Original Study

Do Different Diagnostic Criteria Impact Polycystic Ovary

Syndrome Diagnosis for Adolescents?
€ l MD, PhD *, Yasemin Du
Sinem Akgu € zçeker MD, Nuray Kanbur MD, Orhan Derman MD
Division of Adolescent Medicine, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey

a b s t r a c t
Study Objective: Although early diagnosis of polycystic ovary syndrome (PCOS) in adolescents might allow for earlier treatment and
prevention of chronic disorders, incorrect or premature diagnosis carries risks of unnecessary treatment and psychological distress. There
is no consensus concerning which diagnostic criteria to use for adolescents and current criteria vary. The objective of this study was to
determine whether using different diagnostic criteria will affect PCOS diagnosis in adolescents.
Design, Setting, and Participants: Fifty-two patients aged 13-18 years with at least 2 of the following criteria were included in the study: (1)
oligomenorrhea or amenorrhea; (2) Clinical or biochemical hyperandrogenism; and (3) polycystic ovaries on ultrasonography. Patients
were then categorized according to the 6 different criteria for PCOS. National Institutes of Health, Rotterdam criteria, Androgen Excess
Society, Amsterdam criteria, Endocrine Society criteria, and the Pediatric Endocrine Society criteria. The characteristics of adolescents who
were diagnosed with PCOS were also evaluated.
Interventions and Main Outcome Measures: Forty-one patients out of 52 (78.8%) received diagnosis with National Institutes of Health and
Endocrine Society criteria, all with Rotterdam criteria, 45/52 (86.5%) with Androgen Excess Society criteria, 36/52 (69.2%) with Amsterdam
criteria and 34/52 (65.4%) with the Pediatric Endocrine Society criteria.
Results and Conclusion: This study shows that the choice of guideline used does have a great effect on whether an adolescent received the
PCOS diagnosis or not. For physicians using the broader criteria, care should be taken to ensure the patient does not receive diagnosis
because of the physiological changes seen during puberty, which might mimic PCOS. For those using stricter criteria, close monitoring of
patients who do not receive diagnosis is necessary to prevent chronic complications.
Key Words: Adolescents, Diagnostic criteria, Polycystic ovary syndrome

Introduction regular menstrual cycles or those with no hyperandrogenism

Currently, there are different criteria proposed for the
diagnosis of polycystic ovary syndrome (PCOS). Although all
require the exclusion of other causes of hyperandrogenism,
certain differences are found in each guideline and no
definite consensus has been made concerning the diagnosis
in adolescents.1
The first criteria were introduced in 1990 by the National
Institutes of Health (NIH). The consensus reached by the
NIH concluded that PCOS diagnosis could be made in a
patient with clinical and/or biochemical hyperandrogenism
associated with a menstrual irregularity.2
After the NIH criteria, the European Society of Human
Reproduction and Embryology/American Society for Repro-
ductive Medicine criteria were developed, which are often
called the Rotterdam criteria, this guideline includes poly-
cystic ovary morphology (PCOM) on ultrasonography to the
other 2 NIH criteria but allows for combination of any 2 of the
3 findings of hyperandrogenism, menstrual irregularity, and
PCOM. These guidelines added 2 new phenotypes to those
described by the NIH Consensus because women with
The authors indicate no conflicts of interest.
* Address correspondence to: Sinem Akgu € l, MD, PhD, Division of Adolescent
Medicine, Department of Pediatrics, Hacettepe University Faculty of Medicine,
Ankara 06100, Turkey; Phone 0312-3051160
E-mail address: sinemhusnu@gmail.com (S. Akgu € l).
1083-3188/$ - see front matter Ó 2017 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc.
https://doi.org/10.1016/j.jpag.2017.12.002
might receive diagnosis. So, according to the Rotterdam
phenotypic application models, individuals with all Rotter-
dam diagnostic criteria (hyperandrogenism, chronic anov-
ulation, and PCOM) are in group 1; with hyperandrogenism
and chronic anovulation are in group 2; with hyper-
androgenism and PCOM are in group 3; and with chronic
anovulation and PCOM are in group 4.3
However, this application model, especially for the group
of patients who do not have hyperandrogenism, led to
significant controversy. Thus, in 2006 the Androgen Excess
Society (AES) criteria were defined, the main difference
stated was that diagnosis required the presence of hyper-
androgenism, with the associated findings of either men-
strual irregularity and/or PCOM.4
The diagnosis of PCOS during adolescence is difficult
because many of the signs and symptoms of the syndrome
are also normal findings of pubertal development.5 It has
been argued that using the diagnostic criteria for adults
might cause overdiagnosis of the syndrome and none of the
3 guidelines described previously discussed the diagnosis in
the adolescent population.6 In 2012 at the European Society
of Human Reproduction and Embryology/American Society
for Reproductive Medicine-sponsored PCOS consensus
workshop held in Amsterdam, it was stated that criteria for
the diagnosis of PCOS in adolescents differ from those used
for adult women of reproductive age. These criteria argued
 € l et al. / J Pediatr Adolesc Gynecol 31 (2018) 258e262
S. Akgu
that because physiological characteristics of adolescence
might overlap with PCOS signs, to avoid overdiagnosis PCOS
should require all 3 of the Rotterdam consensus and not just
2 of 3.7 Just 1 year later the Endocrine Society (ES) clinical
practice guideline for the diagnosis and treatment of PCOS
was published. This guideline also devoted separate rec-
ommendations for adolescents. Again, the guidelines state
that the diagnosis of PCOS in an adolescent girl is different
from that of an adult and the diagnostic criteria are similar
to that of the NIH criteria in which clinical and/or
biochemical evidence of hyperandrogenism after exclusion
of other pathologies and oligomenorrhea is required. The
difference between the two being that clinical hyper-
androgenism is defined with only hirsutism by the ES for
adolescents whereas it includes acne and alopecia for NIH
criteria. An important point made in this guideline is that
they state ultrasonography should not be a criterion for
adolescents because the Rotterdam ultrasound polycystic
ovary criteria have not been validated for adolescents and
the PCOM might be a feature of normal puberty that sub-
sides with the onset of regular menstrual cycling.8
In 2015, the Pediatric Endocrine Society (PES) invited
experts to define appropriate diagnostic criteria for the
diagnosis of PCOS in adolescence.9 Their consensus sup-
ported the criteria of the ES in that persistent hyper-
androgenic oligoanovulatory menstrual abnormality on the
basis of age- and stage-appropriate standards should be
used, with some modification. Biochemical hyper-
androgenism was defined as persistent testosterone eleva-
tion above adult norms rather than the other serum
androgens. Clinical hyperandrogenism was defined as
moderate-severe hirsutism rather than mild hirsutism or
moderate-severe inflammatory acne vulgaris. Another dif-
ference these criteria added was that the criteria for evi-
dence of oligoanovulation was defined as abnormal uterine
bleeding pattern for age or gynecologic age with persistent
symptoms for 1-2 years. Again, PCOM was not recom-
mended as a diagnostic criterion by the PES.
With all of these different guidelines being used for PCOS
definition, where does this leave the clinician working with
adolescents? PCOS is not only frequently encountered but also
an important cause of morbidity so it is recommended that
the disorder is diagnosed early,10 but will trying to diagnose
the disorder early on cause over- or premature diagnosis of
the disorder because many findings might be transitory?6
The aim of this report was to evaluate whether a PCOS
diagnosis would change according to the criteria used and
to evaluate characteristics of adolescents who were diag-
nosed with PCOS.
Materials and Methods
A retrospective chart evaluation was conducted and fe-
male patients aged 13-18 years who applied to Hacettepe
University Ihsan Dogramacı Children's Hospital, Division of
Adolescent Medicine between January and July 2016 with
at least 2 of the following criteria were included in the
study: (1) Oligomenorrhea or amenorrhea; (2) clinical or
biochemical hyperandrogenism; and (3) polycystic ovaries
on ultrasound scan.
259
Oligomenorrhea was defined as the absence of menstru-
ation over 45 days and amenorrhea as no menstrual bleeding
for 6 months. Patients were only eligible to enroll 2 years
after menarche. Hyperandrogenism was defined when total
testosterone was greater than 50 ng/mL biochemically, and
the score was at or greater than 8 according to m-Ferriman-
Gallwey (mFG) classification clinically.11 A total score of 8-15
was used to define mild hirsutism, 16-24 moderate hirsut-
ism, and greater than 24 severe hirsutism.5 Moderate to se-
vere acne was noted for clinical hyperandrogenism.
Exclusion criteria were any other cause for oligomenor-
rhea or hyperandrogenism such as nonclassic adrenal
hyperplasia, androgen secreting neoplasms, Cushing syn-
drome, thyroid dysfunction, and hyperprolactinemia, any
patients with a history of androgenic/anabolic drug or
contraceptive use, or any patient who refused participation
in the study.
Systemic physical examination was performed on all
patients and the presence of acne, acanthosis nigricans,
male pattern hair loss, and virilization were recorded. Pu-
bertal stages of patients were performed according to the
Marshall-Tanner method.12 Measurements of weight (kilo-
grams) were obtained using electronic scales (Seca 220;
Hamburg, Germany), and measurements of height (centi-
meters) were obtained using the Harpenden stadiometer.
Measurements were evaluated according to normal values
of Turkish children, which were modified according to age
and gender. Body mass index was calculated by using the
body weight in kilograms divided by the height in meters
squared formula. Children within the 85th-95th percentiles
were accepted as overweight, whereas at and greater than
the 95th percentile was accepted as obese.13
The laboratory evaluation included the total blood count,
liver and kidney function tests, lipid profile, fasting glucose,
fasting insulin level, Insulin Resistance Homeostasis Model of
Assessment (IRHOMA) values, estrogen, total testosterone,
sex hormone binding globulin, dehydroepiandrosterone
sulfate, androstenedione, 17-hydroxy-progesterone, follicle-
stimulating hormone, luteinizing hormone, prolactin levels,
free androgen index, and thyroid function tests.
Blood samples for laboratory evaluations were drawn
during early follicular phase (on day 2-3 of the menstrual
cycle) in patients with menses. For patients with amenor-
rhea blood was drawn on the day of clinical examination
after a 12-hour fasting at 8:00 AM.
Serum follicle-stimulating hormone, luteinizing hor-
mone, estradiol, prolactin, thyrotropin, free triodothyronine
and free thyroxine levels were measured using the 2-step
chemiluminescence microparticle immunoassay method.
Sex hormone binding globulin and 17-OH progesterone
were tested using immunoradiometric assay. Serum dehy-
droepiandrosterone sulfate and total testosterone levels
were determined using solid phase chemiluminescence
immunoassay. Glucose level was measured using the
glucose hexokinase method; total cholesterol was studied
enzymatically using the oxidase method; high-density li-
poprotein cholesterol was studied using the direct non-
immunological method; fasting insulin was studied using
the radioimmunoassay method. Fasting insulin and
IRHOMA values were used in the evaluation of insulin
260 € l et al. / J Pediatr Adolesc Gynecol 31 (2018) 258e262
S. Akgu

resistance. IRHOMA was calculated by using the formula of Table 2

Symptoms of Patients Diagnosed With PCOS
IRHOMA: (fasting insulin in milli-International Units per
milliliter)
(fasting blood glucose in millimoles per liter) Symptom n/52 (%)

divided by 22.5, and patients with IRHOMA value of greater MI 28 (53.4)

Hirsutism 5 (9.6)
than 2.5 was accepted as insulin resistant.
MI and hirsutism 1 (1.9)
Ultrasonographic findings of PCOS were considered as Acne 4 (7.6)
having 12 or more follicles measuring between 2 and 9 mm MI and acne 1 (1.9)
and/or an ovarian volume greater than 10 cm3. Weight gain 7 (13.4)
Abnormal uterine bleeding 3 (5.7)
Patients were then categorized according to the 6 Amenorrhea 2 (3.8)
different criteria for PCOS (Table 1), then additionally Psychosocial problems 4 (7.7)
Other problem irrelevant to PCOS 5 (9.6)
categorized according to the Rotterdam Phenotypical
model. MI, menstrual irregularity; PCOS, polycystic ovary syndrome.

Approval for this study was obtained from Hacettepe

University Research Ethics Board (number GO:16/503).
The mean body mass index of patients was 25.5 (5.6).
One patient was underweight (1.9%), 22/52 patients (42.3%)
Statistical Analyses had normal weight, 15/52 patients (28.8%) were over-
weight, and 14/52 patients (26.9%) were obese.
SPSS (version 23; IBM Corp) was used for statistical The mean mFG score was 7.5 (7.8; range, 0-34) and the
analysis. In the statistical analysis of data, descriptive sta- score was 8 or more in 23/52 cases (44.2%).
tistics such as mean (SD) or median (range) was used for Ten patients (43.5%) had mild, 8/52 (34.8%) had moderate,
continuous variables, whereas number of cases and per- and 5/52 (21.7%) had severe hirsutism according to the mFG
centages were used for nominal variables. score. Moderate to severe acne was present in 32/52 patients
(61.5%) and acanthosis nigricans was present in 6/52 patients
(11.5%). Biochemical hyperandrogenism was detected in 40/
Results
52 (76.9%) patients. Although 18/52 patients (34.6%) had
clinical as well as biochemical hyperandrogenism, 22/52
Fifty-two patients met the inclusion criteria. The mean
(42.3%) had only biochemical, 5/52 (9.6%) had only clinical,
age of patients was 15.6 (1.29) years and the mean age of
and 7/52 patients (13.4%) had neither clinical nor biochem-
menarche was 12.2 (1.3; range,10-15.4) years. The symp-
ical hyperandrogenism.
toms of patients are given in Table 2, some patients had
Ultrasonographically, 38/52 patients (73%) had bilateral
more than 1 symptom. The most frequent symptom was
PCOM, 5/52 patients (10.4%) had unilateral PCOM, 3/52
menstrual irregularity.
patients (5.7%) had ovary volumes greater than 10 cm3 and
When findings were categorized according to which
6/52 patients (11.5%) had normal ovary morphology.
diagnostic criteria were used, 34/52 (65.4%) received a
Nineteen patients (36.5%) had insulin resistance
diagnosis according to the PES criteria, 36/52 (69.2%) with
(IRHOMA O2.5) and 20/52 patients (38.5%) had dyslipide-
Amsterdam criteria, 41/52 (78.8%) with NIH and ES criteria,
mia; hepatosteatosis was not detected in any patient.
45/52 (86.5%) with AES criteria, and all with Rotterdam
criteria.
The patients were also categorized according to the Discussion
Rotterdam phenotypic application model. Thirty-six pa-
tients (69.2%) were grouped in group 1, 5/52 (9.6%) in group In our study, we aimed to evaluate whether PCOS diag-
2, 4/52 (7.7%) in group 3, and 7/52 (13.5%) in group 4. nosis will change according to which criteria was used and
we found that there was an important difference depending
on selected criteria. As expected, all adolescents received a
Table 1 diagnosis according to the Rotterdam criteria whereas this
Diagnostic Criteria for PCOS According to Different Published Definitions decreased by more than 30% when evaluated according to
Criteria Hyperandrogenism Chronic Polycystic the Amsterdam and PES criteria. This result, in turn leads
Anovulation Ovaries the clinician to ask 2 important questions. Will using the
National Institutes of Health þ þ  Rotterdam criteria lead to an overdiagnosis or using the
1990 Amsterdam or PES criteria lead to an underdiagnosis, and
Rotterdam 2003* þ/ þ/ þ/
Androgen Excess Society 2006y þ þ/ þ/ what will the consequences be?
Amsterdam 2012 þ þ þ Although PCOS often presents during adolescence, the
Endocrine Society 2013 þ þ  diagnosis in this age group is complicated by the com-
Pediatric Endocrine Societyz þ þx 
monality between the PCOS signs and symptoms and
þ indicates definite criterion, þ/ indicates might or might not be a criterion.
* Two of the 3 criteria must be met.
physiologic findings observed during the normal progres-
y
Hyperandrogenism and at least 1 of the other 2 criteria must be met. sion of puberty, which are described as follows.14,15
z
Biochemical hyperandrogenism: persistent testosterone elevation above adult
norms. Clinical hyperandrogenism: moderate-severe hirsutism or moderate-severe
(1) Oligomenorrhea is common and physiological after
inflammatory acne vulgaris.
x
Abnormal uterine bleeding pattern for age or gynecologic age, persistent menarche during normal puberty and is therefore not
symptoms for 1-2 years. specific to adolescents with PCOS. Anovulatory cycles
 € l et al. / J Pediatr Adolesc Gynecol 31 (2018) 258e262
S. Akgu
comprise 85% of menstrual cycles in the first year after
menarche, 59% in the third year, and 25% by the sixth
year.16
(2) Acne, a clinical sign of hyperandrogenism is a transitory
common finding of adolescence17 and therefore many
authors suggest that it should not be used in isolation to
define hyperandrogenism in adolescents.6
(3) Diagnosing hirsutism, the main clinical sign of hyper-
androgenism, using the Ferriman-Gallwey scoring sys-
tem might also be difficult in adolescents. It has been
suggested that because of less cumulative time of
exposure to androgens, the cutoff might require modi-
fication for use in adolescents.18 An additional problem
for adolescents might be difficulty in scoring because of
hair removal for cosmetic reasons. We have found that
when we ask adolescents to refrain from hair removal to
evaluate hirsutism they find complying to this very
difficult.
(4) Another problem concerns the definition of biochemical
hyperandrogenism in this age group because during
normal pubertal development there is a lack of well-
defined cutoff points for androgen levels.19
(5) Finally, the PCOM finding on ultrasonography also poses
difficulty for the adolescent. In the guidelines published
by the ES, ultrasonography was removed from the
criteria because of a few factors. Primarily, they stated
that PCOM should be evaluated transvaginally rather
that transabdominally, which would lead to practical
and ethical concerns in adolescents. Secondarily, that
transabdominal ultrasound is limited in evaluating the
ovaries especially in obese patients, which is common in
this patient population. Finally, even if multifollicular
ovaries were observed, this could be a feature of normal
puberty.8 Several studies of healthy adolescents with
regular cycles have reported the incidence of PCOM to
be 33%-35%. A study by Mortensen et al20 reported that
54% of healthy eumenorrheic girls between 1.3 and
3.8 years postmenarche had PCOM.
Because of the physiological reasons stated previously
using a broader definition such as the Rotterdam criteria
(especially group 3 or 4) might be problematic. Incorrectly
assigning a diagnostic label of PCOS to an adolescent might
result in unnecessary treatment and also impose psycho-
logical distress.6 However, using more strict criteria such as
the PES or Amsterdam criteria might lead to underdiagnosis
and there has been growing attention to early recognition
and treatment of the disorder to prevent chronic conditions
such as metabolic syndrome, type 2 diabetes, cardiovascu-
lar problems, and endometrial cancer.21 Additionally,
studies have shown that the physical signs of PCOS such as
hirsutism and obesity might lead to depression in teens so
early intervention is important from this aspect, too.22
Hyperandrogenism is a hallmark of PCOS23; the NIH, AES,
Amsterdam, PES, and ES criteria all require clinical and/or
biochemical hyperandrogenism for the diagnosis of PCOS,
whereas the Rotterdam criteria recognize a phenotype of
PCOS without androgen excess. In our study group, 13.5% of
the patients were in the group with no hyperandrogenism.
261
The NIH and Rotterdam classifications consider hirsutism,
acne, and alopecia as signs of hyperandrogenism in adults. In
contrast, the AES and ES classification only accepts the pres-
ence of hirsutism as a genuine marker of hyperandrogenism
in adolescents. The ES and PES criteria are very similar except
that the PES criteria require moderate to severe hirsutism to
be clinically significant for hyperandrogenism. For patients
without biochemical hyperandrogenism when we only
accepted patients with an mFG score greater than 16, diag-
nosis of PCOS decreased from 78.8% to 65.4%. Clinical hyper-
androgenism is usually reported as high in the adolescent
population24; in our study we found 44.2% of patients to have
hirsutism. Although 61.2% of patients had moderate to severe
acne, we did not accept this on its own as a sign of hyper-
androgenism because it is a common finding in this age
group. A study by Hickey at al,25 in which diagnostic markers
for diagnosis in adolescence were evaluated, they reported no
relationship between acne score and free testosterone level or
PCOM and they concluded that acne should not be used as a
specific marker of hyperandrogenism in PCOS. The PES
criteria state that girls with persistent acne should be evalu-
ated for the presence of hyperandrogenemia but again do not
use it as a criterion on its own.9
Although hirsutism is an important clinical marker
of hyperandrogenism, some authors have argued that
biochemical hyperandrogenism is a more reliable and
consistent marker of hyperandrogenism in the diagnosis of
PCOS in adolescents.26 In our study, biochemical hyper-
androgenism (76.9%) was close to double that of clinical
hyperandrogenism but we did have cases that did not
overlap thus, both should be evaluated in the workup.
Oligomenorrhea is a problematic criterion when it comes
to PCOS diagnosis in adolescents. For this reason, when
using this criterion certain recommendations have been
made when defining menstrual irregularity in adolescents.
The first of this is that at least 2 years have passed after
menarche.1 Merino et al27 suggested that the absence of
menstrual periods exceeding 90 days, or if cycles were
longer than 45 days should suggest the presence of ovula-
tory dysfunction in an adolescent. In our study 92.3% of
patients had menstrual irregularity.
PCOS is associated with metabolic abnormalities including
obesity, insulin resistance, type 2 diabetes, nonalcoholic fatty
liver disease, and dyslipidemia.28 Although obesity is com-
mon in adults as well as in adolescents with PCOS and many
studies show that prevalence in adolescents is greater than
60%,29 it is important not forget that patients might be of
normal weight and in our study close to half of the patient
population was of normal weight. Of all patients, 36.5% had
insulin resistance (IRHOMA O 2.5) and 38.5% had dyslipi-
demia; these findings are similar to other adolescent PCOS
studies.30
Other diagnostic criteria have also been proposed for
adolescents. It has even been suggested that diagnosis
should be avoided until the age of 18 years.6 Sultan and
Paris,31 for example, have proposed a different and more
strict approach in which they suggest that at least 4 of the 5
following criteria be met: clinical hyperandrogenism, bio-
logical hyperandrogenemia, insulin resistance and hyper-
insulinism, oligoamenorrhea persisting for 2 years
262 € l et al. / J Pediatr Adolesc Gynecol 31 (2018) 258e262
S. Akgu
postmenarche, and PCOM. None of the other guidelines
have included insulin resistance as a criterion and in our
study insulin resistance was seen in only 36.5% of the pa-
tient population, which means that if this was a criterion
most patients would not receive a diagnosis. Authors have
argued that because insulin resistance is not necessarily
present, it should not be used as a diagnostic criterion but a
warning sign for the development of comorbid diseases.9
Carmina et al6 propose that patients meeting all 3 criteria
like the Amsterdam criteria be diagnosed with PCOS and
those with hyperandrogenism and chronic anovulation
without PCOM be diagnosed with probably but not
confirmed PCOS. For patients with PCOM morphology with
either hyperandrogenism or chronic anovulation (Rotter-
dam group 3 or 4), it was stated that the diagnosis of PCOS
was not possible during adolescence.
It has also been argued that diagnostic criteria in ado-
lescents can vary depending on the specialty of the physi-
cian.32 An interesting study aiming to evaluate trends in the
clinical workup for PCOS in adolescents by different spe-
cialties showed that gynecologists ordered pelvic ultraso-
nography for 89% of patients, compared with 9% by
adolescent medicine specialists. This result also reflects lack
of standardized care for adolescents.33
Our approach to treatment for these patients was to
discuss lifestyle changes in all patients regardless of
whether they did or did not receive diagnosis according to a
specific guideline. In the overweight and obese adolescents,
we suggested that weight loss strategies began with calorie-
restricted diets and exercise, and an individual plan was
given for each adolescent. The medical treatment of PCOS in
adolescents is still controversial.8 In our study, all patients
who received a diagnosis according to the Amsterdam, NIH,
and ES guidelines were additionally prescribed combined
oral contraceptives. For patients who received diagnosis
according to the AES guideline but did not have oligome-
norrhea or those who received diagnosis according to
Rotterdam criteria without hyperandrogenism or oligome-
norrhea were managed individually depending on the
severity of the other findings.
In conclusion, during adolescence, there is no consensus
concerning which criteria to use to diagnose PCOS. This
study has shown that the use of the different sets of diag-
nostic criteria for PCOS in adolescents alternates the prob-
ability of receiving a diagnosis. We suggest that the
diagnosis of PCOS should be on the basis of the presence of
hirsutism and biochemical hyperandrogenism, together
with menstrual irregularity.
Nevertheless, we do believe it is important that patients
with hyperandrogenism or chronic anovulation who do not
meet diagnostic criteria for any guidelines except the
Rotterdam criteria, warrant closer follow-up and the future
risk of those patients developing PCOS should not be
underestimated.
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