Pcos Case Study

CASE STUDY #1 POLYCYSTIC OVARY SYNDROME (PCOS)

Fall 2009

WHAT IS PCOS? 

PCOS = polycystic ovarian syndrome  Characterized

by polycystic ovaries and abnormalities in the metabolism and control of androgens and estrogen in women of reproductive age  Etiology of PCOS is not known, although there is likely a genetic component causing hyperinsulinemia and increased testosterone production

WHAT IS PCOS? 

Polycystic ovaries:  Defined

by the presence of at least eight small (2 to 8 mm) follicles (cysts) in each ovary with ovarian enlargement

WHAT IS PCOS? Typical symptoms include any of the following:       

Polycystic ovaries Oligo- or amenorrhea Anovulatory infertility Hirsutism Male pattern baldness Acanthosis nigricans Acne

      

Obesity Dyslipidemia Metabolic syndrome Insulin resistance Type 2 diabetes Sleep apnea Fatty liver

PHYSICAL SYMPTOMS acanthosis nigricans

hirsutism polycystic ovaries

HOW IS PCOS DIAGNOSED? No specific diagnostic criteria established  Diagnosed by physical and biochemical evidence and exclusion of other disorders 

 Physical

symptoms: menstrual disturbance, hirsutism, acanthosis nigricans, acne, obesity  Biochemical tests: abnormalities in androgens, LH, FSH, glucose, insulin, cholesterol, triglycerides  Ultrasound: presence of polycystic ovaries

PCOS MEDICAL COMPLICATIONS 

Type 2 diabetes 



Cardiovascular disease 



Caused by elevated blood pressure, cholesterol, triglycerides

Infertility/spontaneous abortion 



Caused by hyperinsulinemia and obesity

Caused by androgen (e.g. excess testosterone) and estrogen abnormalities

Endometrial cancer 

As a consequence of increased estrogen production

THE PATIENT 

Gracie Moore  Race/Sex:

white female  Age: 34 years  Education: graduate student working on doctoral degree  Occupation: graduate teaching assistant  Hours of work: 8a-5p  Household members: husband and adopted infant daughter

PATIENT BACKGROUND 

Medical history: onset of PCOS 6 years ago 

Stopped menstruating in college 



Placed on oral contraceptives to regulate cycle

40 pound weight gain since college  Exacerbated

hirsutism and PCOS symptoms

2 previous miscarriages  Family history of type 2 diabetes  Current medications: oral contraceptives 



Lifestyle history: symptoms exacerbated by stress of juggling career, school, and family 

Prompted to seek medical attention

CHIEF COMPLAINT AND PHYSICAL EXAM 

Chief complaint: unintentional weight gain  “I 



just keep gaining weight, no matter what I do!” Also: hirsutism, sleep apnea

Physical exam within normal limits except:  Skin:

dry/pale, acne, skin tags, acanthosis nigricans

DIAGNOSIS AND TREATMENT PLAN Dx: polycystic ovarian syndrome  Treatment plan 

 Biochemical

tests: CBC, metabolic panel, lipid panel, thyroid panel, testosterone level, 2-hr GTT  Medications: Yaz (oral contraceptive), Glucophage (hypoglycemic agent), Aldactone (antihypertensive), Vaniqua (reduces excessive hair growth)  Nutritional Consultation

ANTHROPOMETRICS Current height and weight: 65”, 180 lbs  Current BMI: 30.0 kg/m2 

 Class



Current waist circumference: 36 in.  >35



I obesity

in. = increased risk

Weight history: college weight = 140 lbs  College

BMI: 23.3 kg/m2

 Normal



weight

IBW= 125 lbs, current %IBW= 144%

LAB VALUES 

CBC with Differential

  

Gracie’s CBC (normal) Monitor Glucophage tolerance Complete blood count (CBC) with differential  Establishes

baseline for general health  Rule out infections 

Examining all five classes of white blood cells 

Neutrophiles , lymphocytes, monocytes, eosinophils, and basophiles

LAB VALUES 

Comprehensive Metabolic Panel  Status

of kidneys and liver  Electrolyte and acid/base balance  Blood sugar  Blood protein Normal/ units Bilirubin

6 yrs ago

≤0.3mg/dl 0.4 H

 Monitor

4 yrs ago

2 yrs ago

present

0.4 H

0.4 H

0.41 H

for steatohepatitis

LIPID PANEL Positive diagnostic profile  Low

HDL, high LDL and cholesterol, elevated triglycerides

Normal/ units

6 yrs ago

4 yrs ago

2 yrs ago

present

Chol

120-199 mg/dL

189

187

207 H

197

HDL-C

>55 mg/dL

60

58

52 L

51 L

LDL

<130 mg/dL

95

85

141 H

132 H

TG

35-135 mg/dL

174 H

224 H

211 H

184 H

THYROID PANEL 

Thyroid Panel with TSH 

R/O thyroid dysfunction presenting with similar symptoms Normal/ units

6 yrs ago

4 yrs ago

2 yrs ago

present

T4

4-12 mcg/dL

11.4

11.2

9.3

10.1

T3 uptake

75-98 mcg/dL

24

28

30

32

TSH

0.35-5.50 mcIU/dL

3.50

2.174

2.515

2.68



Low T3 uptake consistent w/oral contraceptives

LAB VALUES 

Testosterone Level  Affected

by:

5

alpha-reductase enzyme at vellus Hair follicles and sebaceous gland 

promotes acne and terminal hair

 Clearance 

rate increase with production rate

Any elevation indicates excess androgen production

 Free

testosterone measured by available Sex Hormone Binding Globulin (SHBG)

Testosterone

Normal/unit

6 yrs ago

4 yrs ago

2 yrs ago

present

20-76 mg/dL

56

75

87 H

25

LAB VALUES 

Glucose Tolerance Test (GTT)  Monitors  Risk

 Drink

for insulin resistance

for type 2 diabetes

75g glucose solution

 Blood

draw at beginning (base line) q2h following

Fasting Glucose

Normal mg/dL

6 yrs ago

4 yrs ago

GTT 75g

70-115

96

<200

149

<200

134

<200

116

2 yrs ago

present

MEDICATIONS 

Yaz (Drospirenone and Ethinyl estradiol) 

Oral contraceptive  Suppresses

the pituitary's production of LH, FSH  Suppresses the ovarian production of androstenedione 

Is an androgen

 Estrogen

in birth control increases testosterone binding protein in the blood stream 

Less available testosterone to be converted to dihydrotestosterone by 5 alpha-reductase enzyme 

Reduces hirsutism

 Regulates



menstrual cycle

Increase serum K  Should

limit dietary intake

MEDICATIONS 

Glucophage (Metformin) 

Increases insulin sensitivity  Hyperinsulinemia

increases free testosterone

Reduces ovarian androgen production  Decreases hepatic glucose production 

 Reduces



Decreases conversion of testosterone to dihydrotestosterone  Reduces



insulin secretion

hirsutism and acne

Nutritional concerns  B12

absorption, adequate fluid intake, monitor lactic acidosis, GI upset

MEDICATIONS 

Aldactone 

Diuretic used to treat hypertension 

 

Excretion of sodium relaxes blood vessels

Most widely prescribed anti-androgen in the United States At high doses Aldactone blocks cytochrome P-450 system Reduces capacity of the ovary and adrenal glands to make androgens  Alters the conversion of testosterone to dihydrotestosterone (DHT) by 5 alpha-reductase 



K sparing diuretic Increases serum K  Limit dietary intake 

MEDICATIONS 

Vaniqa (Eflornithine)  

Does not inhibit the production or action of androgens Interferes with 5 alpha-reductase enzyme  Reduces

terminal hair formation



Topical cream used twice daily



No nutritional implications

GRACIE’S ENERGY NEEDS Current TEE (180lbs.) = 1858.25 x (1.0 to 1.39 sedentary) = 1858 - 2583 kcal/day  Previous TEE (140 lbs.) = 1676.25 x (1.0 to 1.39 sedentary) = 1676 – 2330 kcal /day 



Gracie’s energy intake should be consistent with her requirements at her previous normal weight to achieve weight loss

24-HOUR FOOD RECALL (MORNING) Quantity

Calories

CHO (g)

Protein (g)

Fat (g)

Calcium-fortified orange juice Coffee (black)

8 oz

110

28

2

0

6 oz

2

0

0

0

Mixed nuts (salted)

1 cup

760

24

20

68

Ice tea (unsweet)

10 oz

0

0

0

0

872

52g

22g

68g

Food

Total Energy

24-HOUR RECALL (LUNCH) Food

Wendy’s Cheeseburger Wendy’s™ French fries Diet Coke™

Total Energy

Quantity Calories

CHO (g)

Protein (g)

Fat (g)

1

440

35

27

22

Small order 18 oz

350

45

4

16

0

0

0

0

790

80g

31g

38g

24-HOUR RECALL (EVENING) Food

Ham and beans

Quantity Calories

CHO (g)

Protein (g)

Fat (g)

420

75

18

5

Corn muffins

1½ cups 2

680

108

8

18

Diet Coke™

12 oz

0

0

0

0

1

160

30

4

2

1260

213g

30g

25g

Skinny Cow ™ ice cream sandwich Total Energy

GRACIE’S CURRENT STATUS 1676-2330 kcal recommended normal BMI  2922 kcal total current intake 

 47%

CHO  11% Protein  42% Fat  4,255 mg Na

No physical activity reported

PES STATEMENTS Excessive energy intake related to consumption of high fat, energy dense foods as evidenced by selfreported intake in excess of requirements, 40 pound weight gain in the past 6 years, and current BMI of 30 kg/m2  Excessive Na intake related to frequent consumption of salty convenience snacks and meals as evidenced by a Na intake of 185% of max recommended intake and elevated blood pressure of 139/85 mmHg 

SAVING GRACIE 

1)Recommend nutrition education and counseling  Re-attain

a normal BMI (<25kg/m2) by decreasing total kcal intake by 500-1000 kcals/day  Reduce

intake of high fat/energy dense foods

No more than 30% of kcal from fat  Less than 10% of kcal from sat fat 

 Increase

intake of fruits and vegetables

5-9 a day  Monitor K 

SAVING GRACIE 

2) Reduce Na intake to below 2,300 mg as recommended by the Dietary Guidelines  Decrease

meals

intake of salty convenience snacks and

SAVING GRACIE 

3) Gradually build to 60 min. moderate intensity physical activity 5 days/wk  Suggest

everyday activities that she can incorporate throughout the day (brisk walking) 4) Keep a diet and physical activity journal Helps pt. see REALITY 5) Meet weekly as needed to check progress Encouragement and check regularly on what is /is not working

QUESTIONS??