Resource Page for Parents
and Medical Professionals
What is meant by Hormone Imbalance? When people use the term "Hormone Imbalance," they are typically describing a girl - or teen, or adult woman - who they suspect have higher than typical levels of testosterone, or other "male" hormones. Often, a child is referred to me for a hormone imbalance when they have early pubic hair, irregular/absent periods, acne, or hair growth on their body or face (or hair loss on their head) that is more profuse and obvious than in others. Levels of androgens in the blood - also termed "male" hormones - are typically at above typical levels. Sometimes a child or teen is referred to me due to a suspicion of having elevated androgen levels, due to acne, extra hair, or irregular menses, even if laboratory testing hasn't yet been performed.
This information page describes a hormone imbalance that relates to irregular periods, called PCOS.
What is Polycystic Ovarian Syndrome (PCOS) is diagnosed when a teen or woman has absent or few (fewer than eight) periods per year, elevated levels of androgens (male hormones) - or , and/or enlarged ovaries containing multiple cysts/follicles that produce androgens. Up to 10 % of teens and women of childbearing age - including teens - have this diagnosis. It is a common reason for difficulty in conceiving. However, this does not explain why this has occurred - the underlying cause - but likely leading to a snowball effect of further hyperandrogenism and anovulation.
Often, teens and their mothers/aunts/grandmothers describe irregular menses, significant acne, extra body hair as a "hormone imbalance" since they recognize the signs of elevated androgen levels - but their loved one hasn't yet had this diagnosis made. In some parts of the country, this is a common term, and in others PCOS is more familiar.
What causes PCOS? The most common cause of PCOS is a condition termed insulin resistance (IR). IR means that the amount of insulin to feed the cells in your body from the sugar carried in the bloodstream is higher than average. You see, all cells need sugar as fuel. The sugar is absorbed from food we eat, or created in our liver in a process called gluconeogenesis. It then circulates in our bloodstream, delivered to our cells, where it is used as fuel - for carrying out its basic function, for repair, and for cell division/growth. Insulin is what permits sugar to enter cells to fuel their activity, in a similar way a key unlocks a door. With insulin resistance, the keyhole can be thought of as sticky, so that the usual low level of insulin doesn't open the door, and that a higher level is needed - sometimes double the level, and sometimes 20x the level.
When insulin resistance is high, there is a lag from the time sugar is available in the bloodstream until enough insulin is made to allow its passage into the cells. This can cause the blood sugar level to rise - since it can't get into the cells, and it is still being made by the liver, or absorbed from the last meal. And after the insulin level final reaches the threshold for glucose entry into the cell, there can be a rapid decline of the blood sugar as all the cells use up their delivered fuel quickly. So, there may be both high and low blood sugar levels in individuals with insulin resistance. If a fasting blood sugar level rises to 125 mg/dl or above, or if blood sugar reaches 200 mg/dl or above at any time, then a person is diagnosed with diabetes. The vast majority of people with insulin resistance have normal blood sugar levels. It is the rapid rise and decline of the blood sugar that cause symptoms, and the high levels of insulin over time that lead to PCOS.
How does insulin resistance lead to PCOS? The role of insulin to feed cells is described above. But, insulin and its receptors also serve as growth factors for cells - for them to grow. In the ovary, some cell types are quite sensitive to insulin's push to grow. The more sensitive cells supporting and surrounding ovarian follicles produce more testosterone, and also make the ovarian structure less able to release an ovum - with resulting higher androgen levels and few ovulatory cycles.
The further result of higher testosterone levels is to disrupt the hypothalamus/pituitary hormone feedback so that the following cycles are further disrupted. This snowball effect is significant, and further contributes to insulin resistance, rising testosterone levels, acne and body hair.
Why does insulin resistance happen? IR is strongly inherited, along with a family history of PCOS, gestational diabetes and Type 2 Diabetes, but the risk for high insulin levels also markedly increases with weight gain, low physical activity, and diet high in saturated fat and/or simple carbohydrates (foods that break down quickly into sugar).
A second , but rather a description of what happens either due to chronic inflammation and insulin resistance, or due to elevated androgens alone
At what age can PCOS start? By definition, PCOS can only be described in an age range for which menstruation would be expected - at least two years after starting breast development. In addition to breast development, there must also be mature pubic hair growth to clearly be pubertal signs caused by developed ovaries. PCOS is a condition in which there is absent ovulation, with further production of androgens by the ovaries. As a result, PCOS is rarely diagnosed before menarche - a girl's first period. If there has been clear maturation for four years, the teen is at least 14 years old, and there are signs of elevated androgens - acne, extra hair growth - then PCOS can be considered.
How is PCOS treated? Classically, PCOS has been treated with birth control pills, to provide estrogen, and the progesterone rise and withdrawal that results in the shedding of the uterine lining - period. Since ab 1998, it has become clear that, for those with insulin resistance, Metformin (glyburide) can reduce
If you would like to schedule an appointment to learn more about early, late, or even typical puberty, please press the button below to learn more, to discuss your child's evaluation, and review your questions about your child's diagnosis.
Resources for learning around the web:
“Dr. Lerner is a very special person and a superb physician. Her care and thoroughness is a rare find these days and her ability to dig deep to find answers is unbelievable.
She explained every aspect of our concerns in incredible detail and with such a caring manner. Dr. Lerner is simply a brilliant and kind person who deeply cares for her patients."