Pediatric emergency medicine trisk 1010 1010
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the Stein–Leventhal syndrome). Although hirsutism and obesity are classic
features of PCOS, many adolescent patients with oligomenorrhea and the
endocrinologic abnormalities of PCOS lack one or both of these signs. Patients
with PCOS are a heterogeneous group with varying combinations of these
features. An adolescent with PCOS may present to the ED with heavy abnormal
uterine bleeding after several months of amenorrhea due to anovulatory cycles
(see Chapter 79 Vaginal Bleeding ). Few adolescents with clinical and
biochemical evidence of PCOS have palpably enlarged ovaries, and their
hyperandrogenism is typically mild. There are no distinct criteria for the
diagnosis of PCOS in adolescents and currently, adolescents are diagnosed
according to adult standards. Although several societies have published criteria
guidelines for PCOS in adult women, the 2003 Rotterdam and the 2009 Androgen
Excess Society’s criteria are considered more applicable for adolescents. Table
51.2 provides both 2003 Rotterdam and 2009 Androgen Excess Society’s criteria
for the diagnosis of PCOS. In 2012, a PCOS consensus workshop in Amsterdam
reevaluated the Rotterdam criteria specifically for diagnosing adolescents. The
expert consensus was as follows: all three criteria should hold true to diagnose an
adolescent, oligomenorrhea or amenorrhea should be present for at least 2 years
after menarche (or primary amenorrhea at 16 years old), and hyperandrogenemia
should be biochemically rather than clinically diagnosed. Similarly, the Pediatric
Endocrine Society (PES) published an expert consensus in 2015 regarding
diagnosis of PCOS in teenagers warning about pitfalls of overdiagnosis given the
overlap of PCOS criteria in adults with normal pubertal development.
The pathophysiologic basis for PCOS is incompletely understood. However,
the principal endocrinologic abnormalities involved are chronic anovulation,
ovarian hyperandrogenism, and, in many affected patients, insulin resistance.
Increased androgen production from the ovaries, adrenal glands, and peripheral
conversion and high levels of free estrogen interferes with the hypothalamic–
pituitary–ovarian feedback system, causing irregular menses. PCOS has been
associated with an increased risk of metabolic dysfunction which can start during
puberty and lead to significant morbidity and mortality.
