Endocronologist (Pediatric) Questions Polycystic Ovary Syndrome

My daughter is 14 years old and has PCOD. What should I do?

My daughter is 14 years old and her periods are extremely irregular. She is suffering from PCOD and is starting to gain weight. Is there anything that I should do?

9 Answers

Pubertal or sexual development is a complex hormonal process that transforms a child from childhood into adulthood. Hormones from the brain ( hypothalamic and pituitary) hormones and ovarian hormones in females (testicular hormones in males) mediate the sexual transformation. These brain hormones mainly (LH) Luteinizing hormone and (FSH) follicular stimulating hormone stimulate the ovaries to produce female hormones call Estrogen and progesterone. These Ovarian hormones mediate the growth of the uterus and preparer it to be conducive for fertilization (baby) and or menses. For fertilization or menses to take place one of the millions of eggs in the ovarian milieu should be extruded (ovulation) and able to travel to the uterus. When the egg in the uterus is fertilized pregnancy starts and menses stops for at list 8-9 months. In the absence of fertilization the egg gets destroyed and menses takes place in about 14 days after ovulation. For a menses to take place there must be recruitment of ovarian follicles (foliculogenesis) and ovulation. Once there is ovulation of one of the ovules, the extruded ovule travels to the uterus and waits 14 days (mostly 8-10days) to be fertilized or in the absence of sperm to fertilize its destroyed due to lack of hormonal support and the uterine lining sloughed off as a menstrual bleeding. The ovaries undergo initial recruitment of competing oocytes for a selection of one of oocyte to mature. Most of the time only one of the dominant (selected) oocyte out of the competing ones (10-30 of them) gets extruded (ovulated). The rest of the competing follicles commit suicide, leaving a room for one of them to succeed. The initial recruitment phase is called follicular phase and the 2 phase (ovulatory phase is called luteal phase. Initial or follicular phase of the ovaries is mediated by FSH and the second phase (ovulatory) phase is mediated by LH. The LH surge heralds ovulation were there is a spike in body temperature and mood swings. The luteal phase of the ovaries and uterus are the most stable and predictable phase. It is almost always 14 days of the cycle. The variation in the menstrual cycle is mostly in the follicular or menstrual phase in an ovulating female. There is also parallel changes is the uterine environment. A mature uterus should have a conducive environment for an egg to be fertilized and develop into a baby. Blood vessels need to be prepared for nutrient supply and comforting and supporting home for the baby. In regular (normal) menstrual cycle of a female the uterus will have thee phases. The first phase is recruitment of blood vessels called follicular phase with the second one called secretory phase or luteal phase and the third phase is called menstrual phase. The early phase (follicular) is mediated by estrogen (through mainly FSH). The second phase is through progesterone ( vial LH). The menstrual bleeding ( 3 rd) phase takes place when level of hormones collapses and the vascular and secretory support sloughs off as a menstrual bleeding. Ovulation is very important for a regular menstrual cycle to take place. Though few women can have bleeding without ovulation. Some women with Amenorrhea or PCOS (more 3 months or more without a period) can have bleeding either due to intermittent ovulation (or women with fibroids) the uterus builds up so much and the inner lining of the uterus (endometrium) started to slough off irregularly on its own. It could be spotty or heavy prolonged irregular bleeding. Few women may have regular bleeding with out ovulation for various reasons but they will not able to conceive without ovulation.
The majority of Caucasian girls start puberty around the age of 10 years and menarche around the age of 12and half years. The minorities in American start their sexual development and menarche much earlier. Human sexual development is divided into 5 stages also called Tanner stages. Stage 1 is pre pubertal and stage 5 is adult. The three stages 2, 3 and 4 are processes were most of the sexual and physical transformation takes place. Breast development acne body odor pubic hair armpit sweating testicular and penile growth takes place progressively in generally predictable way. Most girls will start their period in the middle of Tanner 4 in their sexual development. But they can start to ovulate as early as late Tanner three though boys can be fertile much earlier though they start wet dreams at Tanner three.
Though girls May start ovulation late Tanner 3 and mainly tanner 4, they may start menarche as they ovulate but many of them may not establish a regular menstrual cycle until the 2 rd year of commencing menarche. Some times it may take up to 3 or more years to establish regular menses as the hormonal control (the hypothalamic/pituitary ovarian axis) takes a while to establish rhythmic control of the menstrual cycle. In many females regular ovulation and uterine maturation may take a while to establish. It is also fine to skip a period occasional (2-4 times a year) due to various environmental reasons including stress, diet, weight change, strenuous physical activity, etc. Normal period is considered >8 times a year with average menstrual flow. It is considered abnormal when a women gets her period less than 8 times a year or skips her period three or more months in a row or if she is bleeding more than 10 days a month or have a heavy or spotty period. A regular menstrual bleeding is a bout 3-7 days with bleeding of 30-50 ml ( 6-10 small tampons) per cycle. An average moderately soaked pad or tampon can hold about a teaspoon of blood (5 ml). Heavily soaked tampon may hold about a table spoon (15 ml) of blood. Changing more than 12 small/moderate tampons (80 ml) and less than 2 tampon (10 ml) may be abnormal. Normal menstrual cycle is 21-35 days for an average of 28 days. This may be in response of the moon's electromagnetic forces that may be controlling the hormonal rhythmicity of the female reproductive cycle. Bleeding twice or more a month or bleeding less than 21 days or longer than 35 day after the last cycle is considered abnormal.
In female after 2 years of menarche, irregular period is considered 1) skipping menses 3 or more moths in a row (Amenorrhea), 2) < 8 menses a year 3) heavy bleeding >80 ml bleeding. 4) Little bleeding <2 days (<10ml). 5) Bleeding after 35 days of the last menstrual cycle.
Primary amenorrhea is considered in a female 15 years old or older who nerve started her period. In all conditions pregnancy need to be ruled out. As the commonest cause of amenorrhea is Pregnancy.
There are many causes of irregular period in a female including stress, overweigh/obesity, weight loss/abnormal weight, excessive exercise, illnesses, uterine and ovarian conditions, pituitary abnormalities including pituitary tumors, and genetic conditions such as Turners syndrome or hypogonadism, medications and hormone imbalances.
Hormonal imbalances such as uncontrolled/ undiagnosed/ hypothyroidism, excess cortisol, insulin resistance (metabolic syndrome), high prolactin level etcetera can cause irregular bleeding (period)
Polycystic ovarian syndrome is a mix of disorders consisting some of the following: 1) Amenorrhea or irregular period as mentioned above, 2) hyperandrogenia, (producing more male hormones called androgens such as testosterone, DHEAS and androstendione ), Hyperandrogenism ( skin manifestations such as acne, excess hair, thinning of hair or hair loss etc., with or with out cysts in the ovary. In PCOS (polycystic ovarian syndrome one does not have to have cysts in the ovaries to be diagnosed with PCOS. Many women with PCOS have no cysts in their ovaries and many normal women have cysts in their ovaries without PCOS. Women with PCOS have skin conditions (acne, facial hair and thinning of hair and hair loss) and metabolic conditions such as prediabetes or diabetes, fatty liver disease high lipids cardiovascular problems and infertility.
PCOS could be due to many causes, 1) adrenal causes, abnormal adrenal androgens with or without late onset adrenal hyperplasia. 2) insulin resistance (HAIR AN syndrome (hyperandrogenism insulin resistance ancanthosis nigricans syndrome)). increased insulin causes stimulation of male hormones in the ovaries by stimulating the ovarian theca cell to produce more male hormone. During insulin resistance (obesity) the body is resistant to insulin while the ovaries stay sensitive to insulin. Therefore PCOS is common in insulin resistance. The converse is also true. 3) The Hypothalamic/Pituitary /Ovarian axis abnormality. The pulse generator in the hypothalamus is faster in frequency. The pituitary ovarian axis rhythmicity is altered in PCOS. The rhythmicity is much faster in frequency than normal and ovaries do not have enough time to mature and ovulated. Since there is less ovulation, PCOS is a state of Anovulation. With out ovulation it is less possible to have a normal period. What ever the cause of PCOS, the final effect or out come is similar. PCOS affects the female reproductive, metabolic, hormonal, skin and social conditions. PCOS can cause weight gain and insulin resistance. The other way round is also true (vicious cycle)
Untreated or undiagnosed hypothyroidism, hyperprolactinemia and excess cortisol or adrenal androgens (like late onset adrenal hyperplasia) can also suppress pituitary hormone activity (altering the hormonal rhythmicity) leading to irregular period and/or amenorrhea.
The initial evaluation into irregular period is to take detailed history and complete physical evaluation. Over 80% of the answers come from taking a detailed history and performing complete physical exam. The next step is to perform complete laboratory and imaging work up. Labs for Amenorrhea profile including pregnancy, adrenal androgens, thyroid profile, CAH profile, metabolic profile, prolactin, ovarian hormone insulin karyotype or genetic testing (if indicated) etc. should be performed (complete bill of health).
And once the diagnosis of PCO is established treatment should be initiated including life style change, weight loss, healthy balanced diet and structured regular physical activity. Medical therapy should be initiated as soon as other causes are eliminated (thyroid, adrenal, prolactin etc.). Hormonal causes so as thyroid abnormalities, excess adrenal androgens such as late onset CAH and abnormal prolactin level need to be treated promptly.
PCOS need to be treated with low androgenic birth control pills, metformin and if there is skin manifestation spironolactone, fenastride, vaniqua etc. can be considered.
Going back to your daughter: Your daughter is 14 years old. When did she start her period?. Does she have dark skin on her neck?. Is there a family history of PCOS in females or men who lost hair early (Balding)?.
Lets consider she started her period over 2 years ago and she truly has PCOS. PCOS is a group of disorders. It is not one disease. It is difficult to pinpoint to a single cause, because there is no single cause in PCOS. It is a syndrome (collection of disorders) not a single disorder. It can be due to insulin resistance, adrenal abnormalities, hypothalamic/pituitary/ovarian axis disorder (change in rhythmicity of the pulse generator in the hypothalamus). Any of the above and or combination of the above causes or something else . No one knows for sure. But it has to be evaluated and treated well, because it has long term consequences. Your doctor should also rule out thyroid abnormalities, adrenal anomalies including late onset CAH, prolactin and pregnancy (unlikely) and karyotype or genetic testing if indicated. Let him/her perform a complete evaluation. The history, physical exam and laboratory work up should determine if she has PCOS. PCOS is mostly a diagnosis of exclusion of other hormonal causes. Free and total testosterone are usually high and a protein called SHBG is low in PCOS. Metabolic abnormalities are also common in PCOS.
There is no doubt that PCOS cause excessive weight gain. And it is also true that excessive weight gain may cause PCOS. No one knows which one comes first, weight gain or PCOS. But two of them are locked up in a vicious cycle. Once the diagnosis of PCOS is established, treatment should be commenced swiftly. Life style change should be addressed in detail. weight management is very important. Even as small as 5% weight loss will make a big difference. healthy balanced diet with lots of fresh vegetables is essential. Daily structured physical activity is also very necessary. It will be very helpful to see a good nutritionist for good nutritional guidance. Weight loses is very important aspect of the treatment of PCOS. A desired modest weight loss of 5-10% will lead to a major improving in the PCOS. If weight loss is difficult through diet and structured daily exercise, appetite suppressing agents can be tried, if your doctor would be willing to help you. Some of the medications to be considered besides of course metformin, would be Topamax 100-200mg twice a day, contrave (naltrexone/welbuterin), orlestat, Adderall, qysmia, Belvic phentermine, victoza, saxenda etcetera as indicated or on an individual bases.
It is also very important to realize that she needs to be on low androgenic birth control pills for the PCOS. Since she is not ovulating regularly, she needs those female hormones replaced and the uterus need to be able to shed regularly to protect the uterus from future uterine problems. Metformin is most of the time added in the treatment of PCOS. It can be used liberally to help her with the metabolic conditions (insulin resistance) of PCOS and help the ovaries function better. Other medications such as spironolactone, vaniqua etc. can be considered if indicated and if she has skin conditions such as hirsutism or thinning of hair (hair loss).
You need to work with your daughter, nutritionist and your physician closely. Involve her in structured sports activity and make sure you have a good handle in a healthy balanced diet with lost fresh vegetable. If needed get a referral to see a specialist in PCOS.
Good Luck

She should probably see either an adolescent gynecologist or a reproductive endocrinologist for these issues. They will usually prescribe a combination of medications to help treat your daughter's issues.
has she been seen by her pediatrician or gynecologist? she can be placed on birth control for cycle control or she can be cycled on a progestin.
She needs to lose weight. Join Weight Watchers, also, see a gynendocrinologist who can devise a long-term treatment plan for her.
She should see a physician who knows about pcos. If she has irregular periods, she should be put on birth control pills. There are tests that need to be done in order to determine other potential treatment modalities.
You should discuss a prescription for birth control pills and diet and exercise.
PCOD contributes to a hormonal imbalance, which suppresses normal ovulatory cycles and contributes to irregular excessive menses. The hormonal imbalance stems from a tendency toward insulin resistance, which can increase the risk for diabetes mellitus. Treatment includes both hormonal regulation for management of her cycles
and nutritional management. I recommend scheduling your daughter to see a gynecologist who specializes in adolescent gynecology. I also recommend a book available on Amazon, "The PCOS Diet."

I hope this information is helpful to you and your daughter.

Best regards,

Milinda Morris, MD, FACOG, NCMP, DACBN
Yes. She should be treated with medication to regulate her cycles to prevent uterine cancer and placed on appropriate diet plan. Take her to your gynecologist.
I am assuming that you are referring to Polycystic Ovarian Syndrome. You should consult your daughter's doctor, but eating healthier (less processed foods, less carbohydrates, and more fiber) and one hour of exercise per day (recommended for all adolescents) tend to improve weight gain and PCOS.