pcos case study
TRANSCRIPT
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?
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
Typical symptoms include any of the
following:
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
Caused by hyperinsulinemia and obesity
Cardiovascular disease
Caused by elevated blood pressure, cholesterol, triglycerides
Infertility/spontaneous abortion
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 I obesity
Current waist circumference: 36 in.
>35 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
Monitor for steatohepatitis
Normal/
units
6 yrs ago 4 yrs ago 2 yrs ago present
Bilirubin ≤0.3mg/dl 0.4 H 0.4 H 0.4 H 0.41 H
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
Low T3 uptake consistent w/oral contraceptives
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
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)
Normal/unit 6 yrs ago 4 yrs ago 2 yrs ago present
Testosterone 20-76 mg/dL 56 75 87 H 25
LAB VALUES
Glucose Tolerance Test (GTT)
Monitors for insulin resistance
Risk for type 2 diabetes
Drink 75g glucose solution
Blood draw at beginning (base line) q2h following
Fasting
Glucose
Normal
mg/dL
6 yrs ago 4 yrs ago 2 yrs ago present
GTT 75g 70-115 96
<200 149
<200 134
<200 116
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 insulin secretion
Decreases conversion of testosterone to dihydrotestosterone Reduces 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)
Food Quantity Calories CHO
(g)
Protein
(g)
Fat
(g)
Calcium-fortified
orange juice
8 oz 110 28 2 0
Coffee (black) 6 oz 2 0 0 0
Mixed nuts (salted) 1 cup 760 24 20 68
Ice tea (unsweet) 10 oz 0 0 0 0
Total Energy 872 52g 22g 68g
24-HOUR RECALL (LUNCH)
Food Quantity Calories CHO
(g)
Protein
(g)
Fat
(g)
Wendy’s
Cheeseburger
1 440 35 27 22
Wendy’s™ French
fries
Small
order
350 45 4 16
Diet Coke™ 18 oz 0 0 0 0
Total Energy 790 80g 31g 38g
24-HOUR RECALL (EVENING)
Food Quantity Calories CHO
(g)
Protein
(g)
Fat
(g)
Ham and beans 1 ½
cups
420 75 18 5
Corn muffins 2 680 108 8 18
Diet Coke™ 12 oz 0 0 0 0
Skinny Cow ™ ice
cream sandwich
1 160 30 4 2
Total Energy 1260 213g 30g 25g
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 self-reported 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 intake of salty convenience snacks and
meals
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??