A Review of The Assessment and Management of Polycystic Ovary Syndrome in Adolescents

Alexsia Priolo, ND

Abstract

Polycystic ovary syndrome (PCOS) affects up to 13% of adolescent girls, but diagnosing and managing it during this developmental stage presents unique challenges. In this in-depth clinical review, Dr. Alexsia Priolo breaks down the updated 2023 ASRM guidelines for adolescent PCOS diagnosis, while addressing the condition’s hormonal, metabolic, emotional, and reproductive impacts.

From cycle irregularity and androgen excess to body image, disordered eating, and future fertility, this article provides a comprehensive naturopathic framework for supporting teens with PCOS. Key areas of focus include lifestyle counseling, mental health screening, and evidence-informed use of supplements such as myo-inositol, NAC, and vitamin D.

A must-read for NDs seeking a patient-centered, age-appropriate, and clinically current approach to this increasingly common endocrine disorder.

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Introduction

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in women of reproductive age, impacting people across their lifespan from adolescence (between 10-19 years of age) throughout menopause.¹ Depending on the criteria used to diagnose PCOS, between 8-13% of adolescent girls are impacted by this condition.²

While the pathophysiology of PCOS is not entirely understood, there are certain fetal factors that are associated with an increased risk of PCOS in adolescent girls, including macrosomia (>4000g at birth) and low birth weight (<2500g at birth), born to mothers with excess body weight. Risk factors in adolescence include: premature puberty and metabolic syndrome.³ 

Modified Criteria in Diagnosing Adolescents with PCOS

In 2023, the American Society for Reproductive Medicine (ASRM) released updated guidelines for the assessment of PCOS. When diagnosing PCOS in adults, two of three Rotterdam criteria need to be met, which include:¹

1. Irregular cycles and ovulatory dysfunction
2. Biochemical/clinical hyperandrogenism
3. Polycystic ovarian morphology (PCOM) on ultrasound and/or elevated Anti-Müllerian Hormone (AMH)

However, diagnosing PCOS in adolescents is slightly different compared to their adult counterparts. The only criteria required for diagnosis are irregular periods and hyperandrogenism. Ultrasound and serum AMH are not recommended as the hypothalamic-pituitary-ovarian axis is not yet mature, and the criteria for PCOM are not available.⁴ The third criterion, however, can be utilized 8 years post-menarche for diagnosis. 

Irregular cycles are normal in the first year of an adolescent’s cycle, as it is part of the pubertal transition. This means that the time to diagnosis may take at least one year after menarche. Following the first year, irregular periods are defined in a number of ways, as seen in Table 1. It may take 2-3 years post-menarche for an adolescent to achieve cycle regularity.⁵  Alternatively, if the adolescent has not experienced their cycle by the age of 15 or more than 3 years after breast development, this satisfies the first criterion.  

Table 1: Irregular cycles during adolescence¹

Time Post Menarche	Cycle length
1 to <3 years	<21 days or >45 days
3 years	<21 days or >35 days, or <8 cycles per year
1 year	>90 days for any one cycle

When assessing clinical signs of hyperandrogenism, Naturopathic Doctors should perform a physical exam that includes an assessment of severe acne and hirsutism. Although acne affects 85% of people between the ages of 12 and 25, it is an incredibly common feature of PCOS.⁶ Severe acne is typically considered to be ≥10 comedonal lesions and responds poorly to topical medication.^5,7 Moreover, in people with hirsutism, acne most commonly presents on the chin, jawlines, cheeks, and trunk.⁷ 

While the modified Ferriman Gallwey score can be used in adolescents, and a score of ≥4-6 is indicative of hirsutism, hirsutism in adolescents is less common as hair becomes increasingly thick and coarse with long-term androgen exposure.⁶ When assessing blood work, it’s important to be mindful that serum androgen levels reach those of adults by the age of 12-15 years, and total testosterone concentrations should be >55ng/dL (1.91 nmol/L).^1,8 

Adolescents are considered “at risk” for a PCOS diagnosis if they meet only one of the two criteria required for a PCOS diagnosis, and future evaluation should occur in these situations.¹ 

Additional Testing to Consider

While not diagnostic criteria, insulin resistance, hyperinsulinemia, and obesity are predominant features of PCOS. Because of these comorbidities, the ASRM recommends that blood sugar levels should also be tested.¹ Naturopathic doctors should consider requisitioning a 75g oral glucose tolerance test, fasting plasma glucose, and HbA1c every 1-3 years, as well as measuring blood pressure and lipid levels periodically.^5,8

Prevalence of Mood Disorders

Mood disorders are also prevalent in adolescents diagnosed with PCOS, as they are 2.4x more likely to experience depression, compared to adolescents without PCOS.⁹ This is an added layer of complications in this vulnerable time, due to changes in their hormones, body and brain development, and social environment.¹⁰ A diagnosis of PCOS can further impact their mood, body image, and self-esteem, as one of the features necessary for this diagnosis is male-pattern hair growth and acne.¹⁰ Regular screening for anxiety and depression should frequently occur in this population, using validated questionnaires like the PHQ-9 and the GAD-7.⁴ In addition, the health-related quality of life 20-item questionnaire (APQ-20) can be used to identify adolescents with poor quality of life. Referral to a mental-health practitioner should also be considered if treatment is indicated.¹⁰ 

The Impacts of Body Image and Eating Disorders

Research has shown that in women with PCOS, the risk of obesity and hirsutism is associated with eating disorders.³ A 2020 study utilized a screening questionnaire called the Eating Attitudes Test-26 (EAT-26) in this population and found that patients with a disordered eating attitude (DEA) were 7x more likely to be overweight or obese, compared to those without DEA (OR = 6.88, p = 0.02)³. Moreover, this relationship was higher when controlling for age (OR = 14.74, p = 0.003).³ With this relationship in mind, it would be appropriate for Naturopathic Doctors to screen for eating disorders in this population.  

Traditional Management of PCOS in Adolescents

Combined Oral Contraceptive Pill (COCP)

The ASRM guidelines state that the COCP could be considered for the treatment of hirsutism and anovulation.⁴ COCPs with 35μg ethinyl estradiol (EE) plus cyproterone acetate preparations are considered a second-line therapy, but their increased thrombotic risk needs to be considered before use.⁴ Bone mineralization may also be reduced with the use of COCPs, but less so when 35μg EE is used compared to lower doses.¹¹ In people who experience migraine with aura, estrogen-containing contraception is an absolute contraindication.¹¹ 

Anti-androgen Medications

If COCPs or cosmetic therapies do not substantially manage an adolescent’s hirsutism, anti-androgen medications could be used in combination with COCPs.⁴ While evidence is limited, the ASRM mentions that Spironolactone appears to have a lower risk of adverse effects compared to other anti-androgen medications.⁴ 

Metformin

While evidence is limited in adolescents, the ASRM states that metformin could be considered for cycle regulation in those at risk or diagnosed with PCOS.⁴ Although metformin appears to be safe when used long-term, Vitamin B12 levels should be monitored.⁴ 

Naturopathic Management of PCOS in Adolescents

Managing PCOS in adolescents may be challenging, yet should focus on improving quality of life, improving their hormonal and metabolic status, and reducing their risk of developing future complications. The prescribed components of a treatment plan should be a shared decision between the adolescent, their parent(s)/guardian(s), and the Naturopathic Doctor.¹ Moreover, the treatment plan should be culturally appropriate and reflective of the adolescent’s characteristics, preferences, and values.¹ 

Diet, Exercise, and Weight Loss

While diet and lifestyle recommendations are first-line recommendations for everyone with PCOS, Naturopathic doctors should consider that, regardless of weight, disordered eating and eating disorders are higher in the population.¹ 

Weight stigma is also common in those with PCOS. Suppose weight loss is a treatment goal for adolescents with PCOS and obesity. In that case, caloric reduction can be personalized, and a reduction of 500-700 kcal/day should be considered as a starting point. However, eating behaviours should be monitored closely.⁷ Cognitive behavioural therapy and Acceptance and Commitment Therapy are shown to be effective in addressing body-related concerns in this population, and referrals to appropriate practitioners should be considered.⁷ 

The ASRM recommends that adolescents aim for 60 minutes of moderate to vigorous intensity exercise per day, which includes activities that strengthen bone and muscle, performed at least three times per week.¹ Examples include walking or cycling, work, household chores, playing games, and sports or planned exercise. 

A study of school girls who participated in a 12-week aerobic exercise program (3 times per week for 60 minutes) demonstrated statistically significant decreases in testosterone, body weight, BMI, and various lipid levels.¹² 

While good evidence exists for the recommendation of exercise, no one particular type of diet is recommended over another for the management of PCOS. Dietary patterns that support the consumption of high fibre, low glycemic carbohydrates and promote overall cardiometabolic health include the Mediterranean and Dash diets.⁷ 

Supplementation

A variety of supplements have been studied in adults with PCOS; however, no clear recommendations exist for adolescents. 

Myo-inositol: While dosing and benefit are uncertain in adolescents¹, myo-inositol is commonly used in adults. Myo-inositol positively impacts insulin signalling, cycle regularity, and androgens (free and total testosterone, sex-hormone binding globulin).¹³ Dosing of myo-inositol in adults is 4g per day.¹⁴

Vitamin D. Recommendations for vitamin D supplementation in adolescents are sparse. Vitamin D is commonly prescribed as it improves some blood sugar parameters and HOMA-IR, some lipid parameters, and total testosterone. The effects may be more pronounced in those with a Vitamin D deficiency.¹⁵  One study looked at vitamin D levels in young women with PCOS (ages 14-22). While their vitamin D levels were lower, they were not statistically significant compared to the control group.¹⁶ In adults with PCOS, dosing is based on reaching sufficient Vitamin D levels (≥75 nmol/L).¹⁷  

N-Acetyl Cysteine (NAC): Although evidence is limited in adolescents, NAC has been used in adults due to its ability to positively impact blood glucose, notably improving insulin sensitivity, lipid profile, hormone levels like free testosterone, improving ovulation, and pregnancy outcomes.¹⁸ Dosing NAC depends on the treatment protocol, although the minimum effective dose is between 1200-1800mg per day.¹⁴ 

Sleep

Sleep issues are common in this population. In adolescents specifically, they have increased sleep onset latency, poorer sleep efficiency, and more daytime sleepiness compared to their peers.⁷ If sleep disordered breathing is a concern, in particular for overweight or obese patients, polysomnography is the gold standard to assess for obstructive sleep apnea.⁷ 

Transitional Care Future Fertility Perspectives

As adolescents embark on adulthood, those with PCOS and those “at risk” should transition from pediatric to adult care with a comprehensive plan, as they may have different priorities for their healthcare than their parent(s)/guardian(s)⁷. Prior to transition, it is imperative for Naturopathic Doctors to educate their patients about potential comorbidities so they can assume the responsibility for self-care if necessary.⁴ 

Reproductive planning may be necessary for this population as they reach adulthood. A 2024 study showed that adolescents with PCOS desire to have future biological children and have higher fertility-related concerns compared to controls without PCOS (Salah 2024). They should be informed that they may experience difficulty conceiving, but may successfully conceive a child without assisted reproductive technology.⁷ 

Naturopathic doctors are well-positioned to educate their patients about PCOS and fertility. Timely questions about their desire to have children in the future may ensure comprehensive awareness, provide better reproductive outcomes, and improve overall quality of life.¹⁹ 

Conclusion

Utilizing the updated 2023 ASRM guidelines in the diagnosis of PCOS in adolescents, Naturopathic Doctors are well-positioned to assess and manage this population with first-line recommendations of diet and lifestyle changes. It is crucial for Naturopathic Doctors to regularly assess mood and disordered eating behaviours in adolescents and create a treatment plan that aligns with their values. As adolescents approach adulthood, Naturopathic Doctors should educate their patients about the comorbidities of PCOS in case of patient drop-off, especially as it pertains to their future fertility.

References

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