Polycystic Ovary Syndrome in Pediatric Patients

Educational Objectives

The goal of this program is to polycystic ovary syndrome (PCOS) in the pediatric population. After hearing and assimilating this program, the clinicians will be able to:

1. Diagnose PCOS in the pediatric population.
2. Recommend appropriate treatment options for managing PCOS.

Summary

Polycystic ovary syndrome (PCOS): a complex, heterogeneous familial disorder characterized by chronic anovulation and hyperandrogenism; no definition is universally accepted; depending on diagnostic criteria, PCOS affects 6% to 30% of women; symptoms arise early in pubertal years, and timely intervention improves overall control, prevents comorbidities, and improves future fertility and quality of life

Diagnosis in adolescents: required diagnostic criteria include irregular or infrequent periods (eg, menstrual cycle >45 days in length, secondary amenorrhea with lack of a period for ≥3 mo, primary amenorrhea) and evidence of hyperandrogenism (eg, hirsutism, acne, male-pattern baldness); optional criteria include polycystic ovarian morphology (POM) and severe acne; criteria that should not be included are obesity, insulin resistance, hyperinsulinemia, certain biomarkers, and acanthosis nigricans; diagnosis can be challenging because irregular periods are normal in early adolescence; usefulness of ultrasonography (USG) in diagnosing PCOS in teens is limited; POM can be normal in adolescents, and USG alone does not confirm PCOS; persistent POM may predict future PCOS

Treating PCOS: spironolactone — cannot be used to regulate periods and is not recommended; lifestyle improvements (eg, diet, exercise) — primary treatments for PCOS, especially in overweight or obese individuals; combined hormonal contraceptives (eg, pills, patches, vaginal rings) — effective in addressing PCOS symptoms like hirsutism and acne; potential risks include increased triglycerides and thromboembolism risk; contraindications include a history of migraine headaches with aura, personal history of deep vein thrombosis, known inherited thrombophilia, and antiphospholipid antibody syndrome; a family history of stroke, heart attacks, or blood clots before the age of 50 yr is also a red flag, prompting further investigation, with focus on estradiol components

Oral contraceptive pills: commonly used for treating PCOS; third- and fourth-generation pills — eg, ethinyl estradiol and desogestrel (eg, Apri, Azurette, Cyred), ethinyl estradiol and norgestimate (eg, Estarylla, Femynor, Sprintec), and drospirenone and ethinyl estradiol (eg, Gianvi, Loryna, Yasmin) can be effective; while preferences exist, no specific combination of estrogen and progestin has been proven superior; progestin-only options — drospirenone (Slynd) is a new medication with antiandrogenic properties that offers longer-lasting effects and helps regulate periods; medroxyprogesterone acetate (Provera) can be used for those who prefer not to take a daily pill (triggers a withdrawal bleed; recommended every 3 mo if no spontaneous period occurs)

Intrauterine devices: eg, Mirena, Kyleena, Liletta; recommended for PCOS patients; maintain a thin uterine lining and provide low-maintenance, effective birth control with minimal systemic side effect

Spironolactone: an option for treating PCOS-related hirsutism and acne; can take 3 to 6 mo before results are noticeable; however, it may cause hyperkalemia or menstrual irregularities in ≤20% of patients and has rare teratogenic effects; effective birth control is essential for sexually active patients using spironolactone

Other treatment options: cosmetic hair removal — options for patients with PCOS include waxing, plucking, shaving, bleaching, and depilatory creams; laser hair removal is an effective choice (the US Food and Drug Administration has approved some home devices); for those not achieving desired results with spironolactone, laser hair removal is a complementary option; topical eflornithine (Vaniqa) — can be used alongside other treatments, but topical finasteride is not recommended

Fertility: unpredictable ovulatory cycles with PCOS can cause fertility issues; medications are available to induce ovulation; women with PCOS can become pregnant

Endometrial cancer: mainly a concern for adults with PCOS because of the unopposed estrogen state; risk is increased for adult women with PCOS but is low (≈5%) in adolescents; however, protecting uterine health and understanding treatment risks and benefits are important for adolescents

Readings

Armanini D, Andrisani A, Bordin L, et al. Spironolactone in the treatment of polycystic ovary syndrome. Expert Opin Pharmacother. 2016;17:1713-1715; Lanzo E, Monge M, Trent M. Diagnosis and management of polycystic ovary syndrome in adolescent girls. Pediatr Annals. 2015;44:e223-230; Pasquali R. Contemporary approaches to the management of polycystic ovary syndrome. Ther Adv Endocrinol Metab. 2018;9(4):123-134. doi:10.1177/2042018818756790; Rosen MW, Tasset J, Kobernik EK, et al. Risk factors for endometrial cancer or hyperplasia in adolescents and women 25 years old or younger. J Pediatr Adolesc Gynecol.2019;3:546-549; Rosenfield RL. Identifying children at risk for polycystic ovary syndrome. J Clin Endocrinol Metabol. 2007;92:787-796; Trent M, Gordon CM. Diagnosis and management of polycystic ovary syndrome in adolescents. Pediatr. 2020;145(Supplement_2):S210-218.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Parks was recorded at the 46th Annual Melvin L. Cohen MD Pediatric Update Conference, held March 6-9, 2023, in Scottsdale, AZ, and presented by Phoenix Children’s Hospital. For more information about upcoming CME activities from this presenter, please visit https://www.phoenixchildrens.org/continuing-medical-education. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

PD700102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.