Transcript PCOS: From Novice to Knowing

From Novice to Knowing: A
Primer on PCOS
Kay M. Czaplewski, BSN, RN, BC,
CDE, NHA
Press to begin
What is PCOS?
PCOS (polycystic ovary disease) is a
condition most often characterized by
irregular or absent periods; abnormal
hair growth; obesity and insulin
resistance. It affects 5-10% of women
of reproductive age, without regard to
ethnicity (Legro, 2007)
PCOS can lead to long term complications
like diabetes, endometrial cancer,
dyslipidemia and cardiovascular disease, if
left untreated (MayoClinic, 2007; Hill, 2003)
NEXT SLIDE
Why do we Care?
Nurses need to understand the basic
physiology and treatment
modalities of PCOS in order
provide education, guidance, and
support.
Patients chief concerns with PCOS
may change over time, and many
will seek advice from different
health care providers, including
nurses.
Nurses need to understand how
PCOS is managed and the
potential health risks associated
with this common condition.
next, please
(There’s no place like )
HOME PAGE
This tutorial will focus on four aspects of PCOS
(click on an area of interest)
Menstrual Dysfunction
Anovulation/Infertility
Hyperandrogen
Insulin Resistance
(click here for a refresher on normal menstrual function)
Click here for pathophysiology of PCOS Or press next
How do we know what is abnormal
until we know normal?
Menstruation 101
TAKE ME ON A QUICK REVIEW
NO TIME FOR REVIEW, JUST TELL ME ABOUT
PCOS AND MENSTRUAL DYSFUNCTION
Back to home page
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Normal Menstrual Cycle
Four Main Phases
Click on
the daisies to
learn more!
home
(Hole, 1989)
Phase 1
Day 1-5
Shedding of
endometrium
Average blood shed
10-80 ml
Plasmin enzyme
released by
endometrium inhibits
clotting
Take me to phase 2!
(Hole, 1989)
home
Phase 2: follicular
Hypothalamus
pituitary
Follicular stimulating hormone
(FSH)
Luetinizing Hormone (LH)
Follicles mature
Releases estrogen
Causes lining of uterus to thicken
Hypothalamus releases luteinizing hormone releasing factor (LHRF) which
causes increased LH
Triggers most mature follicle to burst and release egg
(Hole, 1989)
OVULATION
Phase 3, please
home
Phase 3: Ovulation
Blood supply to ovary increases
Surge of LH weakens ovary wall
Ligaments contract pulling ovary closer to fallopian tube
Egg released
Cervix develops clear stringy mucous
Facilitates movement of sperm toward egg
Unfertilized egg dissolves in uterus
Take me to phase 4!
(Hole, 1989)
Take me home
Phase 4: Luteal
After ovulation, residual follicles form corpus luteum, a solid
body that produces progesterone and estrogen for about 2
weeks. Progesterone make uterine lining receptive to
implantation. In absence of pregnancy, progesterone levels
fall, this leads to menstrual shedding.
(Hole, 1989)
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home
For a summary of
menstruation in graph
form, Please press me!
Kay,RN
Otherwise, proceed
With test
Phase 1 question
Average blood shed during menstruation
is 300ml.
A. True
B. False
back to menstrual cycle
back home
That’s Correct!
• The average blood
loss is 10-80 ml
(Wikipedia, 2007)
Back to test
Take me to question 2
home
Oops! Try again
• Blood shed in that
amount may be
detrimental!
Let me try again!
Phase 2 question
Multiple choice
Press on the correct answer
In the follicular phase, the
endometrium:
A. Thickens
C. Dissolves
B. Thins
C. Sheds
Take me to menstrual cycle
home
Correct!
Increasing levels of estrogen
would produce thickening of
endometrium in preparation of
a potential fertilized egg.
Back to test
(Hole, 1989)
Phase 3 question
no…
A dissolving endometrium
That’s just silly
Ha…ha…ha…
Return to test
Next question
no…
thinning
would
be
Menstruation!!!
(Hole, 1989)
Back to test
No…
shedding
Would
be
menstruation
Back to test
(Hole, 1989)
Phase 3 Question
During Ovulation
Egg is released
No egg
released
home
Menstrual cycle
correct
Under the influence of
FSH secreted by the
anterior pituitary, the
follicle matures, a
rush of LH cases the
mature follicle to
rupture. This is called
ovulation
(Tabers, 2006).
Next question
Back to test
home
Not quite…
Remember, during
ovulation, the mature
egg is released.
Back to test question
home
Phase 4 Question
• After ovulation, what
do the follicles form?
1. Corpus luteum
2. Corpus Christi
Yes…
After ovulation residual follicles form
corpus luteum, a solid body that
produces progesterone and estrogen for
about 2 weeks. Progesterone makes the
uterine lining receptive to implantation. In
absence of pregnancy progesterone
levels fall, this leads to menstrual
shedding
(Hole, 1989).
Next
home
No Ya…all…
Back to test
Next slide
home
Pathophysiology of PCOS
Polycystic ovary syndrome is characterized by inappropriate gonadotropin secretion,
Androgen excess and often hyperinsulinemia, all of which contribute to anovulation
Impaired estrogen feedback leads to
increased LH and decreased FSH
Treatments are directed at
Restoring gonadotropin
secretion (clomiphene)
Decreasing androgen levels
(follicle-stimulating hormone
Or ablative surgery)
Decreasing insulin levels
(metformin, insulin sensitizers,
weight loss, exercise
Disordered
GnRH Release
Increased
LH release
Increased
Ovarian
Androgen
biosynthesis
Pituitary secretion of LH increases
Hyperinsulinemia stimulates
ovarian and adrenal androgen
synthesis
Increased androgen and
Insulin levels decrease levels
of circulating binding proteins
that limit androgen bioactivity
Next slide
home
(Adapted from Legro ,R.S. JAMA 2007 used with permission)
Menstrual Dysfunction
• Problem: Endometrium is in an
unopposed estrogen
state resulting in
anovulation. This results
in suppression of FSH
and increase of LH
leading to endometrium
proliferation. (Hill, 2003)
Press here for a refresher on normal menstrual function
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home
Bonus question…
What is the
problem with
endometrial
Proliferation?
answer
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Endometrial Cancer
• For women with PCOS, chronic
unopposed estrogen is a risk factor for
endometrial carcinoma.
• Four menses per year are recommended
to to help control this risk. Sheehan, 2004
continue
home
Treatment of Menstrual Dysfunction
Oral contraceptives and
progesterone withdrawal
Lifestyle modification/weight loss
Metformin
(Barbieri & Ehrmann, 2007)
continue
home
Oral Contraceptives and Progesterone Withdrawal
Oral contraceptives (OCs) affect the ovary by
maintaining a constant level of estrogen and
progesterone. This prevents fluctuation of estrogen
and progesterone. Thus OCs manage oligomenorrhea
and reduce the risk of endometrial cancer (Kelly, 2003).
Provera (progesterone withdrawal) results in
menses. Four menses per year are recommended
to decrease risk of development of uterine
cancer from endometrial proliferation.
(Sheehan, 2004, Hill, 2003)
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Lifestyle Modification and Weight Loss
Weight loss can lead to resumption of
ovulation within weeks.
Improving insulin resistance through
Diet and exercise can result in improvement
In menstrual function (Stankiewicz & Norman, 2006).
weight
hyperinsulinemia
hyperandrogen
menstruation
home
Test
Time!
Test Time
The purpose of a
progesterone
withdrawal is to
cause
A. No Menses
B. Menses
C-o-r-r-e-c-t
• Progesterone levels are
elevated during the luteal
phase of the menstrual
cycle. As they fall,
menstrual shedding
occurs.
• For a woman with PCOS,
it is necessary to induce
menstrual shedding for
the prevention of cervical
cancer. This done with
progesterone withdrawal
course, taken about four
times per year.
(Barbieri & Ehrmann, 2007)
next
home
Back to test
Ooops!…try again
(hint…it’s just the opposite!)
Back to question
Back to menstrual dysfunction
Back to home
Anovulation and Infertility
Normally in the follicular phase, follicles
in the ovary begin developing under the
influence of a complex interplay of
hormones, and after several days, the
dominant follicle releases an egg in an
event known as ovulation. (Hole, 1989). In
PCOS, LH remains elevated, ovulation
cannot occur (Sheehan, 2004).
home
next
Treatment of Anovulation and Infertility
In most patients, Clomiphene and extended
release metformin are used alone or
together to induce ovulation.
(Legro, Barnhardt, Schlaff, Carr, Diabmond, et al, 2007)
Next page
Lifestyle Changes
Weight Loss reduces
hyperinsulinemia
And subsequently,
hyperandrogenism
(Hill, 2003).
weight
hyperinsulinemia
hyperandrogen
next
home
Treatment of Anovulation and Infertility
Metformin…
…decreases hepatic glucose production
thus reducing the need for insulin
secretion. This helps suppress androgen
production and improves ovulation
AND
…decreases intestinal absorption of
glucose and improves insulin resistance
(Legro, Barnhardt, Schlaff, Carr, Diamond, et al, 2007)
back
TEST TIME!
home
Anovulation and Infertility
For practical purposes, anovulation and
infertility are the same thing.
• True
• False
Next slide
home
For practical purposes, true
When the egg has matured, it secretes
enough estradiol to trigger the release
of LH. The surge of LH matures the
egg and weakens the wall of the
follicle in the ovary. This process leads
to ovulation.
(Wikipedia, 2007)
A woman must ovulate to be fertile.
(Hole, 1989)
Back to test
Next slide
home
Normal
Menstrual
Cycle
(Wikipedia, 2007)
Press for test
Insulin Resistance (IR)
(IR) is a condition in which the cells of the body become resistant to the
effects of insulin. The normal response to a given amount of insulin is reduced.
As a result, higher levels of insulin are needed in order for insulin to have the
desired effect
(Franz, 2003; Stankiewicz & Norman, 2006).
• Fasting glucose 100-125
• Impaired 2 hour glucose tolerance test 140-199
• Fasting insulin ratio <4.5 (Stankiewicz & Norman, 2006)
(Acanthosis nigricans, a dark, velvety pigmentation seen on back
of neck, axilla, or skin folds is symptom of insulin resistance
(Franz, 2003)
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Treatment of Insulin Resistance
METFORMIN decreases hepatic glucose
production thus reducing the need for insulin
secretion. This helps suppress androgen
production and improves ovulation. Metformin
also decreases intestinal absorption of glucose
and improves insulin resistance
(Legro, Barnhardt, Schlaff, Carr, Diamond, et al, 2007).
Next slide
Treatment of Insulin Resistance
Metformin also lowers fatty acid concentrations,
thus reducing gluconeogenesis (The formation of
glucose, especially by the liver, from noncarbohydrate sources, such as amino acids and the
glycerol portion of fats)
(Barbieir & Ehrmann, 2007; Franz, 2003)
Test time!
Test-time
What is glyconeogenesis?
The first book of the bible?
The formation of glucose from
non-carbohydrate sources?
The formation of free fatty
acids?
Previous slide
Home
Yes, genesis is
the first book in
the bible
No, genesis
is not
gluconeogenesis
Back to test
You are a rock star!!
As you know, gluconeogenesis
is the formation
of glucose, especially by the
liver, from noncarbohydrate sources, such as
amino acids and
the glycerol portions of fats
(Barbieri & Ehrmann, 2007)
Back to test
Back home
next
Close, but no cigar!
Free fatty acids are an
important source of fuel
for many tissues since
they can yield relatively
large quantities of energy.
Many cell types can use
either glucose or fatty
acids for this purpose (Franz,
2003).
Metformin inhibits this
process (Barbieir & Ehrmann, 2007).
Back to test
Hyperandrogen
Hirsutism is one bothersome aspect of PCOS, often seen as
Distribution of hair on the face, chest, abdomen, back, thumbs
Or toes. It is also seen as male-pattern balding or thinning hair.
The goals of medication therapy are to lower
androgen levels, increase sex hormone
binding globulin (SHBG) levels to allow
less circulating testosterone, and if the
patient wants, hair removal.
(Hill, 2003)
next
home
Q. How does circulating
androgens
contribute to hirsutism?
A. The anagen (growth) phase
of the hair cycle is
prolonged in
hyperandrogenic states,
resulting in increased
male pattern hair
distribution (Hill, 2003)
next
Treatment of Hirsutism
Spironolactone is often used for its
aldosterone antagonist side effect
(Barbieri & Ehrmann, 2007)
Mechanical Hair Removal
 shaving
 plucking
 electrolysis
 waxing
 bleaching (Hill, 2003)
Vaniqua
(inhibits an enzyme for normal hair growth)
(Barbieri & Ehrmann, 2007)
Test time
2. Aldosterone protagonist
Next slide, please
Hey learner, it’s your birthday, hey, learner, it’s your birthday…
you are correct!
Spironolactone inhibits the effect of aldosterone by
competing for intracellular aldosterone
receptors.
Spironolactone has anti-androgen activity by
binding to the androgen receptor and thus
preventing it to interact with dihydrotestosterone.
This blocks the action of testosterone and
reduces hirsutism
(Sheehan, 2004; Hill, 2003, Wikipedia, 2007)
next
Not quite…
We want to decrease androgen secretion and action
Back to test
Summary
PCOS is a chronic condition, most often
characterized by irregular or absent periods;
abnormal hair growth; obesity and insulin
resistance. It affects 5-10% of women of
reproductive age (Legro, 2007).
PCOS can lead to long term complications
like diabetes, endometrial cancer,
dyslipidemia and cardiovascular disease, if
left untreated
(MayoClinic, 2007; Hill, 2003).
Next slide
Summary
Treatment of PCOS is
focused on areas that
cause the patient the
most distress, however,
as nurses, we need to be
familiar with the
complexity of PCOS and
potential health risks
associated with this
common condition, to
better help our patients.
home
next
I would like to thank
Kimberly Woyach, MSN, APNP,
CDE for inspiring me with
her knowledge and passion of
PCOS
Start tutorial over
references
home
References
Barbieri, R. L., Erhmann, D. A. (2007) Patient information: Treatment of polycystic
ovary syndrome. Retrieved February 4, 2007 from UpToDate, licensed by the Medical
College of Wisconsin, Milwaukee, WI.
Franz, M. J. (Ed.). (2003). A core curriculum for diabetes educators, fifth edition: Diabetes in the life
cycle.American Association of Diabetes Educators. Chicago: American Association of Diabetes
Educators.
Hill, K. M. (2003). Update: The pathogenesis and treatment of PCOS. The nurse practitioner. 28 (7):
8-23
Hole, J. W. (1989). Essentials of human anatomy and physiology (3rd ed.). Dubuque, IA: Wm. C. Brown
Legro, R.S. (2007) A 27-year-old woman with a diagnosis of polycystic ovary syndrome. JAMA. 297 (5):
509-519
Legro, R. S., Barnhardt, H. X., Schlaff, W. D., Carr, B. R., Diabmond, M. P., Carson, et al (2007)
Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. The new england
journal of medicine. 346 (6): 551-566.
MayoClinic (nd) Women's health: Polycystic ovary syndrome. Retrieved February 18, 2007 from
http:www.mayoclinic.com/health/polycystic-ovary-syndrome/DSS00423/DSCETION=6
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References
Stankiewicz, M., Norman, R. (2006) Diagnosis and management of polycystic ovary disease: A practical guide. Drugs
2006. 66 (7): 903-912
Sheehan, M.T.(2004). Polycystic ovary syndrome: Diagnosis and management. Clinical medicine & research.
2 (1): 13-27.
Taber’s cyclopedic medical dictionary (20th ed) (2005). Philadelphia. F. A. Davis company.
Wikipedia: The free encyclopedia. (2006) FL: Wikimedia Foundation, Inc. Retrieved February 14, 2007 from
http.www.wikipedia.org
Womenshealth.gov (2007) Polycystic ovarian syndrome. retrieved February 2, 2007
from http://www.4woman.gov/faq/pcos.htm
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