PCOS-like hormone changes are part of normal puberty.
During this transitional period, hyperandrogenemia (high levels of testosterone and similar hormones) is quite common. In fact, it’s actually a normal aspect of the maturing process: acne, and irregular periods are part of pubertal development. So when does it become PCOS?
Lots of girls who are misdiagnosed with PCOS are actually just in normal puberty, and later go on to have completely normal hormones.
On the opposite end of the spectrum, many girls still go undiagnosed—even with clear signs—as there’s so much confusion as to what is normal. With PCOS, it’s better to intervene earlier because this can make a huge difference in their overall health for life.
So, how can you tell if it’s PCOS, and what do you need to know?
Is it PCOS? Or Just Normal Puberty?
Hirsutism is a common symptom when grading androgen excess in teens. The way to differentiate hirsutism from hypertrichosis (or just being more “hairy” is related to coarseness: if the hair is thick and dark it is most likely related to androgen excess. There’s also the distribution aspect—in hirsutism, facial and body hair is distributed in a pattern typically seen in males—under the chin, on the jawline, or a downward a line under the bellybutton.
Acne is also a common problem in most teenagers. That said, it’s typically transient and may not be related to anything except the usual hormonal fluctuations during these years. Acne usually shows up due to the higher testosterone environment that’s found during teen years.
However, if acne isn’t responding to topical therapy, investigation into androgen excess is a good course of action.
Another consideration is something called prematureadrenarche, which is the appearance of pubic hair before a girl reaches 8 years of age. There are many girls who don’t have premature adrenatrche, however, and yet go on to develop PCOS, and vice versa.
It’s confusing, I know.
Some studies have found that premature adrenarche can lead to PCOS, especially if a girl gains enough weight to cause significant insulin resistance. 
When trying to determine whether the girl has PCOS,exclude non-classical CAH with ACTH stimulation testing if warranted, as well as Cushing’s syndrome.
For most girls, irregular menses are common for 2 yrs after their first period. As a result, it’s important not to use irregular menses as a criteria to diagnose any girl within this period of time.
Potential for Misdiagnosis
Some women even experience irregular menses up to the 5th year after the first period without developing PCOS.
Typically, however, cycles longer than 45 days, 2 years after the onset of the first period suggests that PCOS should be investigated.
Also, PCOS-related ovulatory dysfunction in teens can present as primary amenorrhea (not getting their first period). Dysfunctional uterine bleeding with cycles shorter than 21 days, or prolonged bleeding for more than 7 days are also symptoms. This can be caused by excess androgens that block ovulation.
With respect to ultrasound in teens—this is where a lot of women are misdiagnosed.
Since there are numerous follicles and irregular ovulation can be common in adolescence, it’s definitely common to have polycystic ovaries on ultrasound. Many girls who present this way go on and never develop PCOS, so it’s important not to use this alone to diagnose the condition!
Birth Control Pills and Hormone Testing
Unfortunately, many girls with irregular menses and who have PCO on ultrasound are placed on birth control pills before their reproductive axis has the opportunity to develop. As a result, it can be difficult to know if these teens actually had PCOS, or if communication between their hypothalamus and pituitary never had the chance to establish properly.
I’ve found that once these women come off birth control, it can take longer for them to re-establish their cycles. As expected with time, some of them do have PCOS, whereas some don’t!
When it comes to PCOS in adolescence, it’s actually more important to confirm whether androgen lab levels are high. As we discussed previously, most women have lower androgens as they age. In teen girls, however, androgen levels are often on the high side.
As such, in girls who are suspected of having PCOS, there are often elevated total testosterone levels. Do a mass spectrometry testosterone assay if possible, or high quality RIA testing if nothing else.
One study defined hyperandrogenism during the follicular phase as total testosterone concentrations of >42 ng/dL (1.45 nmol/L) with liquid chromatography mass spectrometry.
Other Available guidelines have suggested total testosterone concentrations >55 ng/dL (1.91 nmol/L) are likely consistent with hyperandrogenism.
The same inflammatory changes seen in adults with PCOS are also commonly found in teens with PCOS, even if they’re lean.  High levels of fibrinogen and hs-crp signal low-gradeinflammation.
In addition, fat cell markers associated with PCOS have even been found in children who later go on to develop the condition, including adiponectin. 
Inflammation and Mental Health in Teens with PCOS
Mental health is also an important consideration for teens with PCOS. Although mood disorders in teens are multifactorial, the following are special considerations for women with the condition.
- Depression and anxiety linked to PCOS. Evidence is mounting for inflammation being central to the development of mood disorders, and PCOS is a condition with chronic low grade inflammation.[4, 5]
- Hormonal dysregulation may also contribute to depression and anxiety in teens.
- Differences in nervous system sympathetic tone have been found in teens with PCOS. This may contribute to irregular cycles, but also to increased anxiety, flight-or-fight responses, or sleep issues.
- Social pressure—they may feel stress with rapid weight gain, hair growth, and acne.
- Eating disorders are common in all female adolescents, but they’re even more common in women with PCOS. In particular, binge eating disorder and bulimia are common. These occur because PCOS causes many dysregulations with blood sugar, and appetite control hormones like leptin.
Many women will benefit from help from a licensed psychologist as they heal around eating disorders.
Important Points to Remember:
- In adolescence, good nutrition and lifestyle habits can prevent the development of more severe PCOS phenotypes. Since their endocrine system is still developing, every effort to increase education around nutrition and exercise will pay off for a lifetime.
- Teens suspected of having PCOS should receive a workup for their metabolic health. This should include triglycerides, fibrinogen, lipid panel, ALT, fasting insulin, Vitamin D, HBA1C, and hs-CRP.
- A temporary PCOS-like condition is part of normal pubertal development. It’s only if this doesn’t resolve that it becomes PCOS.
- Since teens can easily look like they have PCOS, it has been suggested that they should have all 3 criteria to be considered for a diagnosis. High androgens, irregular menses for longer than 2 years after their first period, and PCO on ultrasound.
- Stress management and mental health are key for all teens with PCOS. Finding a good psychologist and helping teens learn mindfulness techniques such as meditation or guided visualization can help them navigate the condition as move go through their teen years.
- A session with a skilled PCOS-focused naturopathic doctor, nutritionist, or dietician is important for young women to learn skills about eating for optimal blood sugar balance.
- Many adolescents with PCOS are excellent athletes, as their higher-than-average androgen levels can help build muscle strength and agility. Sports and exercise are a great way for teens with PCOS to build confidence, prevent metabolic disease, and build healthy habits that will last a lifetime.
- McCartney, C. R., Blank, S. K., Prendergast, K. A., Chhabra, S., Eagleson, C. A., Helm, K. D., … Marshall, J. C.Obesity and Sex Steroid Changes across Puberty: Evidence for Marked Hyperandrogenemia in Pre- and Early Pubertal Obese GirlsThe Journal of Clinical Endocrinology Metabolism2007;92(2):430-436.https://doi.org/10.1210/jc.2006-2002
- Mažibrada, I., Djukić, T., Perović, S., Plješa-Ercegovac, M., Plavšić, L., Bojanin, D., … Macut, D.The association of hs-CRP and fibrinogen with anthropometric and lipid parameters in non-obese adolescent girls with polycystic ovary syndromeJournal of Pediatric Endocrinology and Metabolism2018;0(0):1213-1220.https://doi.org/10.1515/jpem-2017-0511
- Toulis, K. A., Goulis, D. G., Farmakiotis, D., Georgopoulos, N. A., Katsikis, I., Tarlatzis, B. C., … Panidis, D.Adiponectin levels in women with polycystic ovary syndrome: a systematic review and a meta-analysisHuman Reproduction Update15(3);297-307.https://doi.org/10.1093/humupd/dmp006
- Ouakinin, S. R. S., Barreira, D. P., Gois, C. J.Depression and Obesity: Integrating the Role of Stress, Neuroendocrine Dysfunction and Inflammatory PathwaysFrontiers in Endocrinology9;:431.https://doi.org/10.3389/fendo.2018.00431
- Dooley, L. N., Kuhlman, K. R., Robles, T. F., Eisenberger, N. I., Craske, M. G., Bower, J. E.The role of inflammation in core features of depression: Insights from paradigms using exogenously-induced inflammationNeuroscience Biobehavioral Reviews94;:219-237.https://doi.org/10.1016/j.neubiorev.2018.09.006