TORONTO — Physicians who are hasty to do a lab work-up on teenage girls with irregular periods may find themselves chasing a false diagnosis of polycystic ovary syndrome.
“The biggest thing we’re asked to face as pediatric gynecologists is teenagers with dysfunctional uterine bleeding. But it’s absolutely normal to have abnormal periods. We should not panic, and we should not overtreat,” Dr. Jay Spence said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.
Ovarian hyperandrogenism is a normal transient stage in teens that usually resolves within a few years of the start of menarche, said Dr. Spence, who is professor of ob.gyn. at the University of Ottawa.
Polycystic ovary syndrome (PCOS) is a diagnosis that should be made very reticently early on, he said.
Physicians who see teenagers with irregular periods should be aware that the first 2 years of menstrual periods are characterized by wide swings in the length of menstrual cycles. Studies have shown a range of around 18-83 days between periods in the first year of menarche, compared with a range of 19-42 days by the seventh year of menarche.
From 2 to 4 years after the first period the intervals should begin to normalize, and the periods should become more predictable and less heavy, he said in an interview.
Dr. Spence strongly advises against drawing blood early in the investigation because early postmenarchal endocrine patterns look misleadingly like PCOS; they include elevated testosterone, androstenedione, dehydroepiandrosterone, and luteinizing hormone, as well as decreased sex hormone-binding globulin.
“Most of the time I would advise people not to do the blood work. There is a tendency to overinvestigate when you should just be a little more patient and give it time,” he said.
“Occasionally, I’ll see a kid in her early gynecologic years with irregular periods and nothing else except this kind of PCOS-like lab work,” agreed Dr. Kristi Mulchahey, a pediatric and adolescent gynecologist in Atlanta. “In that kind of situation I treat the irregular periods with the oral contraceptive pill and tell the parents that the child might have an androgen problem, but she is so young, that it’s too early to tell… and we [will] need to reassess when she’s older,” she said in an interview.
Anovulatory cycles are largely responsible for these symptoms: These cycles decrease from about 80% of cycles in the first menstrual year to about 20% in the fifth year.
Still, the incidence of PCOS is very, much population based. Although the syndrome occurs in about 2%-6% of the general population, it can be present in as many as 53% of teens who have persistent anovulation with no physiologic cause.
In a separate presentation at the meeting, Dr. Mulchahey said that there are definite cases of PCOS that are clearly evident, even in early adolescence. It is necessary to look out for those patients who have really marked hirsutism and obesity because they are the ones in whom the ovarian hyperandrogenism may not be transient, she said.
But seven in these patients, there is no way of telling which girls will have persistent problems, Dr. Spence said.
“It’s those patients with the more obvious signs that you will be more suspicious of. But you can’t make the diagnosis on any one test,” he said.
Even ultrasound, once used to visualize the classic PCOS ovarian cysts, is no longer helpful. “A lot of adolescent ovaries are full of cysts, similar to what we see in PCOS. And now we know that even a lot of normal women shave ovaries that look like PCOS,” Dr. Spence said.
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Source: International Medical News Group in association with The Gale Group and LookSmart.