Transcript PCOS: Polycystic Ovarian Syndrome

PCOS: Polycystic Ovarian Syndrome

NURS 541: Women’s
Healthcare – Diagnosis
and Management
Objectives
 Etiology
 Clinical Presentation
 Assessment
 Diagnosing PCOS
 Management
 Patient Counseling
Introduction
 Classified as a hyperandrogenic disorder
 Affects 6-8% of women
 Approximately 70% of women with clinical features of
PCOS have the disorder
Etiology
 Imbalance of several reproductive hormones
 Dehydroepiandrosterone sulfate (DHEA-S)
 Dehydroepiandrosterone (DHEA)
 Androstenedione
Testosterone
 Most testosterone is bound to sex hormone-binding
globulin (SHBG)
 The amount of free testosterone dictates the amount of
hyperandrogenic effects that are seen
Etiology
 SHBG levels (and therefore the amount of testosterone
binding) are influenced by hormonal changes
 Estrogen and thyroid hormone INCREASE levels
 Androgens and insulin DECREASE levels
SHBG
free testosterone
effects
 Testosterone converted into dihydrotestosterone (DHT) by
5α reductase (enzyme)
 DHT responsible for androgenic symptoms
Etiology
 Women with PCOS have more steady levels of
gonadotropins and sex hormones than women without
PCOS
 Gonadotropin-releasing hormone (GnRH), and therefore
luteinizing hormone (LH) pulse frequently versus with the
menstrual cycle
 Increased level of LH => decreased follicle-stimulating
hormone (FSH)
 Decreased ovulation
Etiology
Typical cyclical LH surge
(below) compared to the
frequent LH surges seen in
PCOS (left)
Etiology
 Determining the cause of the increased androgen production is
key to individualized treatment
 Is it an issue of excess insulin?
 Is it an issue of decreased thyroid hormone?
 Is there too little estrogen?
 Is there too much DHEA/DHEA-S/androstenedione?
Clinical Presentation
Clinical Presentation
 Signs
 Associated conditions
 Hirsutism
 Obesity
 Alopecia
 Infertility
 Acne
 Insulin resistance
 Menstrual irregularities
 Dyslipidemia
 Polycystic ovaries
 Metabolic syndrome
 Virilization
 Psychological effects
 Cancer risks
Signs/Symptoms
 Hirsutism
 Excessive hair growth in most androgenic-sensitive areas
(face, chin, upper lip, areolae, lower abdomen, inner thighs,
perineum)
 Alopecia
 Androgen-related hair loss, usually frontal/crown region
 Acne
 Enlargement of sebaceous glands, sebum
Signs/Symptoms
 Menstrual Irregularities
 Irregular menses, anovulatory cycles
 Possible heavy menses due to persistent endometrial
stimulation, endometrial hyperplasia
 If normal cycles, may be still anovulatory – lack of
premenstrual symptoms indication
 Polycystic ovaries
 As a result of chronic anovulation
 One or more ovaries with 12+ enlarged follicles and/or
enlarged ovarian volume over 10mL (2003 ESHRE/ASRM
consensus)
Signs/Symptoms
 Virilization
 Cluster of symptoms including clitoral hypertrophy, severe
hirsutism, deepening of the voice, increased muscle mass,
breast atrophy, and male pattern baldness
 If rapidly progressing, may indicate less common cause of
hyperandrogenism
 Ovarian or adrenal tumor
 Congenital adrenal hyperplasia
 Hyperthecosis
Associated conditions
 Obesity
 Approximately ½ of all women with PCOS are obese
 Insulin resistance
 Affects 50-70% of women with PCOS
 Instrumental in hormonal changes associated with
hyperandrogenism
 Increases risk for Type 2 Diabetes and glucose intolerance
 Dyslipidemia
 70% of women with PCOS have at least 1 elevated lipid level
Associated conditions
 Metabolic syndrome
 Cluster of conditions – obesity, insulin resistance,
dyslipidemia
 Increases risk for CV disease and diabetes
 Diagnostic criteria - 3 or more of the following:
 Waist circumference ≥ 35 inches
 Triglycerides ≥ 150mg/dL
 HDL cholesterol ≤ 50 mg/dL
 Systolic BP ≥ 130 mmHg and/or diastolic BP ≥ 85 mmHg
 Fasting glucose ≥ 100 mg/dL
Associated conditions
 Infertility
 Related to anovulation
 More than ½ of women with PCOS are fertile, although may
take longer to conceive
 Psychological effects
 Higher rates of depression, anxiety, binge eating higher for
women with PCOS
 Cancer risks
 3-fold increased risk of endometrial cancer
 2-fold increased risk of ovarian cancer
Differential Diagnosis
Differential Diagnosis
 PCOS (80%)
 Nonclassical congenital adrenal hyperplasia (2%)
 Hyperandrogenism, insulin resistance, and acanthosis nigricans
(HAIR-AN) syndrome (4%)
 Androgen-producing tumors (rare) – ovarian or adrenal
 Idiopathic hirsutism (5%)
 Thyroid disorders, androgenic medication, pregnancy,
hyperprolactinemia, Cushing syndrome
Assessment
Assessment
 History
 Thorough menstrual history (menarche, menstrual pattern,
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flow, symptoms)
Pregnancy history (ability to conceive, time to conception)
Symptoms/associated conditions of PCOS, including onset
and severity – rapid vs slow onset
Medication history
Family history of associated conditions
Assessment
 Physical Exam
 Anthropometric measurements – height, weight, BMI, waist
circumference
 Blood pressure
 Skin examination – look for hirsutism, acne, alopecia
 Acanthosis nigricans often seen with insulin resistance
 Thyroid exam
 Breast exam
 Pelvic exam – assess for uterine/ovarian masses
Assessment
 Laboratory testing
 Mixed evidence re: appropriate testing
 Testing should reflect findings in history/exam
 Hyperandrogenism and ovulatory dysfunction
 TSH, prolactin, fasting lipid profile, 2hr OGTT (ACOG, AEPCOS, 2009)
 Hyperandrogenism and regular menstrual cycles
 Above, PLUS serum progesterone on day 20-24 of cycle
 Less than 3-4 ng/mL = oligo-ovulatory cycle
Assessment
 Laboratory testing (continued)
 Testosterone testing – mixed evidence as to usefulness
 If tumor suspected, total testosterone recommended, and
refer if > 150 ng/dL (100 ng/dL if menopausal)
 17-OHP (hydroxyprogesterone)
 If congenital adrenal hyperplasia is suspected
 Imaging/Procedures
 Pelvic ultrasonography
 To identify ovarian cysts and endometrial hyperplasia
 Endometrial biopsy – chronic anovulation
Diagnosing PCOS
Differential Diagnosis
 PCOS (80%)
 Nonclassical congenital adrenal hyperplasia (2%)
 Hyperandrogenism, insulin resistance, and acanthosis nigricans
(HAIR-AN) syndrome (4%)
 Androgen-producing tumors (rare) – ovarian or adrenal
 Idiopathic hirsutism (5%)
 Thyroid disorders, androgenic medication, pregnancy,
hyperprolactinemia, Cushing syndrome
Diagnosing PCOS
 Two established criteria:
 Rotterdam PCOS Consensus Group (2004)
 Two of three of the following:
 Oligo- or anovulation
 Clinical and/or biochemical signs of hyperandrogenism
 Polycystic ovaries
 Androgen Excess and Polycystic Ovary Syndrome Society
 Hyperandrogenism: hirsutism and/or hyperandrogenemia
 Ovarian dysfunction: oligo-anovulation and/or polycystic ovaries
 Exclusion of other androgen excess or related disorders
Management
Management
 Non-pharmacologic modalities
 Lifestyle modification – diet, nutrition, exercise
 Mechanical hair removal
Management
 Pharmacologic modalities
 Combined hormonal contraceptives
 Progestin with a non- or low androgenic potential preferred
 Desogestrel, norgestimate, drospirenone
 Signs/symptoms may be reduced/resolve within 2-12 months
 Help protect against endometrial hyperplasia with monthly
withdrawal bleeds
Management
 Pharmacologic modalities
 Progestogens
 To prevent endometrial hyperplasia and cancer
 LNG-IUS, progestin-only pills, DMPA, implant
 Medroxyprogesterone acetate 5-10mg or 200mg micronized
progesterone first 14 days of each month
 Anti-androgens
 For refractory hirsutism or alopecia
 May be teratogenic so need effective contraception
Management
 Pharmacologic management (continued)
 Insulin sensitizing agents
 Metformin – if impaired glucose tolerance, inability to lose
weight with diet and exercise or with those at normal weight
 Not recommended for treatment of PCOS symptoms
 Also helpful for those with infertility
 Topical agent
 Eflornithine HCl 13.9% (Vaniqa) – to treat hirsutism
When to Refer
 If diagnosis other than PCOS
 If initial treatment not successful
 Women with infertility issues (not successful with
metformin)
 If metabolic syndrome present
Patient Counseling
 Follow up is necessary due to long-term risks of PCOS
 Weight management, nutrition, exercise
 Screening and management of BP, lipids, diabetes
 Management of menstrual cycle, withdrawal bleeds
 Support, encouragement, woman-centered care
Questions?