AFJOG

REVIEW African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | Polycystic Ovary Syndrome: An update from the 2023 international guideline MENSTRUAL ABNORMALITIES IN THE ADOLESCENT POPULATION The 2023 International evidence-based guideline for the assessment and management of polycystic ovary syndrome specifically sought to answer at which point, after the onset of menarche, do irregular cycles indicate ongoing menstrual dysfunction. There was no evidence found which specifically focussed on the adolescent population and therefore a consensus recommendation was made based on the natural history of menstruation and ovulation in adolescents. (9) The consensus recommendation was that irregular periods be defined as: • Normal in the first-year post menarche as part of the pubertal transition • >1 to <3 years post menarche: <21 days or >45 days • >3 years post menarche to the perimenopause: <21 days or >35 days or < 8 cycles • 1 year post menarche: > 90 days for any 1 cycle Primary amenorrhoea is diagnosed by age 15 or >3 years post thelarche, in the absence of any menstruation. When irregular cycles are present, a diagnosis of PCOS should be considered and assessed according to the guidelines. It is important to note that ovulatory dysfunction can occur with regular cycles and if anovulation needs to be confirmed, is ideally tested by a midluteal progesterone assessment. HYPERANDROGENISM The manifestation of clinical hyperandrogenism depends on the interactions between circulating androgen concentrations, local androgen concentrations and the sensitivity of the pilosebaceous unit to those androgens. The severity of hirsutism does not always correlate with the circulating androgens as there are ethnic and genetic variations in its manifestation eg. hirsutism is not a common manifestation of PCOS in women from the Far East. Hirsutism is defined as excessive terminal hair growth in a male pattern distribution. This is the primary clinical sign of hyperandrogenism. Hirsutism can be overestimated if vellus and terminal hair are not distinguished from each other. There are various tools to quantify hirsutism, but the modified Ferrimen Gallwey (mFG) scoring system is most widely used. (11, 12) A mFG of 4-6 should be used to detect hirsutism, depending on ethnicity. (9) The presence of hirsutismalone should be considered predictive of biochemical hyperandrogenism. Female pattern hair loss and acne without hirsutism are relatively weak predictors of biochemical hyperandrogenism. It is important to note that self-assessment of unwanted excess hair growth, acne and female pattern hair loss has a high degree of validity and is important even if clinical signs are not overtly evident. Only severe acne is considered a sign of hyperandrogenism in the adolescent period. In PCOS, the assessment of biochemical hyperandrogenism is of greatest value when there is no or minimal signs of hyperandrogenism. In most adolescents, androgen levels reach adult ranges at the age of 12-15 years. It is recommended to test total and free testosterone (by calculating free androgen index) to assess for biochemical hyperandrogenism as it had the highest sensitivity and specificity to diagnose biochemical hyperandrogenism when compared to all the other tests. If this is normal, clinicians could consider measuring androstenedione or DHEAS noting the poorer specificity and decreasing DHEAS with age. Biochemical hyperandrogenism is difficult to assess in women on the combined oral contraceptive (COC) as the pill increases sex hormone binding globulin and decreases gonadotrophin dependent androgen production. The assessments should therefore be done after a period of withdrawal of the COC. The 2023 guideline suggests a pill free interval of 3 months before assessment of androgens, with use of an alternative contraceptive method. Repeated measurements of androgens in ongoing assessment of PCOS has a limited role. Other androgens are measured to exclude alternate causes of hyperandrogenism in the presence of clinical manifestations, as PCOS is a diagnosis which is made following exclusion of other pathologies. These include DHEAS and 17 α hydroxyprogesterone, to rule out adrenal, neoplastic or other ovarian pathology. PCOS is considered a lifelong condition but new onset, severe or worsening clinical hyperandrogenism in the postmenopausal woman warrants further investigation to rule out ovarian hyperthecosis or an androgen producing tumour. POLYCYSTICOVARYMORPHOLOGY Polycystic ovary morphology (PCOM) is based on the appearance of large ovaries with increased stroma with multiple small peripheral cysts. According to the original definition of PCOM in the Rotterdam criteria was 12 or more follicles measuring 2-9mm throughout the entire ovary or an ovarian volume of ≥ 10ml. (7) Natural changes occur to antral follicles in the pubertal and perimenopausal periods and up to 70% of adolescents have PCOM based on the original criteria. (13) Based on the better resolution ultrasound technology that has evolved over the past 2 decades, the definition of polycystic ovarian morphology (PCOM) has been changed. According to the latest guideline, follicle number per ovary (FNPO) should be considered the most effective ultrasound marker to diagnose PCOM in adults. FNPO≥ 20 in at least one ovary should be considered the threshold for PCOM. Other accurate ultrasound markers of PCOM in adults include follicle number per cross-section (FNPS) and ovarian volume (OV). When using an older technology ultrasound machine or if the image quality is insufficient to allow an accurate assessment of the follicles in the entire ovary, then OV≥10mm or FNPS ≥ 10 may be used. There are no definitive criteria to define PCOM on ultrasound in adolescents, therefore it is not recommended. The transvaginal route is the most accurate method of assessing PCOM, but the abdominal route may be used when vaginal scan cannot be undertaken. When interpreting the ultrasound findings, it is important to note the following: Last menstrual period or the stage of the menstrual cycle; transducer bandwidth frequency; whether transabdominal or transvaginal approach was used; total number of 2-9mm follicles per ovary; measurement of ovarian volume; other ovarian features including ovarian cysts, corpus lutea, dominant follicles (>10mm); reliance on the contralateral ovary FNPO for diagnosis of PCOM where a dominant follicle is noted in one ovary and for uterine features and/or pathology including endometrial thickness and pattern. (9,10) Anti-Mullerian Hormone According to the latest international guidelines of 2023, serum AMH could be used for defining PCOM in adults. However, it should be used in accordance with the diagnostic algorithm (Figure 1). Either AMH or ultrasound may be used to define PCOM – it is not necessary to perform both tests. It is unnecessary to do an AMH measurement in a woman with African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | 07