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Polycystic Ovary Syndrome: Current Concepts for A Complex Condition
Dr. Tania Burgert discusses Polycystic Ovary Syndrome (PCOS) and the current ideas surrounding a complex condition.
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Learn more about Tania Burgert, MD
Tania Burgert, MD
Dr. Burgert is a pediatric endocrinologist specializing in polycystic ovary syndrome, menstrual disturbances, and disorders of puberty. She received her medical degree from Westfaeliche-Wilhelms University Medical School in Muenster, Germany. She completed a residency in Pediatrics and a fellowship in Pediatric Endocrinology at Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY. She is board certified in Pediatrics and Pediatric Endocrinology. Dr. Burgert is chair of the Education Committee- Androgen Excess and PCOCS Society.Learn more about Tania Burgert, MD
Transcription:
Polycystic Ovary Syndrome: Current Concepts for A Complex Condition
Dr. Michael Smith (Host): Polycystic ovarian syndrome can be a complex condition to manage. Here to help us get a handle on it is Dr. Tania Burgert. She is a Pediatric Endocrinologist at Children’s Mercy and Associate Professor of Pediatrics at the University of Missouri Kansas City School of Medicine. This is Transformational Pediatrics, the podcast from Children’s Mercy. I’m Dr. Mike. Dr. Burgert how common is polycystic ovarian syndrome?
Tania Burgert, MD (Guest): Polycystic ovarian syndrome is actually the most common endocrinopathy in women worldwide. It affects about 10% of the female population.
Host: Wow, so that’s a lot more than I was familiar with. Is this something that in your experience and your expertise, that we are seeing more often? Is there an increase in prevalence of this? Or has that been pretty consistent, that statistic you just shared, pretty consistent?
Dr. Burgert: It’s been a pretty consistent statistic. I think we are a little bit more aware of the condition now and we are certainly diagnosing it more in adolescents and just due to more awareness and probably it is more prevalent than 10% in some populations. So, but it’s always been there. It’s one of those very conserved conditions throughout evolution actually.
Host: So, let’s talk a little bit, for a nice review, some of the causes and some of the risk factors in obviously the adolescent population for polycystic ovarian syndrome. So could you just kind of run us through some of the causes and risk factors?
Dr. Burgert: Oh, yes, yes. So, actually – so PCOS as I just mentioned is a genetic predisposition so, you are just born with it, but the manifestation can be variable. So, in some women they will have a full typical phenotype such as very irregular periods, excessive weight gain, the hormonal dysregulation leads to an elevation in testosterone which leads to severe acne, hirsutism. So, that is kind of the classic phenotype that we have, but there is a big spectrum in that clinical manifestation. And so, a lot of women will have one or two or some of these signs.
So, it’s not the same for everybody. And therefore, we like to really individualize our care in this condition.
Host: I guess that’s one of the reasons that I think most experts like yourself consider this to be a complex condition to manage. Because it can manifest in so many different ways. Tell us a little bit again, in your experience, what are some of those common diagnostic and therapeutic challenges that a primary care or a general pediatrician might face and how can we work around those challenges or overcome them?
Dr. Burgert: Yes. Okay so those – these challenges are mainly – they are challenges in all ages, but from my standpoint in adolescence, there is significant overlap between normal symptoms of puberty and PCOS. For example, one of the hallmarks of the condition is irregular periods. And it is not uncommon for adolescents to have irregular periods. And trying to figure out at what point is that still part of adolescence or does that constitute early PCOS and so, what I think the primary care providers should know is that we give about a year of menstrual dysregulation post menarche as kind of – you can still be regular about one year after your first period. Once you get beyond one year, if your periods skip more than 90 days; that should be a red flag. The second year, post menarche, yes you can still have irregularities, you can have every 21 to 45 days cycles. That’s still considered normal but once in that second year you go beyond 45 days, you go to 90 days; you should kind of at least do some kind of evaluation why this girl is not menstruating in a normal fashion.
We like to consider the menstrual cycle kind of a vital sign. We look at heart rate, blood pressure, all those things and if your menstrual cycle is off, we should really go looking for a cause. So, at that point, second year post menarche, if cycles are beyond 90 days; we should do an evaluation. So and that evaluation should include excluding some of the other common endocrine conditions that might affect your menstrual cycle such as thyroid dysfunction, an elevated prolactin could sometimes give you irregular cycles. So, a general evaluation for what would contribute to irregular periods at this point would be desired.
Now, to diagnose PCOS, you would have to find an elevation in testosterone in those patients with irregular periods and so, that would be a diagnostic criteria for PCOS. Irregular cycles and elevation in testosterone.
Host: During this whole evaluation period, when should the primary care physician or nurse practitioner – when should they decide that this needs to move on to the specialists? So, they are evaluating when the menses began and they are looking at if there’s any irregularities there; maybe they can do some of the hormone tests; but at what point, does this need to go onto somebody like you Dr. Burgert?
Dr. Burgert: Yes. So, if there’s menstrual dysregulation, we can’t really find a cause and we find that there’s an elevation in testosterone and this elevation may not be very elevated, it may just be borderline, it may not be consistent, because hormones fluctuate. So, you may have an afternoon testosterone that still looks kind of in a normal range but if you check it in the morning, it’s more elevated that’s because of the diurnal variation so if you’re suspicious that this patient has irregular periods and maybe some clinical manifestations of high testosterone such as excessive acne and hirsutism even though the testosterone may not be classically elevated above 50; you may still want to refer.
Of course if the patient’s testosterone is elevated, in a typical way and the periods are irregular, I would recommend referral as well.
Host: Yeah. So, we’ve kind of gone through what the experience might be for the patient and the primary care physician or general pediatrician early on; if the referral is made to an expert like yourself, can you walk us through your workup of the patient and what then guides your treatment recommendation?
Dr. Burgert: So, again, it’s very important to understand that treatment is very individualized. We kind of like to see the patient as a whole and see what is their main concern. Some adolescents may be mostly concerned about the irregularity of the cycles. Others are more focused on the cosmetic aspect, another one is very concerned about the weight gain that’s associated with the hormonal dysregulation. We as physicians we may be concerned about the metabolic risks, the risks for diabetes. There’s also a lot that we know nowadays about the mood disorder and especially anxiety associated with PCOS, so we want to be mindful about that and kind of ask how they are feeling with – in terms of dealing with depression and anxiety because that also is hormonally related in PCOS. So, we try to get a really good understanding what are the symptoms of the individual patient, which are the ones that they are most bothered by. Which are the most concerning and then we decide a plan of attack and treatment and we want to take into consideration, immediate symptom relief as well as benefitting them long-term in terms of metabolic health and later on fertility.
Because if you have PCOS, and you have irregular periods, it’s more difficult to conceive later on in life. So, we like to have a good look at all aspects of PCOS and then offer the most comprehensive evaluation so that the patient really knows everything about the condition, knows about their metabolic state so every patient with PCOS does get an oral glucose tolerance test in our system because our previous data have shown that even if you are not overweight, or excessively overweight, you are at risk for prediabetes or diabetes. So, we evaluate all patients on that. All patients receive nutrition consultation. We refer them to specialists who may be able to help them with mood and anxiety and we have our adolescence medicine colleagues to kind of talk about reproductive health and kind of moving forward in terms of transitioning to adulthood.
So, yes, we have a comprehensive approach.
Host: Right, right. So, as a complex condition and in summary Dr. Burgert, what would you like the general pediatrician, the primary care physician to know about polycystic ovarian syndrome?
Dr. Burgert: That it is variable in expression. It’s very difficult to diagnose. We would like to err on the side of making the diagnosis and even if we’re not 100% sure that this patient has PCOS, if they are at risk of PCOS or even if they have PCOS like symptoms; there’s treatment that may benefit them. And it’s better to kind of look for this and to fully evaluate and to get them in, than to just kind of wait and see if this really turns out to be PCOS.
Host: Perfect summary. I really appreciate that. That’s Dr. Tania Burgert, a Pediatric Endocrinologist at Children’s Mercy. Thanks for checking out this episode of Transformational Pediatrics. Please visit www.childrensmercy.org, that’s www.childrensmercy.org to get connected with Dr. Burgert or other providers. If you found this podcast helpful, please share it on your social channels and be sure to check the entire podcast library for topics of interest to you. And be sure to check back soon for the next podcast.
Polycystic Ovary Syndrome: Current Concepts for A Complex Condition
Dr. Michael Smith (Host): Polycystic ovarian syndrome can be a complex condition to manage. Here to help us get a handle on it is Dr. Tania Burgert. She is a Pediatric Endocrinologist at Children’s Mercy and Associate Professor of Pediatrics at the University of Missouri Kansas City School of Medicine. This is Transformational Pediatrics, the podcast from Children’s Mercy. I’m Dr. Mike. Dr. Burgert how common is polycystic ovarian syndrome?
Tania Burgert, MD (Guest): Polycystic ovarian syndrome is actually the most common endocrinopathy in women worldwide. It affects about 10% of the female population.
Host: Wow, so that’s a lot more than I was familiar with. Is this something that in your experience and your expertise, that we are seeing more often? Is there an increase in prevalence of this? Or has that been pretty consistent, that statistic you just shared, pretty consistent?
Dr. Burgert: It’s been a pretty consistent statistic. I think we are a little bit more aware of the condition now and we are certainly diagnosing it more in adolescents and just due to more awareness and probably it is more prevalent than 10% in some populations. So, but it’s always been there. It’s one of those very conserved conditions throughout evolution actually.
Host: So, let’s talk a little bit, for a nice review, some of the causes and some of the risk factors in obviously the adolescent population for polycystic ovarian syndrome. So could you just kind of run us through some of the causes and risk factors?
Dr. Burgert: Oh, yes, yes. So, actually – so PCOS as I just mentioned is a genetic predisposition so, you are just born with it, but the manifestation can be variable. So, in some women they will have a full typical phenotype such as very irregular periods, excessive weight gain, the hormonal dysregulation leads to an elevation in testosterone which leads to severe acne, hirsutism. So, that is kind of the classic phenotype that we have, but there is a big spectrum in that clinical manifestation. And so, a lot of women will have one or two or some of these signs.
So, it’s not the same for everybody. And therefore, we like to really individualize our care in this condition.
Host: I guess that’s one of the reasons that I think most experts like yourself consider this to be a complex condition to manage. Because it can manifest in so many different ways. Tell us a little bit again, in your experience, what are some of those common diagnostic and therapeutic challenges that a primary care or a general pediatrician might face and how can we work around those challenges or overcome them?
Dr. Burgert: Yes. Okay so those – these challenges are mainly – they are challenges in all ages, but from my standpoint in adolescence, there is significant overlap between normal symptoms of puberty and PCOS. For example, one of the hallmarks of the condition is irregular periods. And it is not uncommon for adolescents to have irregular periods. And trying to figure out at what point is that still part of adolescence or does that constitute early PCOS and so, what I think the primary care providers should know is that we give about a year of menstrual dysregulation post menarche as kind of – you can still be regular about one year after your first period. Once you get beyond one year, if your periods skip more than 90 days; that should be a red flag. The second year, post menarche, yes you can still have irregularities, you can have every 21 to 45 days cycles. That’s still considered normal but once in that second year you go beyond 45 days, you go to 90 days; you should kind of at least do some kind of evaluation why this girl is not menstruating in a normal fashion.
We like to consider the menstrual cycle kind of a vital sign. We look at heart rate, blood pressure, all those things and if your menstrual cycle is off, we should really go looking for a cause. So, at that point, second year post menarche, if cycles are beyond 90 days; we should do an evaluation. So and that evaluation should include excluding some of the other common endocrine conditions that might affect your menstrual cycle such as thyroid dysfunction, an elevated prolactin could sometimes give you irregular cycles. So, a general evaluation for what would contribute to irregular periods at this point would be desired.
Now, to diagnose PCOS, you would have to find an elevation in testosterone in those patients with irregular periods and so, that would be a diagnostic criteria for PCOS. Irregular cycles and elevation in testosterone.
Host: During this whole evaluation period, when should the primary care physician or nurse practitioner – when should they decide that this needs to move on to the specialists? So, they are evaluating when the menses began and they are looking at if there’s any irregularities there; maybe they can do some of the hormone tests; but at what point, does this need to go onto somebody like you Dr. Burgert?
Dr. Burgert: Yes. So, if there’s menstrual dysregulation, we can’t really find a cause and we find that there’s an elevation in testosterone and this elevation may not be very elevated, it may just be borderline, it may not be consistent, because hormones fluctuate. So, you may have an afternoon testosterone that still looks kind of in a normal range but if you check it in the morning, it’s more elevated that’s because of the diurnal variation so if you’re suspicious that this patient has irregular periods and maybe some clinical manifestations of high testosterone such as excessive acne and hirsutism even though the testosterone may not be classically elevated above 50; you may still want to refer.
Of course if the patient’s testosterone is elevated, in a typical way and the periods are irregular, I would recommend referral as well.
Host: Yeah. So, we’ve kind of gone through what the experience might be for the patient and the primary care physician or general pediatrician early on; if the referral is made to an expert like yourself, can you walk us through your workup of the patient and what then guides your treatment recommendation?
Dr. Burgert: So, again, it’s very important to understand that treatment is very individualized. We kind of like to see the patient as a whole and see what is their main concern. Some adolescents may be mostly concerned about the irregularity of the cycles. Others are more focused on the cosmetic aspect, another one is very concerned about the weight gain that’s associated with the hormonal dysregulation. We as physicians we may be concerned about the metabolic risks, the risks for diabetes. There’s also a lot that we know nowadays about the mood disorder and especially anxiety associated with PCOS, so we want to be mindful about that and kind of ask how they are feeling with – in terms of dealing with depression and anxiety because that also is hormonally related in PCOS. So, we try to get a really good understanding what are the symptoms of the individual patient, which are the ones that they are most bothered by. Which are the most concerning and then we decide a plan of attack and treatment and we want to take into consideration, immediate symptom relief as well as benefitting them long-term in terms of metabolic health and later on fertility.
Because if you have PCOS, and you have irregular periods, it’s more difficult to conceive later on in life. So, we like to have a good look at all aspects of PCOS and then offer the most comprehensive evaluation so that the patient really knows everything about the condition, knows about their metabolic state so every patient with PCOS does get an oral glucose tolerance test in our system because our previous data have shown that even if you are not overweight, or excessively overweight, you are at risk for prediabetes or diabetes. So, we evaluate all patients on that. All patients receive nutrition consultation. We refer them to specialists who may be able to help them with mood and anxiety and we have our adolescence medicine colleagues to kind of talk about reproductive health and kind of moving forward in terms of transitioning to adulthood.
So, yes, we have a comprehensive approach.
Host: Right, right. So, as a complex condition and in summary Dr. Burgert, what would you like the general pediatrician, the primary care physician to know about polycystic ovarian syndrome?
Dr. Burgert: That it is variable in expression. It’s very difficult to diagnose. We would like to err on the side of making the diagnosis and even if we’re not 100% sure that this patient has PCOS, if they are at risk of PCOS or even if they have PCOS like symptoms; there’s treatment that may benefit them. And it’s better to kind of look for this and to fully evaluate and to get them in, than to just kind of wait and see if this really turns out to be PCOS.
Host: Perfect summary. I really appreciate that. That’s Dr. Tania Burgert, a Pediatric Endocrinologist at Children’s Mercy. Thanks for checking out this episode of Transformational Pediatrics. Please visit www.childrensmercy.org, that’s www.childrensmercy.org to get connected with Dr. Burgert or other providers. If you found this podcast helpful, please share it on your social channels and be sure to check the entire podcast library for topics of interest to you. And be sure to check back soon for the next podcast.