Journal of Adolescent Health 43 (2008) 103105
Editorial
Whither PCOS? The Challenges of Establishing Hyperandrogenism in
Adolescent Girls
In this issue of the Journal, Rieder et al [1] report on the
key features of hyperandrogenic anovulation in a group of
ethnic minority adolescents. The authors extensively eval-
uated a group of girls recruited through an adolescent out-
patient unit, the emergency room, and adolescent inpatient
unit in an urban childrens hospital. They note that subjects
who had evidence of hyperandrogenism and/or obesity or
acanthosis nigricans on physical examination, as well as
abnormal menstrual patterns, had greater waist circumfer-
ence measures, greater serum androgen levels, and lower
sex-hormone binding globulin (SHBG) than the other three
groups (controls; those with abnormal menstrual patterns
but normal physical examination; and those with evidence
of hyperandrogenism or acanthosis, but normal menstrual
pattern). Utilizing receiver operating characteristic (ROC)
analyses, the group with hyperandrogenism and/or obesity
or acanthosis as well as abnormal menstrual patterns were
best distinguished from controls by the free androgen index
(FAI, [total testosterone concentration]/SHBG), the inverse
of the SHBG concentration, and by waist circumference.
The authors note that adolescents with hyperandrogenic
anovulation are at increased risk of polycystic ovary syn-
drome (PCOS).
PCOS is the most common endocrinologic abnormality
in women, with an estimated prevalence of 6% to 7% [2].
There are three sets of criteria that have been proposed to
establish the diagnosis in adult women: the NIH criteria, the
Rotterdam criteria [3], and the Androgen Excess Society
guideline [4]. All agree that the exclusion of other disorders
is necessary. The 2003 Rotterdam criteria require two of
three criteria: (1) oligo- or anovulation, (2) clinical and/or
biochemical signs of hyperandrogenism, and/or (3) polycys-
tic ovaries on transvaginal ultrasound (12 or more follicles
in each ovary measuring 29 mm or increased ovarian
volume 10 mL of one ovary). This definition would then
result in four subsets of PCOS: (1) irregular menstrual
pattern plus polycystic ovary morphology plus (clinical or
laboratory) hyperandrogenism, (2) irregular menses plus
See Related Article p. 115
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doi:10.1016/j.jadohealth.2008.05.004
hyperandrogenism, (3) hyperandrogenism plus polycystic
ovary morphology, and (4) irregular menses plus polycystic
ovary morphology [5]. The last category remains in dispute,
of whether these patients should be diagnosed under the
broad rubric of PCOS, because of some similar metabolic
findings, or whether such labeling is premature. The An-
drogen Excess Society, publishing their guidelines in 2006,
underscored the need to define PCOS as a disorder with
primary hyperandrogenism. The criteria for PCOS were
defined as: clinical or biochemical hyperandrogenism and
ovarian dysfunction (oligo-anovulation and/or polycystic
ovaries on ultrasound).
However, the establishment of hyperandrogenism and
the assessment of other laboratory tests in PCOS is not
without challenges [6]. Clinical hyperandrogenism is man-
ifested typically by hirsutism and scored using the Ferriman
Gallwey system, and varies by ethnicity, time since puberty,
sensitivity of the hair follicles, and level of androgens. Of
note, the Ferriman-Gallwey system was standardized with
only white women, with the majority over 24 years of age;
this system may not be a sensitive instrument in adolescents,
who may only exhibit upper lip hair [7]. In addition, laser
and other treatments make clinical hirsutism inapparent to
the examiner. To add to the complexity, some adolescents
experience transient hyperandrogenism, and may run the
risk of being prematurely labeled with PCOS. In Rieders
series more than half of the sample was over 18 years (mean
age was 17.5 years) facilitating the ease of diagnosing
clinical hyperandrogenism and PCOS. Biochemical hy-
perandrogenism is even more complex as noted below, and
has led the Endocrine Society to publish a review of the
clinical and research challenges with testosterone assays [8].
There are other challenges with measurement of other se-
rum values of insulin, progesterone, and 17OH progester-
one. For example, blood samples are often drawn in the
afternoon when 17OH progesterone level is low, and thus
the adolescent would need to return for a first-morning
sample to exclude late-onset congenital adrenal hyperplasia.
104 F.M. Biro and S.J. Emans / Journal of Adolescent Health 43 (2008) 103105
Similarly, the adolescent with hirsutism and regular menses
may not be considered to have PCOS unless serum proges-
terone is drawn on days 22 to 24 of the cycle, to demonstrate
anovulation. Insulin levels have significant variability
among laboratories. Ultrasound, not part of the Rieder
study, has been increasingly used to aid in the diagnosis of
PCOS. However, in adolescents a transabdominal rather
than transvaginal ultrasound typically is performed. Ovarian
volume can often be calculated with a transabdominal ap-
proach, but counting ovarian follicles is more problematic.
In addition, adolescents are less likely to have developed
classic polycystic ovaries. Additional findings such as obe-
sity, acanthosis nigricans, and hyperinsulinism are clearly
associated with PCOS, but whether these clinical features
(physical markers) should be given the same importance
in establishing a hyperandrogenic group (Group IV) ex-
amined in the Rieder paper is unclear. Of note, in the
authors extensive analyses, they also looked at the Group
IV patients who were not overweight or had acanthosis
nigricans, and the four remaining patients still had higher
BMI and waist circumference. Given the risk of metabolic
abnormalities in girls with PCOS, such as impaired glucose
intolerance [9] and diabetes as well as dyslipidemias, sev-
eral professional groups have recommended routine 2-hour
glucose testing in patients with PCOS [10].
Clinical evidence of hyperandrogenism may not be ap-
parent early in the teen years [11], and adolescents with a
PCOS-like picture may lack abnormalities on ultrasound of
the ovaries. Additionally, adolescents often have irregular
menstrual patterns, especially in the years immediately after
menarche. Measurement of androgens and in particular,
testosterone, is an important component of the evaluation of
PCOS. Series have found that 60% to 90% of those with
PCOS have elevated free testosterone [5]. Unfortunately,
there are many challenges to the interpretation and variabil-
ity of androgen levels. This challenge is underscored by
Rieders report that 11 of the subjects had testosterone
levels 200 ng/dL and 5 had normal menses and physical
examination.
There are three forms of circulating testosterone: the
portion of testosterone bound (tightly, that is, with high
affinity) to SHBG, the portion loosely bound to albumin,
and the portion not bound to SHBG or albumin, also called
free (dialyzable) testosterone. Most researchers feel that
biologically active testosterone includes both the free frac-
tion as well as the portion bound to albumin. There have
been several recent papers that examine the evaluation of
testosterone, free testosterone, and biologically active tes-
tosterone. Although there are direct measures of free testos-
terone, many measures as well as all derived testosterone
indices depend on accurate assessment of total testosterone.
Relatively low testosterone concentrations, such as those
encountered in women and early adolescent males, may
present issues with accuracy and sensitivity.
Commercial radioimmunoassay (RIA) and immunoassay
kits without radioactivity (utilizing enzyme-linked or
chemiluminescent techniques) are the most common ap-
proaches to measure total testosterone. These approaches
are relatively straightforward and inexpensive, but may not
be accurate enough to measure total testosterone in females
and prepubertal males [8,1214]. There is high measure-
ment variability within as well as between laboratories,
especially when testosterone levels are below 100 ng/dL;
additionally, immunoassays have typically demonstrated a
bias toward overestimation in that concentration range,
when compared to more definitive diagnostic approaches
[13,14]. A proficiency survey conducted by the American
College of Pathologists noted a coefficient of variability of
34.9% for evaluation by several immunoassay instruments,
conducted in multiple laboratories, of a test sample contain-
ing testosterone concentrations in the range of a normal
adult woman [8]. Additionally, commercial testosterone im-
munoassays are regulated through demonstrating results
comparable to previously approved assays that may not
have been validated against gold standards [12]. RIA after
extraction and chromatography has improved sensitivity
when contrasted to direct RIA [8]. The greatest accuracy for
determination of total testosterone is achieved by mass
spectroscopy; a recent position statement by the Endocrine
Society recommended use of extraction and chromatogra-
phy, followed by mass spectroscopy (or mass spec/mass
spec) as the most definitive approach and gold standard [8].
There are multiple methods available for the evaluation
of free testosterone. These include direct RIA, separation of
protein bound from free testosterone through equilibrium
dialysis or ultrafiltration, precipitation with ammonium sul-
fate (measurement of biologically active testosterone), and
calculation utilizing one of three methods: FAI, algorithms
based on law of mass action (Vermeulens calculation) [15],
and empirical equations. Similar to RIA of total testosterone
levels, direct RIA of free testosterone has limited accuracy
and precision, and did not correlate as well with the gold
standard, equilibrium dialysis, as did other measures of free
testosterone [1517]. Direct RIA tends to underestimate
free testosterone levels in women and adolescent males
[15]. Free testosterone determined by equilibrium dialysis,
as noted above, is considered the gold standard for deter-
mination of free testosterone; however, this method, as
many other methods for determination of free testosterone,
depends on the accuracy of the method used for determining
total testosterone. The three approaches using calculations
require accurate assessment of total testosterone and SHBG.
In addition to the issues discussed above regarding total
testosterone, there are differences in SHBG concentrations
among commercially available kits for SHBG determination
[17,18]. FAI, used by Rieder et al, correlates well with free
testosterone as determined by equilibrium dialysis. Re-
searchers have noted that FAI is unitless, and is less accu-
rate at lower testosterone levels [15,17]. Two recent reviews
 F.M. Biro and S.J. Emans / Journal of Adolescent Health 43 (2008) 103105
both recommend the other calculation approaches, because
all three approaches require total testosterone and SHBG
levels [8,12]. The calculation based on the law of mass
action (Vermeulens approach) also requires serum albumin
level, although the calculation is reliable over a range of
albumin levels [15]. In a similar fashion, the empirical
equations are based on computer modeling, with excellent
correlation to the gold standard [8]. There are free testos-
terone calculators available online (http://www.issam.ch//
freetesto.htm) (accessed May 3, 2008).
As noted above, the most widely available assays for
testosterone, RIA, are the least expensive as well as the least
accurate. However, because the majority of testosterone is
bound tightly to SHBG, the biologically active component
requires determination of SHBG, especially in pubertal and
adult women. It is of interest to note that in the paper by
Rieder et al that 1/SHBG produced a better fit than the
calculation of FAI in the ROC analysis for identifying
adolescents with hyperandrogenic anovulation.
In summary, clinicians need to become more savvy about
the challenges of diagnosing PCOS and the quality of the
tests they have available to help them. Improved assays for
androgens are essential; in the future, the use of genetic
markers may help us to better describe the full spectrum of
this disorder. For the present, the challenge is to investigate
the etiology and at the same time address the associated
long-term consequences for our patients including poorer
quality of life [19], infertility, diabetes, and cardiovascular
disease. Once we diagnose young women with PCOS we
have an important responsibility to provide them with sup-
port through individual or group counseling, or through
internet education (http://www.youngwomenshealth.org/
pcosinfo.html), management options, and healthy lifestyle
change.
Frank M. Biro, M.D.
Division of Adolescent Medicine
Cincinnati Childrens Hospital Medical Center
Cincinnati, Ohio
S. Jean Emans, M.D.
Division of Adolescent/Young Adult Medicine
Childrens Hospital Boston
Boston, Massachusetts
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