Women’s Health Discussion: Polycystic Ovary Syndrome Essay
Women’s Health Discussion Polycystic Ovary Syndrome Essay
Polycystic Ovary Syndrome (PCOS) is a syndrome of ovarian dysfunction characterized by abnormalities in the metabolism of estrogen and androgens and the control of the production of androgen hormone (Sirmans & Pate, 2014). In addition to ovarian dysfunction, PCOS presents with cardinal characteristics of hyperandrogenism and polycystic ovary morphology.
Pathophysiology: The exact pathophysiology of PCOS is unclear, but the condition is thought to be a result of abnormal function of the Hypothalamus-Pituitary-Ovarian axis (Escobar-Morreale, 2018). The pathophysiology of PCOS is linked to altered activity of the luteinizing hormone, insulin resistance, and probable predisposition to hyperandrogenism (Williams, Mortada & Porter, 2016). Insulin resistance worsens hyperandrogenism as it suppresses the synthesis of sex hormone-binding globulin and increases the adrenal and ovarian synthesis of androgens hence increasing androgen levels (Williams, Mortada & Porter, 2016). The androgens cause irregular menstruation and the physical features of hyperandrogenism.
Epidemiology: PCOS has a prevalence of 4-12% in the US, and about 10% of these women are diagnosed with the condition during gynecologic check-up visits (Williams, Mortada & Porter, 2016). PCOS occurs in premenopausal women, and the onset is mostly during the perimenarchal period that is around 16 years (Sirmans & Pate, 2014). Significant ethnic variability is observed in hirsutism. For instance, Asian women have a lesser degree of hirsutism than Caucasian women despite having the same serum androgen levels.
Risk Factors: The risk factors for PCOS include obesity with obese people having a higher incidence of PCOS than individuals with a normal BMI. Besides, female children born with a high birth weight by mothers with obesity and PCOS are at risk of developing PCOS in adolescence (Williams, Mortada & Porter, 2016). A family history of PCOS is also a risk factor since the X-linked dominant mode of inheritance is involved. Individuals with a history of smoking, sedentary lifestyle, and exogenous hormone administration are also at risk of developing PCOS(Sirmans & Pate, 2014). Other factors include a family history of hypertension and diabetes, engaging in heavy exercises and a history of tuberculosis, and thyroid disease.
Clinical Assessment
The typical clinical assessment findings in PCOS include menstrual dysfunction, anovulation, hyperandrogenism, and hirsutism. Menstrual dysfunction manifests as abnormal menstruation patterns associated with chronic anovulation (Pfieffer, 2019). A patient often has a history of menstrual disturbance since menarche. Some patients present with oligomenorrhea or secondary amenorrhea. The anovulatory menstrual cycles can result in dysfunctional uterine bleeding or infertility (Matheson & Bain, 2019).
Hyperandrogenism is characterized by excess terminal body hair that has a male distribution pattern. Hair commonly grows on the chin, upper lip, around the nipples, and the linea alba of the lower abdomen (Williams, Mortada & Porter, 2016). It also manifests with acne and hair loss in a male pattern known as androgenic alopecia. Hyperthecosis, which is an extreme form of PCOS, presents with symptoms of hyperandrogenism, such as increased muscle mass, voice deepening, and clitoromegaly (Matheson & Bain, 2019). Hirsutism manifests with excessive body hair in a male distribution pattern and acne, which occur as a result of hyperandrogenism.
Differential Diagnoses
Iatrogenic Cushing Syndrome: Cushing syndrome represents signs and symptoms that arise as a result of excess free plasma glucocorticoids. The excess glucocorticoids are usually from increased endogenous production or due to prolonged exposure to exogenous administration of glucocorticoid products (Zil-E-Ali, Janjua, Latif & Aadil, 2018). Women with Cushing syndrome experience menstrual irregularities such as amenorrhea and oligomenorrhea and infertility (Zil-E-Ali et al., 2018). Besides, patients with the Cushing are typically obese with an increased adipose tissue in the upper back at the base of the neck, I the face, and above the clavicles.
Idiopathic Hirsutism: Hirsutism is an endocrine disorder and is defined as excessive hairiness (Matheson & Bain, 2019). It presents with excess growth of terminal hair in a male pattern in women. The hairiness symptoms occur due to abnormal androgen action. Idiopathic hirsutism usually begins at puberty and has a slow progression over many years (Matheson & Bain, 2019). PCOS should be differentiated from Idiopathic Hirsutism when there are no features of menstrual dysfunction, anovulation, infertility, and obesity.
Hyperprolactinemia: Hyperprolactinemia is a condition characterized by elevated levels of serum prolactin (Glezer & Bronstein, 2018). The primary function of Prolactin is to stimulate breast development during pregnancy and induce lactation. Patients with hyperprolactinemia present with a history of menstrual dysfunction such as amenorrhea and oligomenorrhea and infertility (Glezer & Bronstein, 2018). The symptoms occur due to the suppression of gonadotropin-releasing hormone by prolactin.
Diagnostic Studies and Laboratory Tests
Imaging studies and biochemical tests are conducted to rule out other possible conditions that result in hyperandrogenism and menstrual irregularity and to ascertain the diagnosis of PCOS.
Diagnostic studies: Imaging studies used in the diagnosis of PCOS include ovarian ultrasonography using a transvaginal approach,
which aids in the assessment of ovarian morphology. A polycystic ovary is diagnosed when an ovary with 12 or more follicles having a diameter of 2-9 mm is visualized with ultrasound or an ovary with a volume higher than 10 ml on ultrasonography (Williams, Mortada & Porter, 2016). Pelvic CT scan or MRI to help in the visualization of the adrenal glands and the ovaries if a tumor suspected. MRI is an effective method of visualizing the ovaries in very obese patients in whom the ovaries may not be visualized through transvaginal ultrasonography.
Laboratory tests: The recommended baseline laboratory tests for patients suspected of having PCOS include, serum prolactin levels, Thyroid function tests, and free androgen index (Williams, Mortada & Porter, 2016).
A free androgen index or Total and free testosterone levels should be measured to evaluate for androgen excess. A high free testosterone level is a sensitive marker of androgen excess.
Free cortisol levels and creatinine levels in the urine should be done using a 24-hour urine sample to rule out the possibility of Cushing syndrome.
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The goals of treatment for patients with PCOS include managing infertility, regulating menses to protect the endometrium, and to control hyperandrogenic symptoms such as hirsutism and acne.
Non-pharmacological Approaches: Lifestyle modification such as diet and exercise is considered the first-line treatment for adolescents and women with PCOS. Lifestyle interventions aim to promote weight loss and include increasing physical activity along with a diet modification to lower the risk of diabetes (Sirmans & Pate, 2014). Besides, weight reduction helps to reduce insulin resistance and can improve ovulation.
Non-pharmacological management of hirsutism includes shaving excess body hair and using chemical depilatories.
Pharmacological Treatment: Treatment should be patient-centered based on a woman’s presentation and desire for pregnancy. Treatment options for the various PCOS presentations include:
Anovulation or Infertility: First-line drugs include Clomiphene or Letrozole to induce ovulation in women who desire pregnancy. For women who do not wish to get pregnant, the first-line treatment is Hormonal contraception, such as Levonorgestrel-releasing intrauterine contraceptive (Williams, Mortada & Porter, 2016). The second-line drug is Metformin.
Insulin resistance: the First-line drug is Metformin, which is a hypoglycemic agent that improves insulin resistance and lowers hyperinsulinemia in PCOS patients. Metformin also has a minimal but beneficial impact on metabolic syndrome and causes a modest decrease in androgen levels (Williams, Mortada & Porter, 2016). Besides, it promotes weight loss, but patients with a BMI greater than 37 may not have a good prognosis with Metformin.
Hirsutism: Electrolysis and light-based therapies are useful for mild cases in cases where contraception is desired. Eflornithine can be used as an adjunct to laser therapy since it slows hair growth (Sirmans & Pate, 2014). In women who do not desire contraception, the first-line treatment is Hormonal contraception with or without antiandrogen therapy. Second-line therapy entails Spironolactone monotherapy after six months of oral contraceptives if the desired outcome is not achieved (Williams, Mortada & Porter, 2016). Other second-line treatments include electrolysis, and Eflornithine while the third-line agent is Metformin.
Acne: Treatment of acne entails the use of topical creams such as benzoyl peroxide, antibiotic creams tretinoin, and differin (Williams, Mortada & Porter, 2016). Hormonal contraception is often prescribed in patients who do not desire pregnancy.
Education
Health education to a patient diagnosed with PCOS should be directed at helping the patient modify her lifestyle to promote weight loss, which reduces insulin resistance and improve ovulation and fertility. Besides, weight loss suppresses androgen production in obese women; hence it is an effective approach to slow hair growth (Pfieffer, 2019). A calorie-restricted diet should be recommended for all patients with PCOS who are overweight and those having glucose intolerance to lower their risk of developing diabetes. Patients should be recommended a diet patterned for type 2 diabetes, which consists of increased fiber, omega-3ncl and omega-9 fatty acids intake, and a decreased intake of trans fats, refined carbohydrates, and saturated fats (Sirmans & Pate, 2014). Women with a high lipid profile should be recommended to take a diet low in saturated fats and cholesterol and increase physical activity to manage dyslipidemia.
Furthermore, patients should be discouraged from cigarette smoking as it increases their risk of diabetes and cardiovascular diseases. Patients with hirsutism should be advised against plucking or waxing unwanted body hair as it may result in ingrown hairs and folliculitis and be recommended to shave instead (Williams, Mortada & Porter, 2016). Families should be educated on the disease process, who is at risk, and how it is managed to empower them and relieve anxiety (Pfieffer, 2019). Lastly, patients should be encouraged to participate in peer support groups to help in alleviating stress and to improve self-management skills.
Optimal Outcomes
The optimal outcomes with the recommended treatment will include the induction of ovulation and the achievement of a regular menstrual cycle. Besides, excessive hair growth should slow down, and acne should resolve. With lifestyle modification, a patient will be expected to lose weight and have reduced insulin resistance; hence hyperinsulinemia will resolve.
Follow-up care: PCOS is associated with many long-term complications, and patients require regular follow-up with their healthcare provider to enable early detection and treatment of any complication (Williams, Mortada & Porter, 2016). Besides, pregnant women with a history of PCOS need constant follow-up during delivery as they ate at an increased risk of preeclampsia, gestational diabetes, preterm, and post-term delivery.
Open-Ended Questions
- What are the common comorbidities associated with PCOS?
PCOS is associated with hyperinsulinemia and insulin resistance which result in Type 2 Diabetes mellitus. Patients with PCOS have a four-fold risk of developing type 2 diabetes (Williams, Mortada & Porter, 2016). PCOS has also been associated with multiple metabolic defects such as metabolic syndrome which contribute to obesity in half of the women (Williams, Mortada & Porter, 2016). Other comorbidities associated with PCOS include non-alcoholic fatty liver, dyslipidemia, sleep apnea, mood disorders, and cardiovascular diseases (Williams, Mortada & Porter, 2016).
- What are the essential diagnostic tests for PCOS patients during their follow-up visits?
Based on the comorbidities associated with PCOS, it is recommended that PCOS patients have their blood pressure monitored at every follow-up visit (Williams, Mortada & Porter, 2016). The Lipid profile should be done every three months, and a two-hour oral glucose test despite the patient’s body mass index (Williams, Mortada & Porter, 2016). Depression screening is also recommended due to mood disorders.
- A 17-year old girl comes to the consultation office with features of hirsutism. She reports that her classmates are making fun of her due to excessive hair growth, and this has affected her self-esteem. How would you manage and educate this patient?
I would manage this patient with Hormonal therapy using Ethinyl estradiol. Ethinyl estradiol is an oral contraceptive that lowers the secretion of luteinizing and follicle-stimulating hormone from the pituitary gland, decreasing the amount of circulating gonadotropin-releasing hormone. It also reduces the levels of free testosterone and androgen production. I would then educate the patient that the excessive hair growth is a result of high androgen levels due to increased production of androgen, which is a male hormone, by the adrenal glands and the ovary (Matheson & Bain, 2019). Using oral contraceptives would help to lower the level of androgen and slows the growth of excess hair (Matheson & Bain, 2019). I will also recommend her to shave but not to pluck or wax the hairs. Besides, I will educate her on taking a healthy diet and engaging in physical activity to promote weight loss which also helps slow hair growth. I will advise her if there is no improvement despite using the oral contraceptives she should come for follow-up.