Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Definition, clinical features and differential diagnosis of polycystic ovary syndrome in adolescents

Robert L Rosenfield, MD
Section Editors
Amy B Middleman, MD, MPH, MS Ed
Mitchell E Geffner, MD
Deputy Editor
Alison G Hoppin, MD


Polycystic ovary syndrome (PCOS) is the most common cause of infertility in women [1], frequently becomes manifest during adolescence, and is primarily characterized by ovulatory dysfunction and hyperandrogenism. The syndrome is heterogeneous clinically and biochemically. The diagnosis of PCOS has lifelong implications with increased risk for metabolic syndrome, type 2 diabetes mellitus, and possibly cardiovascular disease and endometrial carcinoma. PCOS should be considered in any adolescent girl with a chief complaint of hirsutism, treatment-resistant acne, menstrual irregularity, or obesity. (See 'Clinical features' below.)

The cause of PCOS is unknown. Considerable evidence suggests that it arises as a complex trait with contributions from both heritable and nonheritable intrauterine and extrauterine factors, among which insulin resistance and obesity are most common [2,3]. Functional ovarian hyperandrogenism is usually the major source of the androgen excess [4-6] and can account for the major features of the syndrome, ie, hirsutism, anovulation, and polycystic ovaries [4,7]. This ovarian dysfunction is unique: it appears to be intrinsic and is characterized by abnormal ovarian steroidogenesis [8] and folliculogenesis [3] that are manifested clinically by androgen excess and anovulation.

The definition, clinical manifestations, and differential diagnosis of PCOS in adolescents are presented here. Other aspects of PCOS in adolescents are reviewed separately:

(See "Diagnostic evaluation of polycystic ovary syndrome in adolescents".)

(See "Treatment of polycystic ovary syndrome in adolescents".)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jan 2017. | This topic last updated: Fri Feb 10 00:00:00 GMT+00:00 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Azziz R, Woods KS, Reyna R, et al. The prevalence and features of the polycystic ovary syndrome in an unselected population. J Clin Endocrinol Metab 2004; 89:2745.
  2. Rosenfield RL. Clinical review: Identifying children at risk for polycystic ovary syndrome. J Clin Endocrinol Metab 2007; 92:787.
  3. Franks S, Stark J, Hardy K. Follicle dynamics and anovulation in polycystic ovary syndrome. Hum Reprod Update 2008; 14:367.
  4. Ehrmann DA, Barnes RB, Rosenfield RL. Polycystic ovary syndrome as a form of functional ovarian hyperandrogenism due to dysregulation of androgen secretion. Endocr Rev 1995; 16:322.
  5. Ibañez L, Hall JE, Potau N, et al. Ovarian 17-hydroxyprogesterone hyperresponsiveness to gonadotropin-releasing hormone (GnRH) agonist challenge in women with polycystic ovary syndrome is not mediated by luteinizing hormone hypersecretion: evidence from GnRH agonist and human chorionic gonadotropin stimulation testing. J Clin Endocrinol Metab 1996; 81:4103.
  6. Rosenfield RL, Mortensen M, Wroblewski K, et al. Determination of the source of androgen excess in functionally atypical polycystic ovary syndrome by a short dexamethasone androgen-suppression test and a low-dose ACTH test. Hum Reprod 2011; 26:3138.
  7. Jonard S, Dewailly D. The follicular excess in polycystic ovaries, due to intra-ovarian hyperandrogenism, may be the main culprit for the follicular arrest. Hum Reprod Update 2004; 10:107.
  8. Nelson VL, Legro RS, Strauss JF 3rd, McAllister JM. Augmented androgen production is a stable steroidogenic phenotype of propagated theca cells from polycystic ovaries. Mol Endocrinol 1999; 13:946.
  9. Stein IF, Leventhal ML. Amenorrhea associated with bilateral polycystic ovaries. Am J Obstet Gynecol 1935; 29:181.
  10. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004; 81:19.
  11. Zawadzki J, Dunaif A. Diagnostic criteria for polycystic ovary syndrome: Towards a rational approach.. In: Polycystic ovary syndrome, Dunaif A, Givens J, Haseltine F, et al. (Eds), Blackwell Scientific Publications, Cambridge 1992. p.377.
  12. Azziz R, Carmina E, Dewailly D, et al. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril 2009; 91:456.
  13. Johnson TRB, Kaplan LK, Ouyang P, Rizza RA. Evidence-based methodology workshop on polycystic ovary syndrome, 2012. Executive Summary. Available at: http://prevention.nih.gov/workshops/2012/pcos/docs/FinalReport.pdf (Accessed on December 24, 2013).
  14. Rosenfield RL. The Diagnosis of Polycystic Ovary Syndrome in Adolescents. Pediatrics 2015; 136:1154.
  15. Rosenfield RL. The Polycystic Ovary Morphology-Polycystic Ovary Syndrome Spectrum. J Pediatr Adolesc Gynecol 2015; 28:412.
  16. Witchel SF, Oberfield S, Rosenfield RL, et al. The Diagnosis of Polycystic Ovary Syndrome during Adolescence. Horm Res Paediatr 2015.
  17. Rosenfield RL, Ehrmann DA, Littlejohn EE. Adolescent polycystic ovary syndrome due to functional ovarian hyperandrogenism persists into adulthood. J Clin Endocrinol Metab 2015; 100:1537.
  18. Adams JM, Taylor AE, Crowley WF Jr, Hall JE. Polycystic ovarian morphology with regular ovulatory cycles: insights into the pathophysiology of polycystic ovarian syndrome. J Clin Endocrinol Metab 2004; 89:4343.
  19. Barber TM, Wass JA, McCarthy MI, Franks S. Metabolic characteristics of women with polycystic ovaries and oligo-amenorrhoea but normal androgen levels: implications for the management of polycystic ovary syndrome. Clin Endocrinol (Oxf) 2007; 66:513.
  20. Guastella E, Longo RA, Carmina E. Clinical and endocrine characteristics of the main polycystic ovary syndrome phenotypes. Fertil Steril 2010; 94:2197.
  21. Carmina E, Chu MC, Longo RA, et al. Phenotypic variation in hyperandrogenic women influences the findings of abnormal metabolic and cardiovascular risk parameters. J Clin Endocrinol Metab 2005; 90:2545.
  22. Burgers JA, Fong SL, Louwers YV, et al. Oligoovulatory and anovulatory cycles in women with polycystic ovary syndrome (PCOS): what's the difference? J Clin Endocrinol Metab 2010; 95:E485.
  23. Brower M, Brennan K, Pall M, Azziz R. The severity of menstrual dysfunction as a predictor of insulin resistance in PCOS. J Clin Endocrinol Metab 2013; 98:E1967.
  24. Moghetti P, Tosi F, Bonin C, et al. Divergences in insulin resistance between the different phenotypes of the polycystic ovary syndrome. J Clin Endocrinol Metab 2013; 98:E628.
  25. Pelusi C, Fanelli F, Pariali M, et al. Parallel variations of insulin-like peptide 3 (INSL3) and antimüllerian hormone (AMH) in women with the polycystic ovary syndrome according to menstrual cycle pattern. J Clin Endocrinol Metab 2013; 98:E1575.
  26. Legro RS, Arslanian SA, Ehrmann DA, et al. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2013; 98:4565.
  27. Martin KA, Chang RJ, Ehrmann DA, et al. Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2008; 93:1105.
  28. FERRIMAN D, GALLWEY JD. Clinical assessment of body hair growth in women. J Clin Endocrinol Metab 1961; 21:1440.
  29. Lucky AW, Biro FM, Daniels SR, et al. The prevalence of upper lip hair in black and white girls during puberty: a new standard. J Pediatr 2001; 138:134.
  30. Escobar-Morreale HF, Carmina E, Dewailly D, et al. Epidemiology, diagnosis and management of hirsutism: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome Society. Hum Reprod Update 2012; 18:146.
  31. Deplewski D, Rosenfield RL. Role of hormones in pilosebaceous unit development. Endocr Rev 2000; 21:363.
  32. Lucky AW, Biro FM, Simbartl LA, et al. Predictors of severity of acne vulgaris in young adolescent girls: results of a five-year longitudinal study. J Pediatr 1997; 130:30.
  33. Eichenfield LF, Krakowski AC, Piggott C, et al. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics 2013; 131 Suppl 3:S163.
  34. Lucky AW, McGuire J, Rosenfield RL, et al. Plasma androgens in women with acne vulgaris. J Invest Dermatol 1983; 81:70.
  35. Buggs C, Rosenfield RL. Polycystic ovary syndrome in adolescence. Endocrinol Metab Clin North Am 2005; 34:677.
  36. ACOG Committee Opinion No. 651: Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign. Obstet Gynecol 2015; 126:e143.
  37. Rosenfield RL. Clinical review: Adolescent anovulation: maturational mechanisms and implications. J Clin Endocrinol Metab 2013; 98:3572.
  38. Fraser IS, Critchley HO, Broder M, Munro MG. The FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding. Semin Reprod Med 2011; 29:383.
  39. Van Look PF, Hunter WM, Fraser IS, Baird DT. Impaired estrogen-induced luteinizing hormone release in young women with anovulatory dysfunctional uterine bleeding. J Clin Endocrinol Metab 1978; 46:816.
  40. Arronet GH, Arrata WS. Dysfunctional uterine bleeding. A classification. Obstet Gynecol 1967; 29:97.
  41. Mitra K, Chowdhury MK. Histological and histochemical study of endometrium in dysfunctional uterine haemorrhage. J Indian Med Assoc 2003; 101:484.
  42. Futterweit W, Deligdisch L. Histopathological effects of exogenously administered testosterone in 19 female to male transsexuals. J Clin Endocrinol Metab 1986; 62:16.
  43. Southam AL, Richart RM. The prognosis for adolescents with menstrual abnormalities. Am J Obstet Gynecol 1966; 94:637.
  44. van Hooff MH, Voorhorst FJ, Kaptein MB, et al. Predictive value of menstrual cycle pattern, body mass index, hormone levels and polycystic ovaries at age 15 years for oligo-amenorrhoea at age 18 years. Hum Reprod 2004; 19:383.
  45. West S, Lashen H, Bloigu A, et al. Irregular menstruation and hyperandrogenaemia in adolescence are associated with polycystic ovary syndrome and infertility in later life: Northern Finland Birth Cohort 1986 study. Hum Reprod 2014; 29:2339.
  46. Apter D, Vihko R. Endocrine determinants of fertility: serum androgen concentrations during follow-up of adolescents into the third decade of life. J Clin Endocrinol Metab 1990; 71:970.
  47. Venturoli S, Porcu E, Fabbri R, et al. Menstrual irregularities in adolescents: hormonal pattern and ovarian morphology. Horm Res 1986; 24:269.
  48. Porcu E, Venturoli S, Magrini O, et al. Circadian variations of luteinizing hormone can have two different profiles in adolescent anovulation. J Clin Endocrinol Metab 1987; 65:488.
  49. Venturoli S, Porcu E, Fabbri R, et al. Longitudinal evaluation of the different gonadotropin pulsatile patterns in anovulatory cycles of young girls. J Clin Endocrinol Metab 1992; 74:836.
  50. Venturoli S, Porcu E, Fabbri R, et al. Longitudinal change of sonographic ovarian aspects and endocrine parameters in irregular cycles of adolescence. Pediatr Res 1995; 38:974.
  51. Wiksten-Almströmer M, Hirschberg AL, Hagenfeldt K. Prospective follow-up of menstrual disorders in adolescence and prognostic factors. Acta Obstet Gynecol Scand 2008; 87:1162.
  52. Ibáñez L, de Zegher F, Potau N. Anovulation after precocious pubarche: early markers and time course in adolescence. J Clin Endocrinol Metab 1999; 84:2691.
  53. Adams J, Reginald PW, Franks S, et al. Uterine size and endometrial thickness and the significance of cystic ovaries in women with pelvic pain due to congestion. Br J Obstet Gynaecol 1990; 97:583.
  54. Ehrmann DA. Polycystic ovary syndrome. N Engl J Med 2005; 352:1223.
  55. Ezeh U, Yildiz BO, Azziz R. Referral bias in defining the phenotype and prevalence of obesity in polycystic ovary syndrome. J Clin Endocrinol Metab 2013; 98:E1088.
  56. Kirchengast S, Huber J. Body composition characteristics and body fat distribution in lean women with polycystic ovary syndrome. Hum Reprod 2001; 16:1255.
  57. Borruel S, Fernández-Durán E, Alpañés M, et al. Global adiposity and thickness of intraperitoneal and mesenteric adipose tissue depots are increased in women with polycystic ovary syndrome (PCOS). J Clin Endocrinol Metab 2013; 98:1254.
  58. Barber TM, Golding SJ, Alvey C, et al. Global adiposity rather than abnormal regional fat distribution characterizes women with polycystic ovary syndrome. J Clin Endocrinol Metab 2008; 93:999.
  59. Mannerås-Holm L, Leonhardt H, Kullberg J, et al. Adipose tissue has aberrant morphology and function in PCOS: enlarged adipocytes and low serum adiponectin, but not circulating sex steroids, are strongly associated with insulin resistance. J Clin Endocrinol Metab 2011; 96:E304.
  60. Huang ZH, Manickam B, Ryvkin V, et al. PCOS is associated with increased CD11c expression and crown-like structures in adipose tissue and increased central abdominal fat depots independent of obesity. J Clin Endocrinol Metab 2013; 98:E17.
  61. Leibel NI, Baumann EE, Kocherginsky M, Rosenfield RL. Relationship of adolescent polycystic ovary syndrome to parental metabolic syndrome. J Clin Endocrinol Metab 2006; 91:1275.
  62. Apter D, Bützow T, Laughlin GA, Yen SS. Metabolic features of polycystic ovary syndrome are found in adolescent girls with hyperandrogenism. J Clin Endocrinol Metab 1995; 80:2966.
  63. Lewy VD, Danadian K, Witchel SF, Arslanian S. Early metabolic abnormalities in adolescent girls with polycystic ovarian syndrome. J Pediatr 2001; 138:38.
  64. Mortensen M, Ehrmann DA, Littlejohn E, Rosenfield RL. Asymptomatic volunteers with a polycystic ovary are a functionally distinct but heterogeneous population. J Clin Endocrinol Metab 2009; 94:1579.
  65. Palmert MR, Gordon CM, Kartashov AI, et al. Screening for abnormal glucose tolerance in adolescents with polycystic ovary syndrome. J Clin Endocrinol Metab 2002; 87:1017.
  66. Ehrmann DA, Barnes RB, Rosenfield RL, et al. Prevalence of impaired glucose tolerance and diabetes in women with polycystic ovary syndrome. Diabetes Care 1999; 22:141.
  67. Legro RS, Kunselman AR, Dodson WC, Dunaif A. Prevalence and predictors of risk for type 2 diabetes mellitus and impaired glucose tolerance in polycystic ovary syndrome: a prospective, controlled study in 254 affected women. J Clin Endocrinol Metab 1999; 84:165.
  68. Kahn SE. Clinical review 135: The importance of beta-cell failure in the development and progression of type 2 diabetes. J Clin Endocrinol Metab 2001; 86:4047.
  69. Dunaif A, Green G, Phelps RG, et al. Acanthosis Nigricans, insulin action, and hyperandrogenism: clinical, histological, and biochemical findings. J Clin Endocrinol Metab 1991; 73:590.
  70. Grundy SM, Brewer HB Jr, Cleeman JI, et al. Definition of metabolic syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation 2004; 109:433.
  71. Alberti KG, Eckel RH, Grundy SM, et al. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 2009; 120:1640.
  72. Coviello AD, Legro RS, Dunaif A. Adolescent girls with polycystic ovary syndrome have an increased risk of the metabolic syndrome associated with increasing androgen levels independent of obesity and insulin resistance. J Clin Endocrinol Metab 2006; 91:492.
  73. Nandalike K, Strauss T, Agarwal C, et al. Screening for sleep-disordered breathing and excessive daytime sleepiness in adolescent girls with polycystic ovarian syndrome. J Pediatr 2011; 159:591.
  74. Rossi B, Sukalich S, Droz J, et al. Prevalence of metabolic syndrome and related characteristics in obese adolescents with and without polycystic ovary syndrome. J Clin Endocrinol Metab 2008; 93:4780.
  75. Hart R, Doherty DA, Mori T, et al. Extent of metabolic risk in adolescent girls with features of polycystic ovary syndrome. Fertil Steril 2011; 95:2347.
  76. Gourgari E, Lodish M, Shamburek R, et al. Lipoprotein Particles in Adolescents and Young Women With PCOS Provide Insights Into Their Cardiovascular Risk. J Clin Endocrinol Metab 2015; 100:4291.
  77. de Sousa G, Schlüter B, Buschatz D, et al. A comparison of polysomnographic variables between obese adolescents with polycystic ovarian syndrome and healthy, normal-weight and obese adolescents. Sleep Breath 2010; 14:33.
  78. Nandalike K, Agarwal C, Strauss T, et al. Sleep and cardiometabolic function in obese adolescent girls with polycystic ovary syndrome. Sleep Med 2012; 13:1307.
  79. Michaliszyn SF, Lee S, Tfayli H, Arslanian S. Polycystic ovary syndrome and nonalcoholic fatty liver in obese adolescents: association with metabolic risk profile. Fertil Steril 2013; 100:1745.
  80. Littlejohn EE, Weiss RE, Deplewski D, et al. Intractable early childhood obesity as the initial sign of insulin resistant hyperinsulinism and precursor of polycystic ovary syndrome. J Pediatr Endocrinol Metab 2007; 20:41.
  81. Escobar-Morreale HF, Sanchón R, San Millán JL. A prospective study of the prevalence of nonclassical congenital adrenal hyperplasia among women presenting with hyperandrogenic symptoms and signs. J Clin Endocrinol Metab 2008; 93:527.
  82. Barnes RB, Rosenfield RL, Ehrmann DA, et al. Ovarian hyperandrogynism as a result of congenital adrenal virilizing disorders: evidence for perinatal masculinization of neuroendocrine function in women. J Clin Endocrinol Metab 1994; 79:1328.
  83. Rosenfield RL, Rich BH, Wolfsdorf JI, et al. Pubertal presentation of congenital delta 5-3 beta-hydroxysteroid dehydrogenase deficiency. J Clin Endocrinol Metab 1980; 51:345.
  84. Bachelot A, Chakhtoura Z, Plu-Bureau G, et al. Influence of hormonal control on LH pulsatility and secretion in women with classical congenital adrenal hyperplasia. Eur J Endocrinol 2012; 167:499.
  85. Ghizzoni L, Virdis R, Vottero A, et al. Pituitary-ovarian responses to leuprolide acetate testing in patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. J Clin Endocrinol Metab 1996; 81:601.
  86. Foecking EM, Szabo M, Schwartz NB, Levine JE. Neuroendocrine consequences of prenatal androgen exposure in the female rat: absence of luteinizing hormone surges, suppression of progesterone receptor gene expression, and acceleration of the gonadotropin-releasing hormone pulse generator. Biol Reprod 2005; 72:1475.
  87. Sanchez R, Rhéaume E, Laflamme N, et al. Detection and functional characterization of the novel missense mutation Y254D in type II 3 beta-hydroxysteroid dehydrogenase (3 beta HSD) gene of a female patient with nonsalt-losing 3 beta HSD deficiency. J Clin Endocrinol Metab 1994; 78:561.
  88. Lutfallah C, Wang W, Mason JI, et al. Newly proposed hormonal criteria via genotypic proof for type II 3beta-hydroxysteroid dehydrogenase deficiency. J Clin Endocrinol Metab 2002; 87:2611.
  89. Mermejo LM, Elias LL, Marui S, et al. Refining hormonal diagnosis of type II 3beta-hydroxysteroid dehydrogenase deficiency in patients with premature pubarche and hirsutism based on HSD3B2 genotyping. J Clin Endocrinol Metab 2005; 90:1287.
  90. Zachmann M, Tassinari D, Prader A. Clinical and biochemical variability of congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency. A study of 25 patients. J Clin Endocrinol Metab 1983; 56:222.
  91. Joehrer K, Geley S, Strasser-Wozak EM, et al. CYP11B1 mutations causing non-classic adrenal hyperplasia due to 11 beta-hydroxylase deficiency. Hum Mol Genet 1997; 6:1829.
  92. Charmandari E, Kino T, Ichijo T, Chrousos GP. Generalized glucocorticoid resistance: clinical aspects, molecular mechanisms, and implications of a rare genetic disorder. J Clin Endocrinol Metab 2008; 93:1563.
  93. Qin K, Rosenfield RL. Mutations of the hexose-6-phosphate dehydrogenase gene rarely cause hyperandrogenemic polycystic ovary syndrome. Steroids 2011; 76:135.
  94. Lawson AJ, Walker EA, Lavery GG, et al. Cortisone-reductase deficiency associated with heterozygous mutations in 11beta-hydroxysteroid dehydrogenase type 1. Proc Natl Acad Sci U S A 2011; 108:4111.
  95. Lavery GG, Walker EA, Tiganescu A, et al. Steroid biomarkers and genetic studies reveal inactivating mutations in hexose-6-phosphate dehydrogenase in patients with cortisone reductase deficiency. J Clin Endocrinol Metab 2008; 93:3827.
  96. Noordam C, Dhir V, McNelis JC, et al. Inactivating PAPSS2 mutations in a patient with premature pubarche. N Engl J Med 2009; 360:2310.
  97. Oostdijk W, Idkowiak J, Mueller JW, et al. PAPSS2 deficiency causes androgen excess via impaired DHEA sulfation--in vitro and in vivo studies in a family harboring two novel PAPSS2 mutations. J Clin Endocrinol Metab 2015; 100:E672.
  98. Kaltsas GA, Korbonits M, Isidori AM, et al. How common are polycystic ovaries and the polycystic ovarian syndrome in women with Cushing's syndrome? Clin Endocrinol (Oxf) 2000; 53:493.
  99. Fegan PG, Sandeman DD, Krone N, et al. Cushing's syndrome in women with polycystic ovaries and hyperandrogenism. Nat Clin Pract Endocrinol Metab 2007; 3:778.
  100. Azziz R, Sanchez LA, Knochenhauer ES, et al. Androgen excess in women: experience with over 1000 consecutive patients. J Clin Endocrinol Metab 2004; 89:453.
  101. Carmina E, Rosato F, Jannì A, et al. Extensive clinical experience: relative prevalence of different androgen excess disorders in 950 women referred because of clinical hyperandrogenism. J Clin Endocrinol Metab 2006; 91:2.
  102. Hensleigh PA, Woodruff JD. Differential maternal-fetal response to androgenizing luteoma or hyperreactio luteinalis. Obstet Gynecol Surv 1978; 33:262.
  103. Givens JR, Kerber IJ, Wiser WL, et al. Remission of acanthosis nigricans associated with polycystic ovarian disease and a stromal luteoma. J Clin Endocrinol Metab 1974; 38:347.
  104. Barnes RB, Rosenfield RL, Burstein S, Ehrmann DA. Pituitary-ovarian responses to nafarelin testing in the polycystic ovary syndrome. N Engl J Med 1989; 320:559.
  105. Conte FA, Grumbach MM, Ito Y, et al. A syndrome of female pseudohermaphrodism, hypergonadotropic hypogonadism, and multicystic ovaries associated with missense mutations in the gene encoding aromatase (P450arom). J Clin Endocrinol Metab 1994; 78:1287.
  106. Pang SY, Softness B, Sweeney WJ 3rd, New MI. Hirsutism, polycystic ovarian disease, and ovarian 17-ketosteroid reductase deficiency. N Engl J Med 1987; 316:1295.
  107. Toscano V, Balducci R, Bianchi P, et al. Ovarian 17-ketosteroid reductase deficiency as a possible cause of polycystic ovarian disease. J Clin Endocrinol Metab 1990; 71:288.
  108. Filho RB, Domingues L, Naves L, et al. Polycystic ovary syndrome and hyperprolactinemia are distinct entities. Gynecol Endocrinol 2007; 23:267.
  109. Glickman SP, Rosenfield RL, Bergenstal RM, Helke J. Multiple androgenic abnormalities, including elevated free testosterone, in hyperprolactinemic women. J Clin Endocrinol Metab 1982; 55:251.
  110. Futterweit W, Krieger DT. Pituitary tumors associated with hyperprolactinemia and polycystic ovarian disease. Fertil Steril 1979; 31:608.
  111. Vermeulen A, Andó S, Verdonck L. Prolactinomas, testosterone-binding globulin, and androgen metabolism. J Clin Endocrinol Metab 1982; 54:409.
  112. Lungu AO, Zadeh ES, Goodling A, et al. Insulin resistance is a sufficient basis for hyperandrogenism in lipodystrophic women with polycystic ovarian syndrome. J Clin Endocrinol Metab 2012; 97:563.
  113. Codner E, Escobar-Morreale HF. Clinical review: Hyperandrogenism and polycystic ovary syndrome in women with type 1 diabetes mellitus. J Clin Endocrinol Metab 2007; 92:1209.
  114. Codner E, Iñíguez G, Villarroel C, et al. Hormonal profile in women with polycystic ovarian syndrome with or without type 1 diabetes mellitus. J Clin Endocrinol Metab 2007; 92:4742.
  115. Conn JJ, Jacobs HS, Conway GS. The prevalence of polycystic ovaries in women with type 2 diabetes mellitus. Clin Endocrinol (Oxf) 2000; 52:81.
  116. Peppard HR, Marfori J, Iuorno MJ, Nestler JE. Prevalence of polycystic ovary syndrome among premenopausal women with type 2 diabetes. Diabetes Care 2001; 24:1050.
  117. Kaltsas GA, Mukherjee JJ, Jenkins PJ, et al. Menstrual irregularity in women with acromegaly. J Clin Endocrinol Metab 1999; 84:2731.
  118. Pache TD, Chadha S, Gooren LJ, et al. Ovarian morphology in long-term androgen-treated female to male transsexuals. A human model for the study of polycystic ovarian syndrome? Histopathology 1991; 19:445.
  119. Nelson-DeGrave VL, Wickenheisser JK, Cockrell JE, et al. Valproate potentiates androgen biosynthesis in human ovarian theca cells. Endocrinology 2004; 145:799.
  120. Isojärvi J. Disorders of reproduction in patients with epilepsy: antiepileptic drug related mechanisms. Seizure 2008; 17:111.
  121. Herzog AG. Menstrual disorders in women with epilepsy. Neurology 2006; 66:S23.
  122. Speiser PW, Susin M, Sasano H, et al. Ovarian hyperthecosis in the setting of portal hypertension. J Clin Endocrinol Metab 2000; 85:873.
  123. Satoh M, Yokoya S, Hachiya Y, et al. Two hyperandrogenic adolescent girls with congenital portosystemic shunt. Eur J Pediatr 2001; 160:307.
  124. Bas S, Guran T, Atay Z, et al. Premature pubarche, hyperinsulinemia and hypothyroxinemia: novel manifestations of congenital portosystemic shunts (Abernethy malformation) in children. Horm Res Paediatr 2015; 83:282.
  125. Escobar-Morreale HF, Botella-Carretero JI, Alvarez-Blasco F, et al. The polycystic ovary syndrome associated with morbid obesity may resolve after weight loss induced by bariatric surgery. J Clin Endocrinol Metab 2005; 90:6364.
  126. Center for Young Women's Health. "Polycystic Ovary Syndrome (PCOS): A Guide for Teens." http://www.youngwomenshealth.org/pcos_resource_book.html (Accessed on January 30, 2014).