Diagnosis and Management of Polycystic Ovary Syndrome in Adolescents
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Diagnosis and Management of
Polycystic Ovary Syndrome
in Adolescents
Maria Trent, MD, MPH,a Catherine M. Gordon, MD, MSb
abstract Polycystic ovary syndrome (PCOS) is a common female reproductive disorder that often
manifests during adolescence and is associated with disruptions in health-related quality of
life. Prompt evaluation and clinical support after diagnosis may prevent associated
complications and optimize overall health management. This article incorporates the most
recent evidence and consensus guidelines to provide an updated review of the pathogenesis,
clinical presentation, diagnostic evaluation, and management strategies for adolescents with
this complex condition. We will review the recent international guidelines on PCOS; because
the diagnosis of PCOS remains controversial, management of this condition is inconsistent. In
2019, PCOS remains a common, yet neglected, condition, in part, because of the lack of
agreement around both diagnosis and management.
a
Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland; and bDivision of Adolescent/Young Adult Medicine, Harvard Medical School, Harvard University and Boston
Children’s Hospital, Boston, Massachusetts
All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
DOI: https://doi.org/10.1542/peds.2019-2056J
Accepted for publication Jan 29, 2020
Address correspondence to Catherine M. Gordon, MD, MS, Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston,
MA 02115. E-mail: catherine.gordon@childrens.harvard.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2020 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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SUPPLEMENT ARTICLE PEDIATRICS Volume 145, number s2, May 2020:e20192056J
Polycystic ovary syndrome (PCOS) is expression of this aberration is touch point with these patients who
a common, complex, and revealed in ovarian theca cells must be carefully managed with
heterogeneous familial disorder that through increased expression of thoughtfulness and closely followed
affects 5% to 10% of females of cytochrome P450 enzymatic activity to ensure the patient is successful
reproductive age and is seen across (through the gene CYP17A1 or with its clinical management.
race and ethnicity, country of origin, p450c17).10
The associated clinical findings of
and other sociodemographic
Adolescents with PCOS often PCOS usually begin to manifest
backgrounds.1 PCOS has become an
demonstrate both insulin resistance during adolescence with the
increasingly important adolescent
(IR) and hyperandrogenism. presentation evolving into a clinical
reproductive health diagnosis, given
Associated manifestations may be picture that can vary considerably.
the significant reductions in health-
exacerbated in adolescents who are The reproductive dysfunction
related quality of life observed among
overweight or obese, which can presents with a range of menstrual
affected patients2,3; potential long-
complicate management of PCOS.11,12 disorders, including amenorrhea,
term cardiovascular, metabolic, and
The temporary decline in insulin oligomenorrhea, and abnormal
reproductive health outcomes4; and
sensitivity observed during puberty uterine bleeding associated with
annual clinical management costs that
may be a critical moment in the anovulation or oligoovulation.
exceed $4 billion annually.5 In this
development of IR and Patients may also present with
article, we will highlight current
hyperinsulinemia in patients ovarian enlargement, endometrial
evidence, consensus, and controversy
predisposed to developing PCOS. The hyperplasia, and infertility.
among clinicians regarding the
changes in insulin and androgen
pathogenesis, clinical presentation, Research has demonstrated that up to
metabolism appear to be interrelated,
diagnostic evaluation, and 80% of patients with PCOS will
as increases in androgens reduce
management of adolescents exhibit clinical or laboratory evidence
insulin sensitivity and insulin
with PCOS. of androgen excess. Manifestations
elevations may potentiate androgen
include hirsutism, acne, male-pattern
secretion in fat tissue.13–15 Insulin
Although the etiology of PCOS baldness or alopecia, and elevated
also augments the ovarian response
remains unclear despite decades of androgens (eg, total testosterone, free
to LH and enhances dysregulated LH
both basic science and clinical testosterone,
secretion from the pituitary gland.
research, multiple systems and dehydroepiandrosterone sulfate, or
factors including ovarian function, androstenedione).15,16 Hirsutism is
steroidogenesis, metabolism, DIAGNOSIS common among affected adolescents
neuroendocrinology, genetic, and and women, but often patients have
environmental issues have been Clinical Presentation been using home remedies or
identified as contributing to the Patients seek evaluation when the professional services that range from
pathophysiology.6 Normally, there is absence of or irregularity of menses temporary (eg, tweezing, chemical
a highly functional and coordinated becomes worrisome and they develop depilatory agents, waxing) to
process through which follicular physical findings, such as acne or permanent (eg, electrolysis,
development occurs with each hirsutism. These physical thermolysis, laser) hair removal
menstrual cycle. In adolescents with manifestations, for which home techniques. Although acne is
PCOS, there is an imbalance, resulting treatments are no longer effective, are a common presentation during
from an exaggerated luteinizing typically of great concern to the adolescence, in combination with an
hormone (LH) response driving adolescent patient who is in a period evolving menstrual disorder, it may
androgen production7 and of life when a semblance of normalcy be a manifestation of androgen
inadequate follicle-stimulating with peers is critically important. excess.17 Clinical tools, such as the
hormone (FSH), resulting in They may also have significant Ferriman-Gallwey scoring system,18
inadequate conversion of androgens concerns about sexual health and have been used to document
to estradiol, with follicular arrest.8 their future fertility.14 Attention to hirsutism for clinical management.
Anti-Müllerian hormone (AMH) plays the details of their sexual and However, in more recent work,
a key role in regulating the reproductive health histories and authors suggest that patient-, nurse-,
transitional development of follicles, liberal use of office-based testing to and pediatrician-rated hirsutism are
leading to a dominant follicle. assess for pregnancy in the absence highly variable.19 Temporal recession
However, in adolescents with PCOS, of menses can prevent the need for and/or alopecia as a sign of
follicular growth is arrested, leading a costly and unnecessary diagnostic hyperandrogenism is also important
to the many small follicles stemming workup. Nonetheless, the PCOS to document with tools such as the
from anovulation.9 The phenotypic evaluation becomes an important Ludwig visual score.20 In an era of
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PEDIATRICS Volume 145, number s2, May 2020 S211electronic medical record ultrasound and severe cystic acne. However, clinicians can intervene
documentation, use of images at The consortium did not recommend medically with an oral contraceptive
baseline and during follow-up visits obesity or biochemical (eg, IR or as first-line management after
may be an objective way to assess the hyperinsulinemia) or clinical observance of hirsutism or alopecia,
clinical impact of hyperandrogenism evidence (eg, acanthosis nigricans) of given the known impacts of each on
and the effectiveness of interim aberrant insulin metabolism; these health-related quality of life. Early
treatment over time. It is critically clinical factors may be associated but intervention can serve as a preventive
important to assess preconsultation are not sufficiently specific to PCOS to measure to avoid more severe
hair removal or acne treatment being make the diagnosis.6 AMH and cosmetic problems. For non–sexually
employed by the patient to testosterone-to-dihydrotestosterone active patients, a 3-month hormonal
thoroughly assess the impacts of ratios have emerged as potential washout period can be undertaken to
hyperandrogenism when making the diagnostic biomarkers for clinical use, reassess hormonal status in patients
diagnosis and at each follow-up visit given their association with follicular who are uncertain about their
to ascertain the effectiveness of development and adverse diagnosis and want to determine if
combined therapy, minimize side phenotypes, respectively.22–25 their menses will resume on
effects, and examine the burden of However, additional research is their own.
treatment on health-related quality warranted to define their diagnostic
of life. potential in adolescents; therefore,
CLINICAL ASSESSMENT
they are not recommended in
Clinical Guidelines laboratory evaluation for these History and Physical Examination
Given the heterogeneity of clinical patients. The new guideline also
As with all adolescent visits,
findings observed in patients with stressed the point that a definitive
a detailed, patient-centered interview
PCOS, demonstrating engagement of diagnosis of PCOS cannot be made
is critical; this includes an assessment
multiple endocrine signaling until 2 years postmenarche and,
of present illness(es) focused on the
networks as a manifestation of echoing earlier guidelines, other
patient’s clinical symptoms, past
systems-level disease is critical. causes of hyperandrogenism are first
medical history, reproductive health
Several expert consensus meetings ruled out (eg, nonclassic congenital
history (including details of puberty),
have been convened to generate adrenal hyperplasia, Cushing’s
menstrual history, social history
evidence-based diagnostic criteria to syndrome, etc).7
(including sexual behaviors and
facilitate a uniform approach to
pregnancy history), and contraceptive
identifying and managing this Another recent international
use.15 The review of systems can be
disorder, which is characterized by guideline on PCOS from the
useful in determining the presence of
both disordered menstrual cycles and International PCOS Network is also
symptoms that are consistent with
the clinical symptoms of androgen worth consideration, which reviews
PCOS (eg, weight, hair, or skin
excess. The multiple clinical the available evidence to support
changes) and assessing for other
guidelines that have been published both diagnosis and management in
disorders that may impact menstrual
over the years have led to confusion both adolescents and women.20 This
function (neck enlargement
among clinicians who seek to care for guideline notes the evidence for both
[thyromegaly], headaches,
these patients who present in assessment and management of PCOS
galactorrhea, weight changes, skin
a variety of ways. Most recently, to be of low-to-moderate quality.
and/or nail changes). Use of
a collaborative group under the They also recommend an increased
prescription and over-the-counter
International Consortium of Pediatric focus on patient education, lifestyle
medications and cosmetic procedures
Endocrinology provided an update to modifications, emotional well-being,
to reduce symptoms can also be
the pathophysiology, diagnosis, and and quality of life as critical
assessed. Adolescents may not be as
treatment of PCOS care specific to the components of intervention. The
aware of family history; therefore,
management of adolescents with the guideline also asserts that the
collection of key historical data from
disorder.6 These recommendations evidence supports allowing for only
parents before engaging in alone time
outline the required clinical features 1 year of menstrual irregularity
with the patient may be useful for
and appear to follow most closely the postmenarche before becoming
completing the clinical story of
1990 National Institutes of Health concerned about oligo- or
a patient.
guidelines,21 which include irregular anovulation. Importantly, this
menses and/or oligomenorrhea and guideline allows for a patient to be “at A comprehensive physical
biochemical or clinical evidence of risk for PCOS” with longitudinal examination can be done that
hyperandrogenism.6 Optional factors follow-up as an acceptable alternative includes vital signs, anthropometric
include polycystic ovaries on to making an early diagnosis. assessment, general appearance, skin
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S212 TRENT and GORDONsurvey to detect alopecia, male- follicles) are not recommended to
pattern baldness, acanthosis diagnose PCOS in adolescents.26
nigricans (Fig 1), acne, hirsutism Although ultrasound findings have
(Fig 2), Tanner staging, examination been shown to be supportive of the
of the external genitalia to assess for diagnosis in women, these findings
virilization (indicated by a clitoris are not specific to the disorder and
glans width .5 mm), and bimanual the diagnosis can often be made
examination, if tolerated, to assess for without an ultrasound.25 There is also
an ovarian mass.15,16 significant overlap between normal
adolescent and PCOS morphology. A
Laboratory Evaluation liver ultrasound is warranted for the
The goals of laboratory assessment patient who is obese with evidence of
FIGURE 2
are to support the diagnosis of PCOS Hirsutism in an adolescent with PCOS. (Der-
nonalcoholic fatty liver disease.
to exclude other causes of menstrual mAtlas: Online Dermatology Image Library, with
irregularity and clinical permission [Cohen, B (ed)], All rights reserved).
hyperandrogenism and assess for TREATMENT
associated clinical issues, such as calculation cannot be used to make Because PCOS in adolescence can
diabetes and hyperlipidemia. Free the diagnosis in isolation; many have lifelong implications for
and total testosterone (employing patients with the disorder will not metabolic and reproductive health,
high-quality assays, such as liquid have elevations, and the elevated early treatment is critical, and the
chromatography tandem mass ratio can be seen both in patients goals of therapy should be discussed
spectrometry and extraction or with PCOS and in those who are with each patient.6,15,16 These goals
chromatography)26 and ovulating. As previously noted, AMH include decreasing the risk of
dehydroepiandrosterone sulfate are levels are associated with the endometrial cancer (for unopposed
routinely measured to assess for the anovulation and fertility issues estrogen stimulation, which can lead
contribution of ovarian and adrenal observed in adult women with PCOS, to endometrial hyperplasia),
androgens and consider the but this promising biomarker is managing irregular menses
possibility of an adrenal or ovarian currently not recommended for (oligomenorrhea and abnormal
tumor. If late-onset congenital adrenal diagnostic decision-making because uterine bleeding), reducing hirsutism
hyperplasia is suspected, a morning guidelines for use have not been and acne, decreasing the risk for
serum 17-hydroxyprogesterone can established for adolescents.24,26 development of type 2 diabetes,
be obtained. A serum FSH can be reducing cardiovascular risks,
Patients suspected of having PCOS
measured to ensure that the ovary is improving quality of life, and
can also be screened for thyroid
functioning and assess for ovarian preserving fertility. Affected
disease (thyroxine and thyroid-
insufficiency. Given the aberrant adolescents have an increased
stimulating hormone),
changes in LH, this is often ordered to prevalence of multiple metabolic
hyperprolactinemia (prolactin), and
assess the ratio of LH to FSH. derangements, each of which can
metabolic abnormalities, such as type
Although the LH-to-FSH ratio is often present a target condition that merits
2 diabetes mellitus (fasting glucose or
elevated in patients with PCOS, this treatment. Examples include markers
hemoglobin A1c) and hyperlipidemia
for obesity, IR, dyslipidemia, and
(fasting lipid profile). Patients with
hypertension. Obesity is one of the
PCOS who are significantly obese and
most common findings in patients,
have profound chemical metabolic
with 40% to 80% of women with
abnormalities may present with
PCOS meeting criteria for being
nonalcoholic fatty liver disease;
overweight or obese.26 Obesity can
therefore, liver function (aspartate
lead to ovarian inflammation, reduced
aminotransferase, alanine
oocyte quality, and abnormal
aminotransferase) testing is
ovulatory patterns that can manifest
warranted in this subgroup.6,15,16
as infertility. Although both metabolic
Radiologic procedures, such as pelvic and reproductive abnormalities are
sonograms, to determine the well characterized, there remain
FIGURE 1 presence of the classic ovarian many questions regarding the best
Acanthosis nigricans in an adolescent with
PCOS. (DermAtlas: Online Dermatology Image
morphology (increased ovarian long-term management strategies for
Library, with permission [Cohen, B (ed)], All volume with a thickened white adolescents or women with this
rights reserved). capsule and multiple small 2–8-mm diagnosis.27,28
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PEDIATRICS Volume 145, number s2, May 2020 S213Lifestyle modifications, such dietary increased thrombotic risk with therapy, plucking, waxing, shaving,
changes, exercise, and weight loss, are a combined patch, but these have not and bleaching to achieve the desired
first-line interventions for been substantiated across reports.34 cosmetic result)1,15,38,39 and topical
adolescents with PCOS27 and are The combined preparations suppress therapies for acne. Eflornithine
endorsed by the Endocrine Society’s the hypothalamic-pituitary ovarian hydrochloride (13.9%) cream (which
clinical practice guideline28 as well as axis and decrease ovarian and blocks the enzyme ornithine
the recent international evidence- adrenal androgen production. As decarboxylase, needed for hair
based guideline on PCOS.20 This a result, unwanted hair growth growth) is another option to lessen
nonpharmacologic therapy is improves in 50% to 70% of hirsute facial hirsutism and can augment the
a critical first step for patients who women treated with an oral COC, effects of laser therapy.15 However,
are overweight or obese, which which represents the most effective the benefits of this cream and other
exacerbates the PCOS phenotype.29 therapy for management of topical strategies can be outweighed
Weight loss as a sole maneuver can hirsutism.14,28 However, insulin by their side effects (eg, burning,
decrease androgen production,30 sensitivity does not change.35 folliculitis, etc).15,36 For acne, topical
improving insulin sensitivity and Because there is often the common retinoic acid and antibiotics can be
reducing cardiovascular risk. Lifestyle goal of treating hyperandrogenism helpful adjuncts to oral antibiotics,
modifications, including a calorie- and providing contraception for an hormonal therapy, or antiandrogens.
restricted diet and/or physical adolescent, a COC can address both
Because IR is common in PCOS,
activity, has proven effective in issues.
insulin-sensitizing agents are among
altering the disease course of PCOS.26
Antiandrogens can be helpful for the most frequently studied agents.
One small study of women with PCOS
severe cases of hirsutism, as an Metformin is a biguanide that acts to
revealed that exercise markedly
adjunct to a COC, especially when decrease hepatic glucose production
improved hyperlipidemia.31 In
alopecia is present and if hirsutism and increase peripheral insulin
another study, the authors examined
has not improved after 6 months of sensitivity.28,40 IR, important within
the effectiveness of exercise and/or
a COC as monotherapy.20 Many young the pathophysiology of PCOS,
dietary interventions for affected
women seek pharmacologic predisposes patients to metabolic
adolescents and found beneficial
treatment because of the stigma dysfunction and increases the risk of
effects of exercise for a range of
associated with the male-pattern hair type 2 diabetes mellitus. As an
metabolic, anthropometric, and
growth, even before a diagnosis of insulin-sensitizing agent, metformin
cardiorespiratory fitness-related
PCOS is made. Pediatricians can has the potential to improve glycemic
outcomes.32 Subgroup analyses
consider cultural and societal factors control and prevent or improve type
revealed the greatest improvements
around the hirsutism and take into 2 diabetes, as well as address
in participants who were overweight
account not only the severity of the problems, such as dyslipidemia, that
or obese, and more outcomes
hirsutism but also the patient’s stem from the IR; it has been
improved when interventions were
perception of the severity when endorsed by recent clinical
supervised, aerobic in nature, or
determining appropriate treatment.36 guidelines.6,20
shorter in duration.
Spironolactone is the most commonly
In a recent study, the authors
Estrogen and progestin combination prescribed androgen receptor blocker
compared metformin and
therapy represent the first-line and can be used in combination with
N-acetylcysteine on clinical,
pharmacologic therapy for oral contraceptives because this agent
metabolic, and hormonal parameters
can lead to irregular menses and
adolescents with PCOS, most in women with PCOS.41 Researchers
commonly as a combined oral potential teratogenicity (feminization
studied 100 patients with PCOS who
contraceptive (COC), with 20 to 35 mg of a male fetus).14 The recommended
received metformin (1500 mg/day)
of ethinyl estradiol.20,33 This therapy dose is 50 to 200 mg/day in 1
or N-acetylcysteine (1800 mg/day)
has the potential to mitigate both to 2 divided doses.37 Other
for 24 weeks. There was significant
hirsutism and acne. A combined options include cyproterone
improvement in BMI, waist
transdermal patch and the vaginal acetate, flutamide, and finasteride,
circumference, and waist-to-hip ratio
ring are other options, but there is no but hepatotoxicity has emerged
in the N-acetylcysteine group, but no
evidence to suggest one delivery as a concern, and not all
significant difference was found in
method to be superior to the others.31 medications are available in the
weight reduction among the 2 groups.
However, the transdermal patch is not United States.
Markers of IR, including fasting
recommended for girls or women Systemic therapy can be augmented insulin and the fasting glucose-to-
whose weight is .90 kg. There have by topical and mechanical treatments insulin ratio, improved significantly
been some concerns raised about an for hirsutism (eg, electrolysis, laser after N-acetylcysteine, and a greater
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S214 TRENT and GORDONreduction of total testosterone was model assessment for IR. Anxiety and cosupplementation, compared to
seen. Enhanced improvement of the depression were measured by the a placebo, significantly improved BDI-
metabolic and hormonal profile was Beck Anxiety Inventory and the Beck II scores, general health questionnaire
observed in the N-acetylcysteine Depression Inventory-II (BDI-II). scores, as well as depression, anxiety,
group. Further study is needed, but After 90 days of metformin treatment, and stress scale scores. Vitamin D and
because of potentially fewer side both Beck Anxiety Inventory and BDI- probiotic cosupplementation were
effects compared to metformin, this II scores decreased, and indicators of associated with a significant
therapy may arise as a new option to IR and obesity were improved. The reduction in total testosterone,
consider over metformin in the findings suggest that metformin can hirsutism, and high-sensitivity
treatment of PCOS. decrease IR and improve mood, both C-reactive protein and an increase in
in adolescents and adults with PCOS. total antioxidant capacity compared
Adolescents with PCOS often seek
In another recent study, researchers to the placebo. In a systematic review
care regarding irregular menses,
explored the use of a psychological and meta-analysis, authors similarly
infertility, hirsutism, and acne. For
approach in caring for adolescents concluded that vitamin D
hirsutism, viewed by many
with this diagnosis.43 The researchers supplementation may be beneficial
adolescents as a “cosmetic
examined the prevalence of coping for follicular development and
emergency,” COCs are a first-line
and depression in adolescent girls menstrual regulation in patients with
therapy, as endorsed by recent
with PCOS. Adolescent girls 13 to PCOS45; however, confirmatory trials
guidelines.6,20 More than 2 decades
18 years of age with this diagnosis are needed. Omega-3 fatty acid
ago, we examined whether quality of
completed questionnaires and supplementation has been shown to
life was compromised in young
answered interview questions have short-term (ie, 12 weeks)
adolescents with PCOS.3 We observed
regarding how they coped with their beneficial effects for mental health
that scores on assessments of health-
disease and depression. Adolescents parameters, IR, androgens, and
related quality of life were lower than
perceived little control over many inflammatory markers.28 However,
healthy control subjects, and the issue
aspects of PCOS, with menstrual a meta-analysis46 suggests that IR
that generated the most concern was
irregularities and the threat of was not beneficially impacted by
infertility. Although adolescent
infertility reported as the most omega-3 fatty acids.
specialists typically try to prevent
stressful and least controllable
pregnancy, it is important to
aspects of PCOS. Lower control was In a recent review, authors examined
acknowledge that concerns about
a predictor of more significant the cardiovascular profile of
infertility may be seen even in the
depression among the participants. pharmacologic agents that have been
young adolescent patient. The
These results remind pediatricians to used for the management of PCOS.47
effect of this diagnosis on quality
be aware of and screen for depression It has been unclear whether PCOS is
of life continues to be mentioned,
in this population. associated with increased
including in recent clinical
cardiovascular events in later years,
guidelines.6,20
Authors of a few recent studies have independent of the presence of type 2
Mood disturbances are common explored whether vitamins and diabetes. The medications reviewed
among adolescent girls with PCOS supplements are of benefit to included COCs, antiandrogens,
and have been the subject of recent adolescents and/or women with clomiphene, and drugs specifically
research. The propensity for obesity PCOS; one study was used to examine used in diabetes therapy, including
and cosmetic concerns (eg, hirsutism, vitamin D and probiotic metformin. In the review, the authors
acne, etc) may lead to poor self- cosupplementation.44 In concluded that therapies used to treat
esteem and depression. In a recent a randomized, double-blind, placebo- these patients do not confer an
pilot study, the authors examined controlled trial in 60 adult women increased cardiovascular risk and that
mood disturbances as well as IR in (18–40 years of age) with PCOS, the there is no evidence that any
adolescents and adult women with effect of vitamin D and probiotic interventional medical therapy may
PCOS at baseline and after metformin coadministration on mental health, prevent the onset of diabetes in
therapy (1500 mg/day).42 Nineteen hormonal, and inflammatory and patients with PCOS. However, in the
adolescents (#18 years old) and 25 oxidative stress parameters was case of metformin, this agent was
women ($18 years old) were examined. The intervention was oral suggested to be beneficial in
enrolled and had their baseline and 50 000-IU vitamin D3 every 2 weeks preventing the development of
90-day anthropometric data tracked plus 8 3 109 colony-forming units gestational diabetes. Lastly, orlistat is
as well as measurements of glucose, per day of the probiotic (n = 30) or a noteworthy medication that reduces
androgens, and lipids; IR was placebo (n = 30) for 12 weeks. weight and, therefore, might lead to
calculated by using the homeostasis Vitamin D and probiotic decreased cardiovascular risk.
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PEDIATRICS Volume 145, number s2, May 2020 S215Considering agents that a clinician loss and improve glucose tolerance in REFERENCES
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S218 TRENT and GORDONDiagnosis and Management of Polycystic Ovary Syndrome in Adolescents
Maria Trent and Catherine M. Gordon
Pediatrics 2020;145;S210
DOI: 10.1542/peds.2019-2056J
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Downloaded from www.aappublications.org/news by guest on March 18, 2021Diagnosis and Management of Polycystic Ovary Syndrome in Adolescents
Maria Trent and Catherine M. Gordon
Pediatrics 2020;145;S210
DOI: 10.1542/peds.2019-2056J
The online version of this article, along with updated information and services, is
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