Polycystic ovary syndrome (PCOS) can occur during adolescence, and manifestations of excess androgen (hirsutism, acne) should prompt evaluation, although the diagnostic criteria for PCOS during adolescence are not well established (84). Androgen disorders occur in about 5% to 10% of adult women, making them the most common endocrine disorders in women (see Chapter 31). Classic PCOS, functional ovarian hyperandrogenism, or partial late-onset congenital adrenal hyperplasia can occur in adolescence. These disorders often are overlooked, unrecognized, or untreated. Women with even mild disorders are candidates for intervention, including lifestyle interventions to normalize weight, and pharmacologic interventions to manage abnormal bleeding or hirsutism. These disorders may be a harbinger of type 2 diabetes, endometrial cancer, and cerebrovascular disease. Acne, hirsutism, and menstrual irregularities are often dismissed as normal during adolescence but may be manifestations of hyperandrogenism (52,85). Androgen abnormality can persist beyond adolescence. Obesity, hirsutism, and acne should be evaluated to minimize the significant psychosocial costs. Androgenic changes are partially reversible if detected early and managed appropriately. Behavioral changes in lifestyle (diet and exercise) should be strongly encouraged but are often difficult to achieve. Signs of insulin resistance (acanthosis nigricans) should be evaluated and managed appropriately (86).
Anatomic Causes Obstructive or partially obstructive genital anomalies typically present during adolescence. Complex m¨ullerian abnormalities, such as obstructing longitudinal vaginal septa or uterus didelphys, can cause hematocolpos or hematometra (Fig. 14.12). If these obstructing anomalies have or develop a small outlet, persistent dark-brownish discharge (old blood) may appear instead of or in addition to a pelvic mass. Many varieties of uterine and vaginal anomalies exist, and clinicians who have expertise with these anomalies should be involved in their management. Figure 14.13 illustrates situations in which abnormal bleeding can result from partially obstructing septa.
Examination A careful general physical examination can reveal signs of androgen excess such as acanthosis nigricans or facial, chest or periareolar, or abdominal terminal hair growth. Because body hair is felt by many to be culturally unacceptable in women and girls, sensitive questioning about specific hair removal techniques (bleaching, waxing, use of depilatories, shaving, plucking, threading) is warranted during an examination. A complete pelvic examination is appropriate in patients who are sexually active, are having severe pain, or may have an anatomic anomaly. Testing for gonorrhea and Chlamydia trachomatis infection is appropriate during a speculum examination if the patient is sexually active. Some young teens who have a history that is classic for anovulation, who deny sexual activity, and who agree to return for follow-up evaluation may be managed with a limited gynecologic examination supplemented with pelvic ultrasonography.
Figure 14.12 Uterus didelphys.
Figure 14.13 The types of obstructive or partially obstructive genital anomalies that can occur during adolescence.