Polycystic Ovary Syndrome (PCOS) and Obesity - Endocrinology - Paediatric CPC

For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the relevant specialty service.

Women's and Children's Health Network

• Women’s and Children’s Hospital (08) 8161 7000

Exclusions

• exogenous obesity without co-morbidities where lifestyle modification measures have not been trialled

Triage categories

Category 1 - appointment clinically indicated within 30 days

• nil

Category 2 — appointment clinically indicated within 90 days

• obesity where an underlying medical or endocrine cause is suspected

• obesity with associated significant comorbidities such as:

  • obstructive sleep apnoea (OSA) – consider referral to respiratory and sleep medicine
  • hypertension
  • type 2 diabetes
• obesity in children < 5 years of age
• PCOS

Category 3 — appointment clinically indicated within 365 days

• obesity in children > 5 years of age without significant co-morbidities

For information on referral forms and how to import them, please view general referral information.

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

• identifies as Aboriginal and/or Torres Strait Islander
• identify within your referral if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf
  
• interpreter requirements

History

• past medical/surgical history, including:
  • age of onset of obesity
  • developmental delay
  • previous growth parameters
  • diet and activity history
• onset, duration, and progression of symptoms
• current medications and dosages
• allergies and sensitivities
• family history, including obesity, bariatric surgery, cardiovascular disease, and diabetes
• menstrual history, acne and hirsutism in girls (for PCOS)
• management history including treatments trialled/implemented prior to referral
• identification as Aboriginal and/or Torres Strait Islander

Examination

• examination findings, including:
  • blood pressure (BP)
  • any complications of obesity e.g. sleep apnoea, type 2 diabetes, joint pain, liver dysfunction
  • dysmorphic features
  • acanthosis nigricans
• height/weight/body mass index (BMI), including head circumference and growth charts with prior measurements if available

Investigations

Obesity complications

• liver function test (LFT)
• fasting lipids
• glycated haemoglobin test (HbA1c)

PCOS

• luteinizing hormone (LH)
• follicle-stimulating hormone (FSH)
• oestradiol
• testosterone
• sex hormone-binding globulin (SHBG)
• free androgen index (FAI)
• dehydroepiandrosterone sulphate (DHEAS)
• morning 17-hydroxyprogesterone (17-OHP)
• human chorionic gonadotropin test (Beta-hCG) if primary or secondary amenorrhoea

Additional information to assist triage categorisation

Diet history, including if the child has a very restricted diet, or specific dietary restrictions. Refer to a dietitian.

Extreme weight loss behaviours, signs of eating disorders, high level of negative body image and/or negative social experiences are evident. Refer to psychological services.

Significant psychosocial risk factors, esp. parents mental health, family violence, housing and financial stress, department of child safety involvement.

Pelvic ultrasound is not required as it is not helpful in the diagnosis of PCOS in adolescence.

• Diet history, including if the child has a very restricted diet, or specific dietary restrictions. Refer to a dietitian.
• Extreme weight loss behaviours, signs of eating disorders, high level of negative body image and/or negative social experiences are evident. Refer to psychological services.
• Significant psychosocial risk factors esp. parents mental health, family violence, housing and financial stress, department of child safety involvement.
• Pelvic ultrasound is not required as it is not helpful in the diagnosis of PCOS in adolescence.

Clinical management advice

Obesity

Definitions

• children > 2 years of age with a body mass index (BMI) > 95th centile for age and gender
• children < 2 years with weight for length > 97th centile World Health Organisation (WHO) chart.

Referral to assess for an underlying pathological condition should be considered if:

• obesity onset < 5 years of age
• obesity associated with hyperphagia and/or dysmorphic features
• history of developmental delay
• height < 1st centile or falling height percentiles.

Referral should be considered if:

• patient has failed first-line management outlined below
  • significant risk of type 2 diabetes
  • concerns of polycystic ovary syndrome (PCOS)

Children presenting with obesity associated co-morbidities:

• obstructive sleep apnoea (OSA) consider referral to respiratory medicine
• abnormal liver function tests (LFTs) consider referral to paediatric medicine or Abnormal Liver Function - Hepatology
• hypertension to paediatric medicine, nephrology or urology

General Practitioner management

• counselling on diet, exercise and reducing screen time
• consideration of health care plan to access dietitian/exercise physiologist/psychologist
• consider commencing metformin if child > 10 years. Start at a dose of 500 mg daily. Titrate dose up weekly by 500 mg to a maximal dose of 1000 mg twice daily, or as tolerated.

PCOS

A diagnosis of PCOS can be considered in adolescents who are > 2 years post menarche and requires the following:

• irregular menstrual cycles (shorter than 21 days or longer than 45 days)
• clinical or biochemical evidence of hyperandrogenemia: severe acne, hirsutism, high androgen levels.

Pelvic ultrasound is not required as it is not helpful in the diagnosis of PCOS in adolescence.

General Practitioner management

• do NOT start oral contraceptive pills (OCP) until investigations are performed
• start a menstrual calendar
• consider health care plan for dietitian/exercise physiologist and commencing metformin if obese.

General information

Contact Women’s and Children’s Hospital (WCH) endocrinology on-call on (08) 8161 7000 for advice or to escalate and discuss any clinical concerns.

Recent pathology results will be required prior to outpatient appointment. Consider providing repeat pathology form to patient at time of referral.

Patients who have previously been seen by a specialist are encouraged to be referred back to their care for further review if required.

Clinical resources

• Endocrine Society - Clinical Practice Guideline: Diagnosis and Treatment Of PCOS
• Therapeutic Guidelines - Polycystic Ovary Syndrome

Consumer resources

• Healthdirect – PCOS