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Cited by 3,113Ovarian function and disordersHypothalamic control of reproductive hormonesSexual Differentiation and Disorders

The Diagnosis of Polycystic Ovary Syndrome during Adolescence

Open access
Witchel, Selma F., Oberfield, Sharon, Rosenfield, Robert L., Codner, Ethel, Bonny, Andrea, Ibáñez, Lourdes, Pena, Alexia, Horikawa, Reiko +7 more·2015·Hormone Research in Paediatrics
DOI 10.1159/000375530
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Abstract

Background/Aims: The diagnostic criteria for polycystic ovary syndrome (PCOS) in adolescence are controversial, primarily because the diagnostic pathological features used in adult women may be normal pubertal physiological events. Hence, international pediatric and adolescent specialty societies have defined criteria that have sufficient evidence to be used for the diagnosis of PCOS in adolescents. Methods: The literature has been reviewed and evidence graded to address a series of questions regarding the diagnosis of PCOS during adolescence including the following: clinical and biochemical evidence of hyperandrogenism, criteria for oligo-anovulation and polycystic ovary morphology, diagnostic criteria to exclude other causes of hyperandrogenism and amenorrhea, role of insulin resistance, and intervention. Results and Conclusion: Features of PCOS overlap normal pubertal development. Hence, caution should be taken before diagnosing PCOS without longitudinal evaluation. However, treatment may be indicated even in the absence of a definitive diagnosis. While obesity, insulin resistance, and hyperinsulinemia are common findings in adolescents with hyperandrogenism, these features should not be used to diagnose PCOS among adolescent girls.

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Crossref · 10.1159/000375530

Cites

64 of 64 references verified0 citation errors · 0 not checkable

Statistics

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Claims the paper makes

0 of 99 cited sources checked · 0 supported · 0 flagged

  • Premisecitation

    Diagnostic criteria for polycystic ovary syndrome in adolescence are controversial because adult diagnostic features may be normal pubertal events.

    “The diagnostic criteria for PCOS in adolescence are controversial, primarily because the diagnostic pathological features used in adult women, e.g.acne, irregular menses, and PCOM, may be normal pubertal physiological events [18]”
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  • Premisecitation

    With one published exception, current definitions of polycystic ovary syndrome in adolescent or adult women do not include insulin resistance or hyperinsulinemia as a diagnostic criterion.

    “With the exception of one published recommendation, none of the current definitions of PCOS in adolescent or adult women include insulin resistance/hyperinsulinemia as a diagnostic criterion [1, 10-12, 18, 19, 112]”
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  • Premisecitation

    About half of otherwise asymptomatic mild hirsutism is not associated with hyperandrogenemia.

    “It is important to realize that about half of otherwise asymptomatic mild hirsutism is not associated with hyperandrogenemia [22,24]”
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  • Premisecitation

    Mild or focal hirsutism may indicate hyperandrogenemia in young women when accompanied by other evidence of polycystic ovary syndrome such as menstrual irregularity.

    “However, mild or focal hirsutism may be a sign of hyperandrogenemia in young women when associated with other evidence of PCOS, i.e., menstrual irregularity [29][30][31][32]”
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  • Premisecitation

    Insulin resistance and hyperinsulinemia are intrinsic to polycystic ovary syndrome in adults and adolescents, whether lean or obese.

    “Insulin resistance and hyperinsulinemia are intrinsic to PCOS in adults and adolescents, lean or obese.”
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    Interpretationreasoning

    Insulin resistance and hyperinsulinemia should not be used to diagnose polycystic ovary syndrome in adolescent girls.

    “Therefore, insulin resistance and/ or hyperinsulinemia should not be used to diagnose PCOS among adolescent girls.”
    • Also stated in: § Recommendations · plain
      “Although prevalent among adolescents at risk for PCOS, insulin resistance and hyperinsulinemia should not be utilized as diagnostic criteria (Level B).”
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    Premisecitation

    Upper lip Ferriman-Gallwey scores of 3-4 occur in less than 3% of Black and White US adolescents, while scores of 1-2 increase from 7.3% at less than 2 years after menarche to 28.2% at more than 2 years after menarche.

    “Upper lip scores of 3-4 were found in <3% of Black and White US adolescents, though scores of 1-2 rose in prevalence from 7.3% at <2 years after menarche to 28.2% at >2 years after menarche [40,41]”
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    Premisecitation

    Hyperandrogenism can occur without cutaneous manifestations even though hirsutism is common among women with hyperandrogenism.

    “Even though hirsutism is common among women with hyperandrogenism, the latter can occur in the absence of cutaneous manifestations [2,3]”
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    Interpretationnone given

    Persistent elevation of serum total and/or free testosterone, determined in a reliable reference laboratory, provides the clearest support for hyperandrogenism in an adolescent girl with symptoms of polycystic ovary syndrome.

    “Biochemical evidence of hyperandrogenism, as indicated by persistent elevation of serum total and/or free testosterone levels and determined in a reliable reference laboratory, provides the clearest support for the presence of hyperandrogenism in an adolescent girl with symptoms of PCOS (Level B).”
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    Premisecitation

    Polycystic ovary morphology, variously defined, has been reported with a prevalence of 30-40%, with a range between 26 and 54%, and has been described in healthy girls.

    “PCOM, variously defined, has been reported with a prevalence of 30-40% (range between 26 and 54%) and has been described in healthy girls [82]”
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    Premisecitation

    Weight loss, treatment with metformin, or treatment with rosiglitazone were associated with improved insulin sensitivity and attenuation of hyperandrogenemia in some studies.

    “weight loss, treatment with metformin, or treatment with rosiglitazone were associated with improved insulin sensitivity and attenuation of hyperandrogenemia in some studies [133][134][135][136][137]”
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    Interpretationcitation

    A multifollicular pattern, defined by the presence of large follicles distributed throughout the ovary, does not have a relationship with hyperandrogenism, is more common in adolescents, and should not be considered a pathological finding.

    “Further, a multifollicular pattern, which is defined by the presence of large follicles distributed throughout the ovary, does not have a relationship with hyperandrogenism, is more common in adolescents, and should not be considered a pathological finding (Level C).”
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    Premisecitation

    In a population-based Australian study of adolescents considered to have polycystic ovary syndrome, increased free testosterone concentration was the factor most predictive of insulin resistance, while menstrual irregularities and polycystic ovaries were not associated with insulin resistance.

    “a population-based study from Australia of adolescents considered to have PCOS in which increased free testosterone concentration was the factor most predictive of insulin resistance, while menstrual irregularities and polycystic ovaries were not associated with insulin resistance [127]”
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    Premisenone given

    Menstrual irregularity is common among adolescents and is generally the result of anovulatory cycles.

    “Menstrual irregularity is common among adolescents and is generally the result of anovulatory cycles.”
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    Premisecitation

    Morning 17-hydroxyprogesterone concentrations greater than 200 ng/dl are more common in women with congenital adrenal hyperplasia (87%), but over 20% of women with polycystic ovary syndrome had elevated morning 17-hydroxyprogesterone values.

    “Although morning 17-OHP concentrations (>200 ng/dl) have been reported as being more common in women with CAH (87%), over 20% of women with PCOS had elevated morning 17-OHP values [110]”
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    Premisecitation

    Regular cycles of 21-45 days are established by the third year after menarche in approximately 95% of girls, but cycles can remain irregular until the fifth year.

    “Regular cycles (21-45 days) are established by the third year after menarche in approximately 95% of girls, but cycles can remain irregular until the fifth year.”
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    Interpretationcitation

    Persistence of oligomenorrhea with cycles longer than 45 days, secondary amenorrhea for more than 3 months, or primary amenorrhea in girls with complete pubertal development and adult stature suggests coexisting androgen excess.

    “Accordingly, the persistence of oligomenorrhea (menstrual cycles longer than 45 days), secondary amenorrhea (absence of cycles for more than 3 months), or primary amenorrhea in girls with complete pubertal development and adult stature suggests the coexistence of androgen excess [71,78]”
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    Premisecitation

    Moderate or severe comedonal acne with 10 or more facial lesions in early puberty, or moderate inflammatory acne through the perimenarcheal years, is uncommon, with a prevalence below 5%.

    “While comedonal acne is common in adolescent girls, moderate or severe comedonal acne (i.e., 10 or more facial lesions) in early puberty or moderate inflammatory acne through the perimenarcheal years is uncommon (<5% prevalence) [42,43]”
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    Interpretationreasoning

    Moderate to severe hirsutism constitutes clinical evidence of hyperandrogenism.

    “Moderate to severe hirsutism constitutes clinical evidence of hyperandrogenism (Level B).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The reported prevalence for nonclassic congenital adrenal hyperplasia is 1 in 1,000, with increased prevalence in specific ethnic groups.

    “The reported prevalence for NCAH is 1 in 1,000 with an increased prevalence in specific ethnic groups [99]”
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    Premisecitation

    Over 90% of adolescent females have 10 or more menstrual cycles per year, with an average menstrual interval of 36.5 days, 3 years after menarche.

    “Legro et al. [69] found that over 90% of adolescent females have 10 or more menstrual cycles per year (average menstrual interval 36.5 days) 3 years after menarche.”
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    Premisecitation

    Follow-up of a different group of unselected healthy adolescents for 12 years showed tracking of androgen levels into adulthood, and higher adolescent levels were associated with lower fertility.

    “Follow-up of a different group of unselected healthy adolescents for 12 years showed tracking of androgen levels into adulthood; higher levels in adolescence were associated with lower fertility, suggesting evolving PCOS [59]”
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    Interpretationreasoning

    Follicle counts should not be utilized to define polycystic ovary morphology in adolescents.

    “Follicle counts should not be utilized to define PCOM in adolescents (Level B).”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    No compelling criteria to define polycystic ovary morphology have been established for adolescents.

    “No compelling criteria to define PCOM have been established for adolescents.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: No compelling criteria to define polycystic ovary morphology have been established for adolescents.

  • May combine two claims.

    Premisecitation

    In a study of unselected schoolgirls with oligomenorrhea, 4% had hirsutism and 57% had elevated testosterone levels.

    “In a study of unselected schoolgirls with oligomenorrhea, 4% had hirsutism and 57% had elevated testosterone levels [58]”
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    Interpretationreasoning

    Until further research establishes definitive criteria, an ovarian volume greater than 12.0 cm3 by the formula for a prolate ellipsoid can be considered enlarged in adolescents.

    “Until further research establishes definitive criteria, an ovarian volume >12.0 cm 3 (by formula for a prolate ellipsoid) can be considered en-”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationnone given

    Lack of onset of menses by age 15 years or by more than 2-3 years after thelarche regardless of chronologic age is statistically uncommon and warrants evaluation and consideration of diagnoses such as polycystic ovary syndrome.

    “Lack of onset of menses by age 15 years or by more than 2-3 years after thelarche regardless of chronologic age is statistically uncommon and warrants evaluation and consideration of diagnoses such as PCOS (Level B).”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Testosterone concentrations should be considered elevated when they are persistently greater than adult female normative values according to assays performed by specialty laboratories with well-defined reference intervals.

    “For these reasons, testosterone concentrations should be considered elevated when they are persistently greater than the adult female normative values according to assays performed by specialty laboratories with welldefined reference intervals.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    A single androgen level more than 2 standard deviations above the mean for the specific assay should not be considered evidence of hyperandrogenism in an otherwise asymptomatic adolescent girl.

    “A single androgen level >2 SD above the mean for the specific assay should not be considered to be evidence of hyperandrogenism in an otherwise asymptomatic adolescent girl (Level C).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Polycystic ovary morphology is an inconsistent finding and does not invariably predict the development of polycystic ovary syndrome.

    “Hence, PCOM is an inconsistent finding and does not invariably predict the development of PCOS [82]”
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    Premisecitation

    Gambineri et al. defined hyperandrogenism during the follicular phase as total testosterone concentrations greater than 42 ng/dl using an LC-MS/MS assay.

    “Gambineri et al. [61] defined hyperandrogenism during the follicular phase as total testosterone concentrations >42 ng/dl using a LC-MS/MS assay.”
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    Premisecitation

    Intervention trials in adolescents with polycystic ovary syndrome have also shown improvements related to hirsutism, ovulation, quality of life, sleep, lipid profile, adipocytokine levels, and insulin resistance.

    “These trials have also shown improvements related to hirsutism, ovulation, quality of life, sleep, lipid profile, adipocytokine levels, and insulin resistance [148-160]”
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  • May combine two claims.

    Interpretationnone given

    A diagnosis of polycystic ovary syndrome can impact an adolescent's quality of life and create early and unwarranted anxiety about future fertility for the young woman and her family.

    “A diagnosis of PCOS can impact an adolescent's quality of life; this diagnosis can create early and unwarranted anxiety about future fertility for the young women and her family.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    Polycystic ovary syndrome is a common and heterogeneous condition.

    “PCOS is a common heterogeneous phenotype with features overlapping some features characteristic of normal pubertal development.”
    Quote in the paperNot a substantial claim

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    Study design and conductcitation

    Longer duration trials of 12 months or more in adolescents with polycystic ovary syndrome are very limited and are either open-labelled or lack placebo-controlled arms.

    “Longer duration trials (12 months or more) are very limited and are either open-labelled trials or lack placebocontrolled arms [133, 135, 161-163]”
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30 of 30

  • The paper relies on this without support.

    No consensus exists on the clinical criteria for diagnosing androgen excess in adolescence.

    “No consensus exists on the clinical criteria to reach the diagnosis of androgen excess in adolescence.”

  • The paper relies on this without support.

    The definition of persistent oligomenorrhea is uncertain.

    “However, the definition of 'persistent oligomenorrhea' is uncertain.”

  • The paper relies on this without support.

    Detailed data are not available regarding the accuracy of predicting ongoing hyperandrogenic anovulation from a single elevated testosterone level.

    “However, detailed data are not available regarding the accuracy of the prediction of ongoing hyperandrogenic anovulation from a single elevated testosterone level.”

  • The paper relies on this without support.

    No data are available indicating how long hyperandrogenemia must continue to accurately predict persistence and development of polycystic ovary syndrome in adulthood.

    “Further, no data are available indicating how long hyperandrogenemia must continue to accurately predict persistence and development of PCOS in adulthood.”

  • The paper relies on this without support.

    No compelling criteria to define polycystic ovary morphology have been established for adolescents.

    “No compelling criteria to define PCOM have been established for adolescents.”

  • The paper relies on this without support.

    Available data are inconsistent regarding the usefulness of anti-Müllerian hormone in the diagnosis of polycystic ovary syndrome among adolescent girls.

    “Available data are inconsistent regarding the usefulness of AMH in the diagnosis of PCOS among adolescent girls [92][93][94][95][96]”
6 of 6

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Often each clinical symptom and comorbidity is treated separately, which can delay or obscure a diagnosis of PCOS and limit follow up care.

    “Often each clinical symptom and comorbidity is treated separately, which can delay or obscure a diagnosis of PCOS and limit follow up care [3, 22, 23].”

    From Challenges in diagnosis and health care in polycystic ovary syndrome in Canada: a patient view to improve health care (2023) · cites this paper as [23]

    Question 7 says a timely PCOS diagnosis enables testing for comorbidities and other interventions, and the Recommendations say it is important for appropriate screening and treatment. The paper does not say that symptoms and comorbidities are often treated separately or that this practice delays diagnosis and limits follow-up care. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Similarities between normal pubertal development and the clinical features associated with PCOS confound the diagnosis in adolescent girls.

    “These similarities between normal pubertal development and the clinical features associated with PCOS confound the diagnosis in adolescent girls (Table 1) [125–127].”

    From Polycystic Ovary Syndrome: Pathophysiology, Presentation, and Treatment With Emphasis on Adolescent Girls (2019) · cites this paper as [127]

  • Delineating appropriate diagnostic criteria for PCOS among adolescent girls has been problematic because irregular menses, cystic acne, mild hyperandrogenism, and multifollicular ovarian morphology occur during normal pubertal maturation.

    “However, delineating appropriate diagnostic criteria for PCOS among adolescent girls has been problematic because irregular menses, cystic acne, mild hyperandrogenism, and multifollicular ovarian morphology occur during normal pubertal maturation.”

    From Polycystic Ovary Syndrome: Pathophysiology, Presentation, and Treatment With Emphasis on Adolescent Girls (2019) · cites this paper as [127]

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Cited by

Sorted by citations

Authors
Witchel, S. F., Oberfield, S., Rosenfield, R. L., Codner, E., Bonny, A., Ibáñez, L., Pena, A., Horikawa, R., Gomez-Lobo, V., Joel, D., Tfayli, H., Arslanian, S., Dabadghao, P., Garcia Rudaz, C., & Lee, P. A.
Affiliations
  • Children's Hospital of Pittsburgh (US)
  • Morgan Stanley Children's Hospital (US)
  • University of Chicago (US)
  • Nationwide Children's Hospital (US)
  • Hospital Sant Joan de Déu Barcelona (ES)
  • National Center For Child Health and Development (JP)
  • Baylor College of Medicine (US)
  • American University of Beirut Medical Center (LB)
  • University of Pittsburgh (US)
  • Sanjay Gandhi Post Graduate Institute of Medical Sciences (IN)
  • Pennsylvania State University (US)
ORCID
Venue
Hormone Research in Paediatrics
Publisher
S. Karger AG
Published
2015
Volume
83
Issue
6
Pages
376-389
ISSN
  • 1663-2818 (ISSN-L)
  • 1663-2826
DOI
10.1159/000375530
OpenAlex
W2053105417
Cited by
3,113
References
64
Citations by year
2026: 17 · 2025: 119 · 2024: 197 · 2023: 328 · 2022: 357 · 2021: 237 · 2020: 231 · 2019: 276 · 2018: 244 · 2017: 223 · 2016: 206 · 2015: 187 · 2014: 73 · 2013: 43 · 2012: 27
FWCI
43.18
Type
journal article
Language
en
Open access
Licence
Locations
  • Hormone Research in Paediatrics (publishedVersion)
  • PubMed (publishedVersion)
  • Universidad de Chile (submittedVersion, cc-by-nc-nd)
Funders
  • National Institute of Diabetes and Digestive and Kidney Diseases (R01DK040605)
  • National Center for Research Resources (M01RR010732)
Topics
  • Health Sciences › Medicine › Reproductive Medicine › Ovarian function and disorders
  • Health Sciences › Medicine › Reproductive Medicine › Hypothalamic control of reproductive hormones
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Sexual Differentiation and Disorders
Keywords
polycystic ovary syndrome, adolescents, diagnostic criteria, hyperandrogenism, oligoanovulation, polycystic ovary morphology, insulin resistance, hyperinsulinemia, obesity, amenorrhea, longitudinal assessment
MeSH terms
Adolescent, Female, Humans, Insulin Resistance, Polycystic Ovary Syndrome, Puberty, Hyperandrogenism

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-05.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-05.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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