From a healthcare professional: I have a teenage girl with insulin resistance and hyperandrogenism. What should I rule out before diagnosing polycystic ovary syndrome (PCOS)?
Polycystic Ovary Syndrome (PCOS) is a metabolic disorder characterized by insulin resistance, hyperandrogenemia and in some cases polycystic ovaries. The prevalence of type 2 diabetes is 10 times as high among young women with PCOS as among those without, and impaired glucose tolerance or overt type 2 diabetes develops by the age of 30 in 30-50 percent of obese women with PCOS.
For diagnostic purposes, a teen who has had menarche for two years must have two of the following three findings:
- Fewer than nine periods per year or secondary amenorrhea (3 months without a period)
- Signs of hirsutism (hirsute hair distribution, acne) or clinical hyperandrogenemia
- Polycystic ovaries
The hyperinsulinism stimulates ovarian as well as adrenal androgen production. PCOS is a diagnosis of exclusion.
Thyroid, prolactin and FSH levels should be normal. Testosterone and DHEAS may be mildly elevated. Ovarian and adrenal tumors need to be excluded if testosterone>150ng/dl or DHEAS>700mcg/dl. If DHEAS is elevated, obtain an am 17 hydroxyprogesterone to rule out congenital adrenal hyperplasia.
Cushing's syndrome needs to be ruled out if hypertension, short stature and striae are present.
A course of provera at 10 mg /day for 7 days is indicated if a patient has not had a period for greater than 3 months.
Weight loss and increased physical activity induces a decrease in insulin resistance and androgenic activity. Refer the patient to weight management.
If the patient continues to have symptoms of hyperandrogenemia, menstrual irregularity or glucose intolerance after six months of treatment the following treatment options are available:
- Metformin will lower insulin levels, thus causing a decrease in androgen levels, improving menstrual pattern and reducing hirsutism and acne. Side effects include nausea, mild abdominal discomfort and rarely lactic acidosis.
Do not start metformin, if creatinine is elevated. Begin with 500 mg with dinner for the first two weeks and gradually increase to a dose of between 750 or 1000 mg bid. If 1000 mg bid is not tolerated, then decrease to 750 mg bid. Taking metformin with meals will decrease the nausea. Women desiring contraception could be given an oral contraceptive agent in addition to metformin.
- Oral contraceptive pills are also effective in symptom control, but they do not improve underlying insulin resistance. OCP with estrogen and nonandrogenic progestins (void of norgestimate and desogetrel-e.g. Sprintec, Necon) will regulate periods and decrease hirsutism but not effect insulin levels. They may adversely affect glucose and coagulability. They may be used with metformin.
- Yasmin, an oral contraceptive with antiandrogen effects, will regulate periods, decrease hirsutism, lower androgen levels, but will not affect insulin levels. Yasmin may also be used with metformin.