October 2011 Issue
Recognize Polycystic Ovary Syndrome in Teens — The Importance of Early Detection and Treatment
By Angela Grassi, MS, RD, LDN
Vol. 13 No. 10 P. 58
At the age of 16, Jenny had had difficulty managing her weight since entering puberty at an early age. She craved carbohydrates “all the time,” even after eating dinner, and complained that her weight had been increasing at a rate of 1 to 2 lbs per month over the past year. Jenny had seen a dermatologist for acne on her chin after never having had an acne problem before. She also had visited her primary care physician for dizziness, feeling shaky, and irregular menses. Her doctor started her on a birth control pill to regulate her periods, diagnosed Jenny with hypoglycemia, and encouraged her to follow a South Beach-type diet to moderate her blood sugar and help her lose weight.
Twelve years later, Jenny went off her birth control medication because she was ready to start a family. Her periods never returned. Despite her efforts, Jenny couldn’t lose weight and struggled with severe hypoglycemia and had elevated serum triglycerides. Jenny saw a reproductive endocrinologist who diagnosed her with polycystic ovarian syndrome (PCOS).
PCOS is the most common endocrine disorder in women, affecting 5% to 10% of those of reproductive age.1 Recognized in 1935 by Stein and Leventhal for its relationship to menstrual disturbances, PCOS is characterized by high levels of androgens (male hormones such as testosterone) from the ovary and is associated with insulin resistance. Small cysts called poly cysts usually, but not always, surround the ovaries and appear like a strand of pearls on an ultrasound examination. The cysts develop from hormonal imbalances.
Additional symptoms caused by the overproduction of androgens include excessive hair growth on the face and body (hirsutism), alopecia, acne, skin problems, and irregular or absent periods. Most women with PCOS have some level of insulin resistance and will experience weight gain in the abdomen, have difficulties losing weight, feel intense cravings for carbohydrates, and experience hypoglycemic episodes. Many of these symptoms are commonly experienced during adolescence and easily can be overlooked. The vast array of symptoms, and the fact that not every woman may recognize them, can make PCOS difficult to diagnose. Because of their ongoing relationships with their adolescent patients, dietitians may help assemble the pieces of the puzzle by recognizing the symptoms and encouraging further diagnostic testing. (See Table 1 for more information on whom to suspect may have PCOS.)
The exact cause of PCOS is unknown; however, researchers are seeking the reasons it develops. There appears to be a strong genetic component.2 Researchers have found polycystic-appearing ovaries in young girls even before puberty.3 Some theories suggest that women may develop PCOS from being exposed to high androgen levels in the womb.2
Signs and symptoms of PCOS usually appear at the onset of puberty when there’s a normal increase in insulin levels as part of human development. PCOS is linked to the development of chronic diseases later in life such as the metabolic syndrome type 2 diabetes, heart disease, hypertension, and endometrial cancer, so early recognition and treatment are critical to prevent these conditions. Because most adult women with PCOS aren’t diagnosed until after seeking help with infertility, early detection in adolescence could prevent financial and emotional hardships down the road. Many of the signs and symptoms of PCOS can be detrimental to a young woman’s body image, particularly weight gain, excessive hair growth on the face and body, dirty looking patches on the skin called acanthosis nigricans (all of which are clinical markers of hyperinsulinemia), and acne. Such symptoms can negatively impact the emotional health of adolescents at a time when self-image is developing. In addition, mood disorders are common among adolescent girls with PCOS.4 Such disorders typically stem from hormonal imbalances or struggles with body image. Not surprisingly, many girls with PCOS suffer from eating disorders as they attempt to manage their out-of-control weight gain, mood, and body image issues.
Currently there are no formal diagnostic criteria for PCOS, making it difficult to diagnose and compare studies. The most recent agreed-upon definition was developed by the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine in 2003. They define PCOS as manifestation of two of the three following:
• irregular periods (intervals of more than 40 days) or amenorrhea;
• clinical and/or biochemical signs of hyperandrogenism; and
• polycystic ovaries on a pelvic ultrasound, with exclusion of other causes.
These criteria may not be appropriate for all adolescents as some girls with PCOS may experience regular menses or not have cysts. Some physicians contend that an invasive pelvic ultrasound exam in young girls is unnecessary and even cruel. Although insulin resistance seems to be a hallmark feature of PCOS, insulin resistance isn’t currently part of the diagnostic criteria. Screening for abnormal glucose tolerance in adolescence is important because early treatment can prevent further metabolic consequences. According to a paper published in the February 2002 issue of Pediatric Research, the appearance of pubic hair in girls before the age of 8, called premature pubarche (PP), should be an early marker for PCOS due to the metabolic similarities of girls with PP and women with PCOS.
A client’s answers to the questions shown in Table 2 may suggest she has undiagnosed PCOS and that you should consider referral for diagnostic testing. Table 3 lists the common lab tests physicians order to help detect and monitor PCOS. Sometimes simply asking a client whether she’s ever been told by a healthcare provider that she’s had any abnormal lab results can suggest the possibility of PCOS. I once worked with a 15-year-old whom I suspected had PCOS because of her struggles with weight, acne, and irregular periods. When I asked her about abnormal lab results, she said she was told once that she has high testosterone levels but had never been diagnosed with PCOS. She had just been put on birth control pills to regulate her periods.
Treating PCOS in Teens
PCOS symptoms in adolescents can be alleviated with diet, exercise, and medications such as metformin. In the September 2004 Journal of Clinical Endocrinology and Metabolism, Ibanez and colleagues indicated that besides improvement in insulin sensitivity, metformin is a safe method to regulate menses, lower androgens, and improve cardiovascular health in adolescents with PCOS. Many people with PCOS who take metformin report reduced cravings for carbohydrates. In most people metformin is well tolerated with the main side effects (diarrhea, gas, and nausea) subsiding within two weeks. Patients need to be instructed that metformin isn’t a weight loss pill and that dietary changes and exercise are needed. Traditionally, oral contraceptives have been used to restore and regulate menstrual function and hormone levels as well as decrease acne and hirsutism. However, a study published in the November 2008 issue of the Journal of Clinical Endocrinology and Metabolism found that oral contraceptives increased both c-reactive protein and LDL cholesterol levels in obese adolescents with PCOS, making metformin the more popular drug of choice for this population. Androgen-lowering medications such as spironolactone or flutamide also may be prescribed but usually take several months to produce results of reduced body hair growth.5
The main goals of treatment for an adolescent with PCOS are to regulate menstrual function, reduce androgen and insulin levels, and improve dermatological symptoms. As insulin levels are reduced, often androgen levels will be lowered and menses will become more regulated. Evidence suggests that a moderate weight loss of 5% to 7% of total body weight may significantly improve symptoms and regulate menstrual function.5,6
Dietary and Lifestyle Management
Diet and lifestyle changes are usually the first line of approach for treating young girls with PCOS. According to The Dietitian’s Guide to Polycystic Ovary Syndrome, the optimal diet composition is still unclear for PCOS patients, although the type and amount of carbohydrate appears to matter. A study published last year in the American Journal of Clinical Nutrition examined the effects of a low glycemic index diet compared with a conventional low-fat, high-fiber diet on women with PCOS. They found that women who followed a low glycemic index diet had better insulin sensitivity and more menstrual regularity. Those findings support a large study published in The Journal of the American Medical Association in 2007 that reported a low glycemic load diet facilitates greater weight loss in overweight individuals with high insulin levels. Research has indicated that very low-carbohydrate diets (less than 30% of total calories) aren’t superior to other diet compositions for women with the syndrome. Dietitians who counsel women with PCOS report that their clients crave carbohydrates more than people without PCOS. Some adolescents may find severely limiting carbohydrates too difficult to achieve, which could contribute to binge eating and weight gain in the long term.
Omega-3 fatty acids—including alpha-linolenic acid, EPA, and DHA—are beneficial to women with PCOS because they can reduce insulin and triglyceride levels and aid in regulating hormone levels.7 Adolescent patients should be advised on ways to incorporate foods rich in all forms of omega-3 fatty acids into their diets. Such foods include fatty types of fish or fish oil supplements, nuts, flax, and olive and canola oils.
Adolescents with PCOS need education about low glycemic index foods, appropriate portion sizes, and ways to reduce their intake of simple sugars. Since many teens tend to skip meals, dietitians need to stress the importance of eating every 3 to 4 hours and including protein with meals and snacks to help manage blood sugar levels and prevent hypoglycemia. Provide examples of healthier food choices for when they eat out with friends. Both the patient and her parents need to be educated about PCOS and insulin resistance and the connection with symptoms, including weight gain. Insulin is a very powerful growth hormone that promotes weight gain, sometimes despite diet and exercise efforts. This information could be validating to a young girl who has felt blamed for her weight gain or failed attempts to control weight.
Encourage physical activity for girls with PCOS because exercise can help lower insulin levels and manage weight. Keep in mind that adolescents struggle with body image and may resist exercise; recommend activities that are size appropriate and comfortable to participate in with excess abdominal weight.
Though unproven, it seems that women with PCOS tend to build muscle more quickly than others, possibly due to having higher testosterone levels. Some women with PCOS find weight training more enjoyable than aerobic exercise. It’s easier to do and feeling stronger often improves their body image.
PCOS is a common and complicated endocrine disorder that often goes undiagnosed. Formal diagnostic criteria and more evidence-based dietary guidelines are needed. Adolescents with PCOS experience many symptoms that can have a significant and long-term impact on their self-esteem and body image, and they’re at a higher risk for developing an eating disorder. The syndrome puts people at risk for chronic diseases and infertility later in life, making early recognition and treatment key. Dietitians should screen adolescent clients they suspect may have PCOS and recommend further diagnostic testing. If a client is diagnosed with the disorder, RDs should provide proper dietary and lifestyle management.
— Angela Grassi, MS, RD, LDN, is the author of The Dietitian’s Guide to Polycystic Ovary Syndrome and The PCOS Workbook: Your Guide to Complete Physical and Emotional Health. She is the founder of The PCOS Nutrition Center where she provides nutrition counseling to women with PCOS.
1. Azziz R, Woods KS, Reyna R, Key TJ, Knochenhauer ES, Yildiz BO. The prevalence and features of the polycystic ovary syndrome in an unselected population. J Clin Endocrinol Metab. 2004;89(6):2745-2749.
2. Xita N, Tsatsoulis A. Fetal programming of polycystic ovary syndrome by androgen excess: Evidence from experimental, clinical, and genetic association studies. J Clin Endocrinol Metab. 2006;91(5):1660-1666.
3. Bridges NA, Cooke A, Healy MJ, Hindmarsh PC, Brook CG. Standards for ovarian volume in childhood and puberty. Fertil Steril. 1993;60(3):456-460.
4. Himelein MJ, Thatcher SS. Depression and body image among women with polycystic ovary syndrome. J Health Psych. 2006;11(4):613-625.
5. Salmi DJ, Zisser HC, Jovanovic L. Screening for and treatment of polycystic ovary syndrome in teenagers. Exp Biol Med. 2004;229(5):369-377.
6. Marsh K, Brand-Miller J. The optimal diet for women with polycystic ovary syndrome? Br J Nutr. 2005;94(2):154-165.
7. Bhathena SJ. Relationship between fatty acids and the endocrine system. Biofactors. 2000;13(1-4):35-39.
Table 1. Whom to suspect may have PCOS:
• Family history of PCOS, especially mother, sister, or grandmother
• Excessive abdominal weight (Waist circumference > 35 inches)
• Difficulties losing weight despite diet and exercise
• Heavy, irregular (more than 40 days or frequent bleeding) or absent menses
• Intensive carbohydrate cravings
• Hypoglycemic episodes
• Problems with excessive hair growth on face
• Hair loss from head
• Premature pubarche
Table 2. Questions to ask a patient suspected with PCOS:
“Tell me what your periods are like. Are they heavy, irregular, etc?”
“Do you ever feel lightheadedness, dizziness, or irritability that gets better when you eat?”
“Have you ever been told by your physician or healthcare provider that you have any abnormal lab values?”
“Do you struggle with excessive facial hair?”
“What types of foods do you crave and when do you crave them?
“Do you have dry/rough elbows or any dark patches that look dirty on your body?”
Table 3. Tests used to diagnose and monitor PCOS:
• Luteinizing hormone (LH)
• Follicle-stimulating hormone (FSH)
• Dehydroepiandrosterone (DHEA) sulfate
• Total and free testosterone
• Fasting glucose
• Fasting insulin (usually part of oral glucose tolerance test)
• Transvaginal pelvic ultrasound