Veronica Gomez-Lobo

The Diagnosis of Polycystic Ovary Syndrome during Adolescence

Background/Aims: The diagnostic criteria for polycystic ovary syndrome (PCOS) in adolescence are controversial, primarily because the diagnostic pathological features used in adult women may be normal pubertal physiological events. Hence, international pediatric and adolescent specialty societies have defined criteria that have sufficient evidence to be used for the diagnosis of PCOS in adolescents. Methods: The literature has been reviewed and evidence graded to address a series of questions regarding the diagnosis of PCOS during adolescence including the following: clinical and biochemical evidence of hyperandrogenism, criteria for oligo-anovulation and polycystic ovary morphology, diagnostic criteria to exclude other causes of hyperandrogenism and amenorrhea, role of insulin resistance, and intervention. Results and Conclusion: Features of PCOS overlap normal pubertal development. Hence, caution should be taken before diagnosing PCOS without longitudinal evaluation. However, treatment may be indicated even in the absence of a definitive diagnosis. While obesity, insulin resistance, and hyperinsulinemia are common findings in adolescents with hyperandrogenism, these features should not be used to diagnose PCOS among adolescent girls.

Contraceptive Options for Women With a History of Solid-Organ Transplantation.

Women of reproductive age who have received a solid-organ transplant are at risk for unplanned pregnancy. Fertility can return as soon as 1 month after transplantation, and the baseline unplanned pregnancy rate in the United States is approximately 50%. Pregnancy, although not absolutely contraindicated in this population, carries risk greater than the general population and should be timed with regard to medication regimen and organ function. The Centers for Disease Control categorizes every form of contraception as Category 2—benefits outweigh risks—in women with an uncomplicated transplantation. There is a large range of contraceptive options, varying in drug formulation, route of delivery, and discrepancy between “perfect” and “typical” use. Long-acting reversible contraceptive methods include intrauterine devices (IUDs) and subdermal implants and show great promise for women with solid-organ transplant. These methods have excellent efficacy, eliminate user error, and, in the case of IUDs, have extremely low or no systemic drug absorption. Providers have historical concerns regarding the association of IUD and infection; however, modern studies have shown their safety in both immunocompetent and immunocompromised patients. Women with a history of solid-organ transplantation can be safely offered a wide range of contraceptive options to suit their individualized needs.

Clinical Variability in Approaches to Polycystic Ovary Syndrome

STUDY OBJECTIVE The objective of this study was to evaluate methods of initial diagnosis and management of polycystic ovary syndrome (PCOS) among members of the North American Society for Pediatric and Adolescent Gynecology (NASPAG) to assess the degree of practice heterogeneity among specialist providers of adolescent care. DESIGN Cross-sectional, anonymous, internet survey PARTICIPANTS NASPAG membership (N = 326; Respondents = 127 (39%)) RESULTS Percentage of respondents who incorporated specific tests at initial diagnosis was highly variable ranging from 87% (thyroid stimulating hormone) to 17% (sex hormone binding globulin). Oral contraceptives and diet modification/exercise were the most common therapies recommended by 98% and 90% of respondents respectively. CONCLUSION Considerable practice heterogeneity was present with regards to diagnostic testing for suspected PCOS. Recommendations for first-line therapy were more consistent. Future studies should clarify the clinical utility of specific diagnostic tests for adolescents, such that selection of diagnostic testing is evidence based.

Hormonal Contraceptive Agents: A Need for Pediatric-Specific Studies

Adolescents are frequently prescribed hormonal contraceptive agents for both contraceptive and noncontraceptive purposes. Over half of all sexually experienced females aged 15 to 19 have used some form of hormonal contraception: 56% oral contraceptive pills (OCPs), 20% injectable, 14% emergency, 10% patch, and 5% ring.1 Given that 50% of adolescent girls have been sexually active before age 18, ∼1 in 4 adolescent girls will be exposed to hormonal contraceptives by age 18.2 Additionally, teenagers are more likely than adult women to use hormonal contraceptives for purposes other than birth control: 33% of adolescents on OCPs use the method solely for noncontraceptive purposes.3 Hormonal contraceptive agents have many noncontraceptive benefits that are of particular importance during adolescence. They decrease menstrual flow, anemia, painful periods, acne, functional ovarian cysts, as well as other menstrual-related symptoms such as premenstrual syndrome, headaches, and epilepsy. Menstrual irregularity is common among adolescent girls, particularly in the first 2 years after menarche. These irregular periods can lead to prolonged excessive bleeding. In girls with bleeding disorders, sickle cell disease, polycystic ovary syndrome, or developmental delays, menstrual control may be essential to well-being and indicated soon after menarche. The median age at menarche is 12 to 13 years old. Given this median, girls 10 to 12 years of age could be menstruating and have reason to be prescribed hormonal contraceptive agents. Especially few data are available regarding hormonal contraceptive use in girls under the age of 13. Despite their widespread use, the overwhelming majority of hormonal contraceptive agents have not been adequately studied in pediatric populations. Pharmacokinetic … Address correspondence to Andrea E. Bonny, MD, Division of Adolescent Medicine, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205. E-mail: andrea.bonny{at}nationwidechildrens.org

Pharmacological and Environmental Effects on Pubertal Development

Puberty is essential to human development, health, and reproduction. When it occurs too early or late, there are serious emotional and physical consequences. In the beginning of the twentieth century, there was a steep decline in the age of puberty and menarche in girls which is attributed to better nutrition. More recently, however, there has been minimal change in the age of menarche, but the age of thelarche appears to continue to decrease. Given the relatively short period of time in which these later changes have taken place, it is likely that these changes are due to environmental or epigenetic factors rather than genetic alterations. Certainly, childhood obesity is of concern and a possible cause but so are medications and environmental exposures. In this chapter, we will review the current literature regarding the known impact of certain pharmacologic and environmental substances on pubertal development.