USG Report Interpretation - Meema, 19F

What the Report Shows

• Liver, gallbladder, CBD, pancreas, spleen - all normal
• Both kidneys - normal size, shape, no hydronephrosis, no calculi
• Urinary bladder - normal
• Uterus - anteverted (normal position), size 39x86x28 mm (normal), endometrial thickness 5.0 mm (normal for proliferative phase)
• Cervix - normal, no intrauterine collection

The Key Finding - PCOS Morphology

What is PCOS Morphology on Ultrasound?

• Ovarian volume > 10 mL (this patient: R=10.4 mL, L=11 mL - both borderline to mildly elevated)
• Follicle number per ovary ≥ 12 follicles measuring 2-9 mm

• Multiple small peripheral follicles (2-3 mm) - the classic "string of pearls" sign
• Bilateral ovarian volumes slightly above 10 cc
• FNPS > 10 in both ovaries

Important: USG Alone Does NOT Diagnose PCOS

1. Oligo/anovulation (irregular or absent periods)
2. Clinical or biochemical hyperandrogenism (excess hair, acne, elevated androgens)
3. Polycystic ovarian morphology on USG (which this patient has) ✓

Recommended Next Steps

• LH, FSH (LH:FSH ratio > 2:1 is suggestive of PCOS)
• Total and free Testosterone
• DHEA-S (to rule out adrenal source)
• Prolactin (to rule out hyperprolactinemia)
• TSH (thyroid disorders can mimic PCOS)
• AMH (anti-Mullerian hormone - typically elevated in PCOS)
• Fasting insulin and blood glucose (for insulin resistance assessment)

• Menstrual history (regularity, cycle length)
• Signs of hyperandrogenism (hirsutism, acne, hair loss)
• BMI and waist circumference
• Family history of PCOS or diabetes

Summary

Note: Having PCOM on USG alone - especially at 19 years - does not mean PCOS is confirmed. Around 20-30% of normal women of reproductive age can have polycystic-appearing ovaries without the syndrome. A full clinical and hormonal evaluation is needed before any treatment is started.

PCOS Management in Adolescents - 2023 International Guidelines

1. Diagnosis in Adolescents - Key Differences from Adults

Required for Diagnosis (BOTH must be present):

Menstrual Irregularity Definitions by Pubertal Stage:

• < 1 year post-menarche: Cycles < 21 days or > 45 days
• 1-3 years post-menarche: Cycles < 21 days or > 35 days (or < 8 cycles/year)
• > 2-3 years post-menarche: Cycles < 21 days or > 35 days (same as adult criteria)

What is NOT Used for Diagnosis in Adolescents:

• Pelvic ultrasound (PCOM) - NOT recommended until 8 years post-menarche, because multifollicular ovaries are physiologically normal in teens
• AMH levels - NOT recommended as a diagnostic criterion due to poor specificity in adolescents

For this patient (19-year-old Meema): The ultrasound showing PCOM cannot confirm PCOS diagnosis on its own. Clinical features (cycle regularity, signs of hyperandrogenism) and hormonal profile are mandatory. If she is < 8 years post-menarche (likely, given age 19), the USG PCOM finding is NOT a valid diagnostic criterion.

"At Risk" Category (new 2023 concept):

2. Assessment - What to Screen For

3. Management

First Line - Lifestyle Modification (ALL adolescents)

• Healthy diet - no single best diet; low glycaemic index and Mediterranean diets have evidence
• Regular physical activity - 150 min/week moderate-intensity or 75 min/week vigorous activity
• Weight management - prevent weight gain in all; modest weight loss (5-10%) in those with overweight significantly improves menstrual regularity, hyperandrogenism, and metabolic markers
• Weight stigma must be minimized - healthcare providers should seek permission before discussing weight and frame it around health, not appearance

Second Line - Pharmacological Treatment

For Menstrual Irregularity + Hyperandrogenism:

• Regulates cycles, reduces androgens, treats acne and hirsutism
• No specific preparation is recommended - use lowest effective dose
• Prefer preparations with low androgenic progestins (e.g., norgestimate, desogestrel, drospirenone)
• Duration: minimum 3-6 months to assess hirsutism response
• Always discuss VTE risk, and counsel on contraception/STI prevention (Machado et al., JCEM 2026)

For Metabolic Features (insulin resistance, impaired glucose tolerance):

• Improves insulin sensitivity, supports weight management, helps cycle regulation
• Also considered when COCP is contraindicated or not desired
• Start low, titrate (500 mg OD → 1500-2000 mg/day with food) to minimize GI side effects
• Evidence supports its use as first-line for metabolic comorbidities in adolescents

Additional Options (evidence emerging):

Note on SPIOMET (spironolactone + pioglitazone + metformin): A 2023 multicentre phase II RCT protocol is evaluating this combination vs. lifestyle alone in adolescent PCOS [PMID: 37715279] - results are awaited.

4. Psychological Care

• Screen routinely for anxiety, depression, and eating disorders
• PCOS adolescents have ~2x higher rates of anxiety and depression vs. peers
• Cognitive behavioural therapy (CBT) and mindfulness are recommended adjuncts
• Use non-stigmatizing language around weight and fertility

5. Long-Term Planning

• Develop a lifelong health plan starting in adolescence
• Ensure transition of care to adult endocrinology/gynecology at 18-21 years
• Counsel on long-term risks: type 2 diabetes, cardiovascular disease, endometrial hyperplasia (from chronic anovulation)
• Reassess diagnosis at transition to adult care - some adolescents diagnosed "at risk" may no longer meet criteria in adulthood

Summary Table

• Peña AS et al. International evidence-based recommendations for PCOS in adolescents. BMC Med. 2025 [PMID: 40069730]
• Machado IFR et al. Approach to diagnosis and treatment of PCOS in adolescent patients. JCEM. 2026 [PMID: 42105324]
• Vadan RL et al. Comparative management methods for adolescents with PCOS. Cureus. 2024 [PMID: 38595887]
• 2023 International PCOS Network Guideline (Teede HJ et al., Fertil Steril 2023;120:767-793)