From Novice to Knowing: A Primer on PCOS

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From Novice to Knowing A Primer on PCOS

• Kay M. Czaplewski, BSN, RN, BC, CDE, NHA

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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)
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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.
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This tutorial will focus on four aspects of
PCOS(click on an area of interest)
(Theres no place like ) HOME PAGE

• 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
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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
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Normal Menstrual Cycle

• Four Main Phases

Phase 1 Menses
Phase 2 Follicular Phase
Phase 3 Ovulation
Phase 4 Luteal Phase
Click on the daisies to learn more!
home
(Hole, 1989)
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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!
home
(Hole, 1989)
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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
Phase 3, please
OVULATION
(Hole, 1989)
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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!
Take me home
(Hole, 1989)
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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.
Next slide
(Hole, 1989)
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For a summary of menstruation in graph form,
Please press me!
Kay,RN
Otherwise, proceed With test
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Phase 1 question

• Average blood shed during menstruation is 300ml.
• True
• False

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Thats Correct!

• The average blood loss is 10-80 ml

(Wikipedia, 2007)
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Take me to question 2
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Oops! Try again

• Blood shed in that amount may be detrimental!

Let me try again!
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Multiple choicePress on the correct answer
Phase 2 question

• In the follicular phase, the endometrium

A. Thickens
C. Dissolves
B. Thins
C. Sheds
home
Take me to menstrual cycle
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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
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no

• A dissolving endometrium
• Thats just silly
• Hahaha

Return to test
Next question
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no

• thinning

would
be
Menstruation!!!
(Hole, 1989)
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• No

shedding
Would
be
menstruation
Back to test
(Hole, 1989)
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Phase 3 Question

• During Ovulation

Egg is released
No egg released
home
Menstrual cycle
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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
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Not quite

• Remember, during ovulation, the mature egg is
  released.

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Phase 4 Question

• After ovulation, what do the follicles form?

• Corpus luteum

2. Corpus Christi
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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
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No Yaall
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Great job on getting through the normal menstrual
cycle,
now lets talk about PCOS
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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
Disordered GnRH Release
Pituitary secretion of LH increases
Hyperinsulinemia stimulates ovarian and adrenal
androgen synthesis
Treatments are directed at
Increased LH release
Restoring gonadotropin secretion (clomiphene)
Increased androgen and Insulin levels decrease
levels of circulating binding proteins that
limit androgen bioactivity
Increased Ovarian Androgen biosynthesis
Decreasing androgen levels (follicle-stimulating
hormone Or ablative surgery)
Decreasing insulin levels (metformin, insulin
sensitizers, weight loss, exercise
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(Adapted from Legro ,R.S. JAMA 2007 used with
permission)
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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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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
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Treatment of Menstrual Dysfunction

• Oral contraceptives and
• progesterone withdrawal
• Lifestyle modification/weight loss
• Metformin (Barbieri Ehrmann, 2007)

continue
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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
Test Time!
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Test Time

• The purpose of a progesterone withdrawal is to
  cause
• A. No Menses
• B. Menses

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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.

next
(Barbieri Ehrmann, 2007)
home
Back to test
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Ooops!try again
(hintits just the opposite!)
Back to question
Back to menstrual dysfunction
Back to home
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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).

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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)
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Lifestyle Changes
Weight Loss reduces hyperinsulinemia And
subsequently, hyperandrogenism (Hill, 2003).
weight
hyperinsulinemia
hyperandrogen
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home
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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)
TEST TIME!
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Anovulation and Infertility

• For practical purposes, anovulation and
  infertility are the same thing.
• True
• False

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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)
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Normal Menstrual Cycle
Press for test
(Wikipedia, 2007)
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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 lt4.5 (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).

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Treatment of Insulin Resistance
Metformin also lowers fatty acid concentrations,
thus reducing gluconeogenesis (The formation of
glucose, especially by the liver, from non-
carbohydrate sources, such as amino acids and the
glycerol portion of fats)
(Barbieir Ehrmann, 2007 Franz, 2003)
Test time!
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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?
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Yes, genesis is the first book in the bible
No, genesis is not gluconeogenesis
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You are a rock star!!
As you know, gluconeogenesis is the formation of
glucose, especially by the liver, from
non- carbohydrate sources, such as amino acids
and the glycerol portions of fats (Barbieri
Ehrmann, 2007)
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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).
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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)
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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)
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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)
Test time
(Barbieri Ehrmann, 2007)
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In PCOS, spironolactone is used for its effect
as(press on the correct answer)

• 1. Aldosterone antagonist

2. Aldosterone protagonist
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Hey learner, its your birthday, hey, learner,
its your birthdayyou 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
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Not quite
We want to decrease androgen secretion and action
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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
58
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.

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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
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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 httpwww.mayoclinic.com/health/polycysti
c-ovary-syndrome/DSS00423/DSCETION6
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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. Tabers
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.h
tm
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