What are the treatment guidelines for adolescents with Polycystic Ovary Syndrome (PCOS)?

Treatment Guidelines for Adolescents with PCOS

Lifestyle interventions should be the first-line treatment for all adolescents with PCOS, with multicomponent approaches including diet, exercise, and behavioral strategies being most effective for those with excess weight. 1

Diagnostic Considerations for Adolescents

• Diagnosis of PCOS in adolescents should focus on evidence of ovulatory dysfunction and androgen excess, rather than polycystic ovary morphology 2
• Ovulatory dysfunction indicators include: consecutive menstrual intervals >90 days even in the first year after menarche; menstrual intervals persistently <21 or >45 days 2+ years after menarche; lack of menses by age 15 or 2-3 years after breast budding 2
• Androgen excess indicators include: moderate to severe hirsutism, persistent acne unresponsive to topical therapy, and persistent elevation of serum testosterone levels 2
• Adolescents with history of premature pubarche, family history of PCOS, or obesity require close surveillance 3

Lifestyle Management Recommendations

Healthy Eating Approaches

• No specific diet type has proven superior; focus on individual preferences and cultural needs while maintaining a healthy balanced diet 4
• For weight loss, aim for an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day), considering individual energy requirements 4
• Follow general healthy eating principles across the life course 4
• Avoid unduly restrictive or nutritionally unbalanced diets 4

Physical Activity Guidelines

• Recommend at least 150 minutes/week of moderate intensity physical activity or 75 minutes/week of vigorous intensity activity for prevention of weight gain 4
• Include muscle-strengthening activities on 2 non-consecutive days/week 4
• For modest weight loss, increase to at least 250 minutes/week of moderate intensity activities 4
• Both aerobic and resistance exercises have shown benefits in PCOS 4
• Minimize sedentary, screen, or sitting time 4

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring 1, 4
• Include behavioral strategies such as goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, and relapse prevention 4
• Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence 4
• Address psychological factors such as anxiety, depression, body image concerns, and disordered eating 1, 4

Weight Management

• Set achievable weight loss goals of 5-10% in those with excess weight, which can yield significant clinical improvements 1, 5
• Regular monitoring of weight and waist circumference is recommended 4
• Weight loss through lifestyle intervention has been shown to improve menstrual irregularities, normalize androgens, and improve cardiovascular risk factors in adolescents with PCOS 6
• Consider ethnic-specific BMI and waist circumference categories when optimizing lifestyle and weight 1, 4
• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1

Pharmacological Management

• Combined oral contraceptives (COCs) are first-line pharmacotherapy for management of menstrual irregularity and acne 2
• Metformin is superior to COCs for weight reduction and improved dysglycemia 2
• COCs and metformin have similar effects on hirsutism, but often need to be paired with other treatment modalities for cutaneous symptoms 2
• Metformin in addition to lifestyle modification is likely to improve menstrual cyclicity and hyperandrogenism in girls with PCOS and type 2 diabetes 1
• Oral contraceptive pills for treatment of PCOS are not contraindicated for girls with type 2 diabetes 1

Multidisciplinary Approach

• A multidisciplinary model of care with dietitian, health psychologist, gynecologist, and endocrinologist has shown enhanced weight loss outcomes in adolescents with PCOS 1
• Health professional interactions should be respectful, patient-centered, and considerate of individual preferences and cultural differences 1, 4
• Screen for psychological comorbidities including anxiety, depression, body image concerns, and disordered eating 1, 2
• Regular follow-up is essential for monitoring progress and adjusting treatment plans 1

Important Considerations and Pitfalls

• Deferring a definitive diagnosis while providing symptom treatment and regular follow-up is a recommended option 2
• Treatment may decrease risk of future comorbidity even in the absence of a definitive diagnosis 2
• Screen appropriately for metabolic comorbidities associated with PCOS 2
• Avoid focusing solely on weight loss without addressing psychological aspects of PCOS 1, 4
• Be aware that ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention 1, 4