pcos in adolescents: early detection and intervention · 2016. 4. 23. · pcos in adolescents under...
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PCOS IN ADOLESCENTS: EARLY
DETECTION AND INTERVENTION
R A C H A N A S H A H , M D M S T R
A S S I S TA N T P R O F E S S O R O F P E D I AT R I C S
D I V I S I O N O F E N D O C R I N O L O G Y A N D D I A B E T E S
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DISCLOSURES
Off-label use of metformin in treatment of PCOS
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OBJECTIVES
Review how PCOS develops
Understand clinical presentation of PCOS in teens
Describe the diagnosis of PCOS in teenagers
Understand short and long-term consequences of
PCOS in teens
Discuss treatment options for PCOS in teenagers
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PCOS: HIDDEN MYSTERY?
6-10% of all reproductive age females
Most common endocrine disorder in
women
Major healthcare and economic
burden
Shockingly little known about
pathophysiology and underlying cause
Treatments symptomatic, no cure or
prevention
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NOT JUST A MALE HORMONE
Testosterone made by
gonads & adrenal glands
In women: 60% made in
ovary
Most is turned into
estradiol in the ovary and
never reaches bloodstream MALE
FEM
ALE
FEM
ALE
PCOS
0
200
400
600
800
Te
sto
ste
ron
e n
g/d
l
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ITS NOT JUST IN YOUR HEAD
Imbalance of
hormones from pituitary
(High LH, low FSH) lead to
more T released into
circulation
Low FSH leads to
abnormal follicular
maturation/anovulation
Adrenal androgen
production also increased
BRAIN
OVARIES
SKIN
WHOLE
BODY
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PCOS IN ADOLESCENTS
Under diagnosed in teens, especially lean girls
Symptoms similar to those in adult women
Approach to treatment may be different
Timely diagnosis important to address & reduce
associated risks
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DERMATOLOGIC ISSUES
Hirsutism—terminal
hair in MALE pattern
Does NOT correlate
with testosterone
levels
Found in 69% of
PCOS teens
Racial/ethnic
differences
important
Severity is variable!
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HIRSUTISM SCORING
(MODIFIED FERRIMAN GALLWEY)
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SKIN PROBLEMS
Acne—more severe (cystic, not responding to topical
treatments), different pattern (JAWLINE, back, chest),
worse with periods
Less specific, as 2/3 of normal teens have acne
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SKIN PROBLEMS
Acanthosis nigricans (marker of insulin resistance)
Back of neck, undearms, groin, other skin folds
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SKIN PROBLEMS
Androgenic alopecia: Scalp hair thinning in male pattern
Much less common, incidence not reported
Skin issues cause embarrassment, poor self-esteem
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GYNECOLOGIC ISSUES
can have “regular” periods without ovulation (10-15%), increased
frequency, heavy bleeding
Oligomenorrhea (infrequent periods): >35 day cycles (45 in teens)
or 90 day
interval)
Risk of uterine cancer
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“CYSTS”
“cysts” in PCOS are actually arrested follicles
Do not grow beyond 10mm in size
Do not cause discomfort, pelvic or abdominal
pain, or swelling
Do not require monitoring by ultrasound, will
not need surgery
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FERTILITY IN PCOS
Spontaneous pregnancy possible, take usual contraceptive
measures!
Advise to discuss diagnosis with Gyn and get treatment early when
desiring pregnancy
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METABOLIC RISK
PCOS increases risk compared to same weight/age
If overweight, even HIGHER
Insulin resistance worsens symptoms/high androgens worsen insulin resistance
Risks: Type 2 diabetes, cholesterol problems, fatty liver, high blood pressure,
sleep apnea, heart disease
LEAN LEAN
PCOS OBESE
OBESE
PCOS < <
Insulin
Resistance
High
Androgens
Screen for these at diagnosis
and annually!
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PSYCHIATRIC RISKS Increased depression and anxiety
Disordered eating patterns (bulimia, binge eating)
Poor body image due to: weight, hirsutism, acne, and
fertility concerns
Providers need to ask and make patients feel comfortable
talking about it!
BRAIN/BODY
CONNECTION
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DIAGNOSIS OF PCOS IN ADOLESCENCE
Clinical or biochemical hyperandrogenism
(hirsutism or elevated testosterone in blood)
AND
Irregular periods/lack of ovulation
>2 years after onset of first period
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MAKING THE DIAGNOSIS
• Careful history
• Menstrual
• Dermatologic
• Metabolic
• Family
• Physical exam
• Blood tests if indicated
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BUT I WANT TO SEE MY CYSTS!
Ultrasound not routinely recommended in adolescents due to lack of age
specific guidelines
PCOS-like ovaries seen in many other disease states!
May be performed for unusually high testosterone levels or other
symptoms beyond those of PCOS
If ultrasound needs to be done, TRANS-ABDOMINAL ultrasound is
sufficient in teen
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LABORATORY TESTS Establish hyperandrogenism
Testosterone profile
Rule out other causes
Pregnancy Thyroid
Prolactin (pituitary disease) 17OHP(adrenal disorder)
LH, FSH (Pituitary hormones)
Bleeding disorders (if heavy/frequent)
Comorbidities
Glucose, hemoglobin A1c, insulin (consider OGTT) for diabetes
Fasting lipid profile for cholesterol issues
Liver enzymes for fatty liver disease
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PCOS, OBESITY AND INSULIN RESISTANCE
In the US, at least 2/3 of women with
PCOS are overweight.
Increased insulin levels and decreased
sensitivity amplify the hormonal
features of PCOS.
Treatment of insulin resistance may
improve hyperandrogenism and even
restore ovulation.
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GOALS OF PCOS TREATMENT
Reduce testosterone and its effects on skin (acne, hair)
Protect uterus from cancer risk
Reduce weight and heart disease risk with lifestyle changes
Improve insulin sensitivity
Restore fertility
Treatment tailored to specific symptoms
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TREATMENT OPTIONS: HORMONAL
Combined estrogen/progesterone contraceptives
Contraindications: clot risk, migraine with aura, risk of
breast/uterine cancer
Side effects (common): breakthrough bleeding, mood
change, appetite change, headache nausea, breast change
Side effects (severe): stroke or blood clot, liver mass
Medroxyprogesterone or progesterone for 7-10 days of each
cycle (or every 3-4 months if no spontaneous period)
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TREATMENT OPTIONS: METFORMIN
Metformin: useful even without IR
Insulin sensitizer
Results INDEPENDENT of weight
loss
GI side effects: nausea, diarrhea,
gas (resolve with time)
Difficult for many girls to take
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TREATMENT OPTIONS: DERMATOLOGIC
Acne: topical treatments, antibiotics, retinoids
Hirsutism: topical eflornithine (Vaniqa), slows growth
Laser, electrolysis, waxing, shaving, depilatories, etc..
Even with androgen control, can slow growth & prevent new
growth---already present follicles will not regress
If considering “permanent” option, control androgens FIRST
Alopecia: Minoxidil (Rogaine) to affected areas
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TREATMENT OPTIONS: ANTI-ANDROGENS
Spironolactone: reduction in hirsutism and acne
Lower blood pressure, potassium (high doses), dizziness/fainting
Teratogenic---can block formation of genitalia in male fetus--risky
to use without birth control
finasteride (5a reductase inhibitor) and Flutamide (non-steroidal
anti-androgen)—rarely used in teens or adults
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TREATMENT OPTIONS: LIFESTYLE
With ANY treatment, simultaneous diet/exercise: Just 5% weight
loss can restore ovulation as well as lower metabolic risk
Currently no “best” diet recommendation, though many
recommend lower carbohydrate given insulin resistance
The “best” diet and exercise is the one you can stick to!!!
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LIFESTYLE CHANGES FOR TEENS
Work best as a FAMILY approach
Seek an RD familiar with teens
Exercise should be ENJOYABLE
Nutrition should be FOR LIFE
Major life changes (college!) need to be pre-emptively
addressed to avoid setbacks
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SUMMARY
PCOS is common but under-diagnosed in teens
Irregular periods > 2 years after first period should
be evaluated
Diagnosis can be made with careful
history/examination and laboratory tests
All girls with PCOS should be screened for
metabolic complications yearly
Girls with PCOS are at increased risk of mood
disorders and disordered eating and should be
screened regularly
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SUMMARY
Treatment is tailored to the specific symptoms of the
patient
Treatment should ALWAYS include healthy lifestyle
guidance and many families benefit from meeting
with an RD
No cure yet, but proper management can make an
enormous difference!
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CHOP ADOLESCENT PCOS CLINIC
Multidisciplinary, all pediatric providers
• Endocrinologist (Dr Rachana Shah)
• Dermatologist (Dr Marissa Perman)
• Nutritionist (Sarah Barnes, RD)
Patients/families meet with multiple providers at one clinic visit
to have all their needs met
Laser hair removal offered through Dermatology; may be able to
get insurance coverage
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