virilization, galactorrhea, headaches).
Physical Examination:
Assess Tanner stage for pubertal development
Measure height, weight, and calculate BMI
Perform Ferriman-Gallwey scoring for hirsutism
Examine for acne and alopecia
Inspect for acanthosis nigricans
Palpate thyroid
Measure waist circumference and calculate waist-to-hip ratio
Perform a pelvic examination (if clinically indicated and appropriate for age, to assess for clitoromegaly or other anomalies).
Investigations:
Baseline laboratory tests: Follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, prolactin, thyroid-stimulating hormone (TSH)
Total and free testosterone levels
Dehydroepiandrosterone sulfate (DHEAS) and androstenedione (if DHEAS is elevated or clinical suspicion is high)
17-hydroxyprogesterone (17-OHP) to rule out non-classical congenital adrenal hyperplasia (NCCAH)
HbA1c and fasting glucose/insulin to assess for insulin resistance and diabetes risk
Lipid profile
Pelvic ultrasound: May show polycystic ovaries but is not essential if other criteria are met and should be interpreted cautiously in adolescents
Consider adrenal CT or MRI if marked hyperandrogenism, virilization, or elevated DHEAS suggests an adrenal tumor
Consider pituitary MRI if hyperprolactinemia or other pituitary signs are present.
Differential Diagnosis:
Congenital adrenal hyperplasia (CAH), particularly non-classical forms
Cushing's syndrome
Androgen-secreting tumors (ovarian or adrenal)
Hyperprolactinemia
Hypothyroidism
Medications
Idiopathic hirsutism
Polycystic ovarian morphology on ultrasound alone without other features.
Management
Initial Management:
Lifestyle modification is the cornerstone of management: dietary changes (balanced diet, reduced intake of refined carbohydrates and saturated fats) and regular physical activity
Weight loss in overweight or obese individuals is paramount for improving hormonal balance and insulin sensitivity
Patient education and counseling regarding the chronic nature of PCOS and its management are essential.
Medical Management:
Combined oral contraceptive pills (COCPs) are first-line therapy for menstrual regulation and androgen suppression
Examples include ethinyl estradiol/drospirenone or ethinyl estradiol/cyproterone acetate
Anti-androgen medications (e.g., spironolactone, finasteride) may be added for resistant hirsutism, but caution is advised in adolescent girls of reproductive potential due to teratogenicity
use requires reliable contraception
Metformin is indicated for patients with insulin resistance, impaired glucose tolerance, or type 2 diabetes, and may help improve menstrual regularity and androgen levels
Other medications like eflornithine cream can be used topically for hirsutism.
Surgical Management:
Surgical intervention is rarely indicated for PCOS in adolescents
Ovarian drilling may be considered in select cases of severe anovulation resistant to medical management, but its long-term efficacy and safety in adolescents are still debated
Surgical removal of androgen-secreting tumors is indicated if malignancy is suspected or confirmed.
Supportive Care:
Psychological support is crucial due to the impact of PCOS on self-esteem and body image
Referrals to dietitians for nutritional counseling
Regular monitoring of weight, BMI, blood pressure, and glucose levels
Dermatological evaluation for severe acne or alopecia
Counseling on reproductive health and fertility planning as the patient approaches reproductive age.
Complications
Early Complications:
Psychological distress, anxiety, and depression due to cosmetic concerns
Worsening acne and hirsutism
Metabolic disturbances like insulin resistance and dyslipidemia.
Late Complications:
Infertility
Gestational diabetes and preeclampsia in pregnancy
Increased risk of type 2 diabetes mellitus
Cardiovascular disease (hypertension, coronary artery disease)
Endometrial hyperplasia and increased risk of endometrial cancer (if amenorrhea is prolonged without progestin withdrawal)
Sleep apnea
Non-alcoholic fatty liver disease.
Prevention Strategies:
Early diagnosis and consistent management of hyperandrogenism and metabolic abnormalities
Emphasis on sustainable lifestyle modifications (diet and exercise)
Regular medical follow-up to monitor for complications and adherence to treatment
Patient education on long-term health risks and self-management strategies.
Prognosis
Factors Affecting Prognosis:
Early diagnosis and initiation of appropriate treatment
Severity of hyperandrogenism and metabolic abnormalities at presentation
Patient adherence to lifestyle modifications and medical therapy
Genetic predisposition
Presence of obesity and insulin resistance.
Outcomes:
With consistent management, many adolescents can achieve regular menstrual cycles, reduce hyperandrogenic symptoms, and improve metabolic parameters
However, PCOS is a chronic condition, and long-term monitoring is necessary
Fertility may be affected, but many can achieve pregnancy with appropriate treatment
The risk of long-term metabolic and cardiovascular complications can be significantly reduced with proactive management.
Follow Up:
Regular follow-up every 6-12 months is recommended, or more frequently if symptoms are severe or changing
This includes reassessment of menstrual regularity, hyperandrogenic symptoms, weight, BMI, blood pressure, and metabolic parameters (glucose, lipids)
Transition of care to an adult endocrinologist or gynecologist as the patient approaches adulthood is essential
Counseling on family planning and pregnancy risks should be ongoing.
Key Points
Exam Focus:
Remember the Rotterdam criteria and the importance of excluding other causes of hyperandrogenism
First-line management involves lifestyle changes and COCPs
Metformin is used for insulin resistance
DHEAS is a key marker for adrenal androgen excess
Ultrasound is less critical in adolescents compared to adults for PCOS diagnosis.
Clinical Pearls:
Always consider NCCAH in adolescent girls with hyperandrogenism, especially if there is a family history or rapid virilization
Acanthosis nigricans is a strong indicator of insulin resistance
Don't underestimate the psychological impact of PCOS on adolescents
provide holistic care
Transition of care planning should begin early.
Common Mistakes:
Diagnosing PCOS based solely on ultrasound findings in adolescents without fulfilling other criteria
Inadequate exclusion of other endocrine disorders
Over-reliance on pharmacologic therapy without emphasizing lifestyle modifications
Inconsistent follow-up and monitoring for long-term complications.