Adolescent Gynaecological

Issues
23.4 SPECIAL GYNAECOLOGICAL CONCERNS
OF ADOLESCENTS
23.4.1 Polycystic Ovarian Syndrome (PCOS)
Polycystic ovarian syndrome is a complex endocrine disorder characterized
by chronic anovulation and androgen excess with clinical manifestations of
iregular cycles, hirsutism, acne and obesity. It was first described by Stein
and Leventhal in 1935.The disorder is thought to have a genetic etiology
but the severity and course is determined by life style specially body mass
index.
Health care professionals are now realizing that adolescent females are
presenting with PCOS and the associated health concerns of menstrual
iegularities, obesity, type 2diabetes, 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 iregularities.
PCOS often manifests around the time of menarche as iregular and ofen
lengthened menstrual cycles. Unfortunately, PCOS often goes unrecognized
and undiagnosed at this time because having irregular periods in
adolescence is usually considered normal by many concemed relations or
healthcare professionals. 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 iregularity. 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.
Early intervention through lifestyle modification and the use of various
medications is essential to prevent the medical co-morbidities associated
with PCOS.

) PCOS-Diagnosis
To establish the diagnosis of PCOS two of the three criteria is
required to be present. (Rotterdam consensus workshop 2003)
Oligomenorrhoea /amenorrhoea,
Polycystic ovaries on ultrasound,
Clinical or biochemical signs of hyperandrogenism.
The National Institute of Health Consensus Conference has established
definite probable criteria for PCOS, including menstrual abnormalities
and androgen excess and excluding adrenal hyperplasia and other
causes of hyperandrogenism. Insulin resistance, elevated LH to FSH
ratio, and ultrasonographic signs were defined as possible criteria. 41
Gynaecological Disorders ii) Mechanism of PCOS
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
hyperinsulinemic state 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. Increased circulating levels
of testosterone are noted in women with PCOS 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.
There is non specific hyperandrogenemia due to exaggerated
androgen response to ACTH. 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.
ii) Evaluation of a patient of PCOS
PCOS can be a challenge to diagnose because the disorder presents
with a wide range of signs and symptoms that can easily be missed
When a young patient presents with hirsutism and irregular periods,
the health care provider should always be alerted to the possibility of
PCOS.

Clinical presentation
Following are the clinical features of PCOS.
Hyperandrogenism (acne, hirsuitism, alopecia not virilization)
Menstrual disturbance

Infertility
Obesity
Acanthosis Nigricans
The most common clinical feature is menstrual iregularity which generally
appears at menarche or immediately thereafter, although oligomenorrhoea
and amenorhoea are common findings, polymenorrhoea or even normal
menses may be present. Hirsutism is seen in 30% of cases. Obesity per
se present in only 40% of the cases. Other clinical signs include acne
and acanthosis nigricans.
In the long run these patients are more prone to develop cardiovascular
disease, frank diabetes mellitus, hypertension and rarely endometrial
carcinoma.
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 History Adolescent Gynaecological
Issues

Menstrual history should focus on age at menarche, length of

time between periods, quantity of menstrual flow, and presence of
dysmenorrhoea. Girls with PCOS often begin menstruating with
menstrual cycles that are fairly regular. After a few years, the
menstrual cycles will become quite irregular or not occur at all.
The menstrual flow in girls with PCOS tends to be heavier and
is associated with significant cramping.
Development of secondary sexual characteristics - adolescent girls
diagnosed with PCOS had a history of precocious pubarche.
Precocious pubarche is defined as the appearance of pubic hair
prior to age eight.
Weight Gain - Growth charts often adolescents have had no
prior history of obesity as a child but gain a significant amount
of weight at an accelerated rate following menarche.
Development of acne, hirsutism, balding, and voice changes
manifestations of hyperandrogenism.
Family history of PCOS and diabetes. PCOS tends to cluster in
families and to follow the trend of first degree relatives, especially
mothers and sisters of girls diagnosed with the condition.
Social history - to focus on current diet and exercise patterns.
Patterns of alcohol consumption and tobacco use as metformin
may be one of the medications to be prescribed. Alcohol must
be avoided when on metformin because excessive alcohol intake
is associated with an increased incidence of lactic acidosis.

ii) Physical Exam

Measurement of height and weight and calculate body mass index
(BMI). If the BMI indicates that the patient is obese measure
waist-to-hip ratio to determine if the obesity is considered central/
android. An obtained value of greater than 0.72 indicates this
type of obesity.
Signs of hyperandrogenism - presence of hirsutism, acne, loss of
hair, deepening voice, and clitoromegaly. Acne alone does not
indicate PCOS, but it is certainly a sign to look out for as part
of the constellation of signs with which an adolescent may
present.
Signs of insulin resistance - presence of acanthosis nigricans and
an increased BMI with the presence of central/android obesity
indicate insulin resistance. Acanthosis nigricans is a fairly reliable
clinical marker or indicator of moderate to severe insulin
resistance. This skin manifestation appears as a brown darkening
of the skin at the nape of the neck that will spread laterally to
the upper thorax and shoulders. This darkened, velvety-appearing
skin can also be noted in the axillary and intertrigenous areas.
43
Gynaecological Disorders ii) Investigations
Ultrasound and laboratory data are of key importance to confirming
the diagnosis, although the history and the outward signs seen on
physical exam can lead to the diagnosis of PCOS.
a) Ultrasound
Diagnosis is on the basis of the following criteria
Presence of 12 or more cysts of 2-9 mm in subcapsular region
Ovarian volume equal to or more than 12 cm
Bright echogenic stroma
b) Biochemical Tests
Presently, there no consensus on what biochemical laboratory tests
should be used to confirm a diagnosis of PCOS. Most authorities
agree that testing should rule out other etiologies of amenorrhoea such
as hypothyroidism, hyperprolactinemia, and pregnancy, exclude other
causes of hyperandrogenism such as congenital adrenal hyperplasia
(CAH), as well as adrenal and ovarian tumors and detect the
presence of insulin resistance, glucose intolerance, and lipid
abnormalities.

1. Fasting and 2 hour blood glucose levels: All adolescents who are
suspected of having the disorder be screened by drawing fasting
blood glucose levels. If fasting blood glucose levels are elevated, the
next step is to order a 2 hour 75 g glucose tolerance test (GTT) to
confirm glucose intolerance or type 2 diabetes.
Normal Impaired Diabetes
Fasting (mg/dl) < l10 110-126 >126

2 Hr value (mg/dl) < 140 140-199 >200

Fasting Insulin levels (Normal <30 mU/l). Routine testing of insulin

levels to determine insulin resistance is not recommended because of
the expenses involved.
Fasting blood sugar:insulin ratio (>4.5)
Total and free testosterone (Normal total testosterone 20-80 ng/dL)
DHEAS (Normal-Less than 350 ng/dL)
LH raised (2-10 IUN) Measured on day 2-3 of cycle
FSH normal (2-8 IUM)
Raised LH to FSH ratio

Decreased SHBG (normal 16-119 nmo/l)

Free androgen Index (FAI) TX 100/SHBG (Normal <5)
Serum Prolactin increased. (normal <20 ng/ml) Measure ifoligo- amenorhoeic.
44
 Thyroid Stimulating Hormone. Adolescent Gynaecological
Issues

Lipid Profile - Low desity lipoprotein and high density lipoprotein

cholesterol levels.

c) Screening tests
Since PCOS is a chronic disease affecting many organs regular
screening for:
Insulin resistance with 75 gms GTT should be done.
Lipid profile must be done.
iv) Treatment

Goals of treating PCOS are to treat current troubling signs and

symptoms (hirsutism, acne, weight, and irregularity issues.) and prevent
the long-term health problems commonly seen in women with PCOS
Treatment depends on
Managing weight
Reducing hyperinsulinemia
Treating anovulation and regularising cycles
Antagonising androgens to treat hirsutism and acne
Prevention of endometrial hyperplasia
Preventing long term effect of PCOS
The cornerstones of management involve both the use of lifestyle
modification and medications

1) Weight Loss: It is a very good therapy along with changes in the

lifestyle and must be initiated as part of treatment plan alone or along
with drug therapy for all patients of PCOS. Aim is weight loss of 5
10% and a BMI of < 27. Adolescents who are overweight or obese
at the time of diagnosis should be encouraged to engage in a diet
and exercise plan that will aid them in attaining and subsequently
maintaining a healthy body weight.
a) Diet - Diet modification is advocated
Food with low glycemic index such as vegetables, fruits,
fiber having protein and low fat content should be
consumed.

Limit simple carbohydrates in lieu of complex carbohydrates.

Small, frequent meals that combine healthy proteins, fats, and
complex carbohydrates should be encouraged because small
frequent meals consumed throughout the day help to lower
elevated insulin levels This type of eating plan helps to
modulate the release of insulin when compared with larger
meals filled with simple sugars that cause insulin surges.
The consumption of foods high in polyunsaturated fatty acids 45
(PUFAs) has also been shown to be beneficial in patients
Gynaecological Disorders with PCOS. PUFAs have been shown to modulate blood
glucose as well as to control levels of sex hormones PUFAs
can be found in oily fish, nuts, nut butters, olive oil, and
canola oil.

b Exercise: Moderate physical activity, 30-60 minutes per day, should

be the goal of all patients with PCOS. Aerobic exercise through
walking, jogging, swimming, or biking should be encouraged.
2) Medications
a) Treatment of Hyperinsulinemia
Metformin, Rosiglitazone or pioglitazone may be given. Metformin is a
insulin sensitizing agent and may also be used in these cases for
treatment of insulin resistance as it increases insulin sensitivity leading
to improvement in ovarian function. It also lowers LH, free
testosterone levels, PAI-I and endothelin Ilevels in overweight women
with polycystic ovaries. Metformin induces regular cycles, improves
ovulation, hirsuitism, hyperandrogenemia enhance the effectiveness of
fertility drugs, and decrease BMI and insulin resistance.
Metformin is prescribed doses of 1,500 to 2,000 mg daily in
treating patients with PCOS. Common gastrointestinal side effects
(nausea, vomiting, diarrhoea, and flatulence) can be avoided if the
medication is started at lower doses and titrated upwards slowly.
b) Prevention of endometrial hyperplasia and regularization of
cycles
Monthly medroxyprogesterone in a dose of 5-10 mg lday or
norethindrone in a dose of 5-15 mg for 10-14 days each month
should be given. This avoids abnormal endometrial proliferation
but does not suppress the ovarian androgen production. It
regulates cycles.
Low dose oral contraceptive pills. - Advantages are
contraception, prevention of endometrial hyperplasia, regularization
of cycles and treatmnent of hirsutism. Oral contraceptive pills
containing estradiol and progestogen desogesterel or drosperinone
which is lipid friendly and has no androgenic effect are used.
Newer OCs with progestin component drospirenone(Tarana,) is
now available. Drospirenone is an analog of spironolactone, a
known antiandrogenic agent, which is effective in improving acne,
has a negative influence on fasting insulin concentrations and
triglycerides.
Metformin also induces regular cycles in 68-95% patients treated
for 4-6 months.

c) Treatment of hyperandrogenism
Treatment consists of drugs with antiandrogenic action
Oral contraceptive : They suppress ovarian androgen production
and increase sex homone binding globulin thereby reducing free
46 testosterone OC pills containing 2 mg cyproterone acetate and
 35 ug ethinyl estradiol and those containing desogesterol or Adolescent Gynaecological
Issues
drosperinone are recommended.
Cyproterone acetate: It antagonizes the androgen receptors in the
skin and acts as a weak progestogen that inhibits gonadotrophin
secretion thereby decreasing androgen production.
Spironolactone: It is an oral aldosterone antagonist with anti
androgenic properties. It increases metabolic clearance of
testosterone and reduces cutaneous 5 alfa reductase activity. Dose
100-200 mg/day but may be difficult to tolerate. Lower doses
are used generally.
Flutamide : It is a non steroidal antiandrogen at the receptor
level given in a dose of 250 mg twice a day.
Finasteride: It is a type II 5 alpha reductase inhibitor. It is
given in a dose of 1-5 mg/day.
GnRH agonist: They can be given in a depot preparation with
the goal of reducing serum testosterone to 40 ng/dL for patients
resistant to above therapy.
3) Dealing with unwanted body hairs
Treatment of hirsutism is done by cosmetic methods like electrolysis,
waxing, bleaching, laser therapy etc. Electrolysis and laser ablation
therapy are the only two methods that claim to be permanent hair
removal techniques. Electrolysis and laser therapy can be expensive
and painful procedures. It is also important to refer patients to
reputable technicians who perform these procedures to reduce the
incidence of complications that are often associated with these
methods of hair removal (scarring with electrolysis and
hypopigmentation with laser ablation therapy). Plucking and waxing are
inexpensive methods that can be performed in the privacy of one's
home or through salon services. but are by no means a permanent
solution to hirsutism. Shaving is yet another option, but many women
find this very undesirable.
4) Surgical wedge resection or laparoscopic drilling of the ovaries
It has also been advocated for the treatment of PCOS. Spontaneous
ovulation occurs in 70-90% and hyperandrogenemia is reduced.
However, surgery is not recommended for adolescents.
5) Psychosocial support

Offering psychosocial support by building positive, supportive

relationships with adolescents diagnosed with PCOS, will allow
them to express their feelings and concerns regarding the disease.
Positive communication can greatly impact one's body image and
self-esteem.

Imparting education to the adolescent can make her more

knowledgeable about the disease and available treatment options.
The adolescent will then feel empowered to make informed health 47
care decisions on her own Education can occur through verbal
exchanges, written materials, and/or access to Internet-based
information contained on web sites.