Polycystic ovary syndrome – PCOS

Identification of children who might be at risk for PCOS.

PCOS or Polycystic Ovarian Syndrome is commonly seen in women in the age group of 15 years to 30 years. It can affect 6-18% of adolescent girls and approximately 8-13% of young women worldwide. PCOS in India is widely present based on vast diversity and socioeconomic conditions. It can range anywhere from 3.7% to 22.5%.

Clinical presentation, laboratory evaluation, diagnostic criteria, and treatment of PCOS differ between adolescent girls and adult women. Adolescent girls (10 to19 years) pose a challenging situation due to an overlap of normal pubertal development with adult diagnostic criteria. PCOS can influence reproductive health, metabolic health, cardiovascular health, and emotional well-being. The implications of PCOS in adolescent girls can extend well into adulthood. They can lead to long-term complications, such as hypertension, Type 2 diabetes mellitus, infertility, diabetes during pregnancy, premature labor, recurrent miscarriages, cancer of the endometrium (the lining of the uterus) and psychosocial issues of poor self-esteem, body image issues, depression, anxiety and eating disorders. Women with PCOS and the associated complications are suspected to pose an additional risk factor for COVID-19 infection.

Girls who can be at risk for PCOS in the adolescent period:

• Born with low birth weight.
• Born with low birth weight and rapid weight gain in early childhood years.
• Born with excess birth weight.
• Family history of PCOS in mother or close female relatives and diabetes mellitus.
• Significant weight gain is based on Body Mass Index (BMI) criteria. This defines overweight as 23rd adult equivalent BMI (as against 25th) and obesity as 27th adult equivalent BMI (as against 30th) for Asians. Obesity triggers the underlying process for PCOS and adds to the risk for cardiac and psychosocial complications.
• Lean children (it’s a common myth that lean girls cannot have PCOS) with features of hirsutism (excess body hair distributed in a male pattern area such as sidelocks, upper lip, and chin) or balding or severe acne (pimples) not responding to treatment.
• No onset of the menstrual cycle until 15 years of age.
• Irregular menstrual cycles as defined after one year of its onset:

1. Between 1-3 years of onset, if the interval between cycles is less than 21 days or more than 45 days.
2. Beyond three years of onset, if the interval between cycles is less than 21 days or more than 35 days or if there are less than eight cycles in a year.
3. Interval duration of more than three months for anyone cycle.

It is important to note the following:

• A belief that the menstrual cycle can remain irregular in adolescents and may normalize after marriage can lead to underdiagnosis or delayed diagnosis.
• It is essential to differentiate PCOS from other conditions that mimic the presentation to avoid misdiagnosis as evaluation, management and the future outcome can differ.
• Ultrasonographic criteria in adolescent girls are less defined and can be suggestive (an ovarian volume >12 ccs) but not confirmatory. These criteria considered in isolation can lead to overdiagnosis and mismanagement.

Early identification is possible in adolescent girls with periodic growth monitoring (weight, height and BMI after five years of age), use of growth charts for understanding change in BMI, and an understanding of red flag signs of BMI values, irregularities in menstrual cycles and unusual body hair patterns with or without severe acne.

Timely referral to a specialist, Pediatric and Adolescent Endocrinologist, is a must to prevent long-term morbidities, as mentioned before. Management of PCOS ideally requires a multidisciplinary care team comprising a Pediatrician, Pediatric and Adolescent Endocrinologist, a Gynecologist with an interest in Adolescent Health, a Nutritionist, a Child and Adolescent Psychologist and Pediatric Dermatologist.

Lifestyle modification plays an important role besides other individually tailored treatment modalities. These adolescent girls may undergo a revisit of diagnosis at a later age, nearly eight years after the onset of menstrual cycles, to understand its implications in adulthood.

Dr. Ruchi Parikh, Consultant – Endocrinology – Paediatric, SRCC Children’s Hospital, Mumbai.