Case Study: Polycystic Ovary Syndrome (PCOS) Treatment Plan

This presentation focuses on a case study of a 17-year-old female adolescent presenting with obesity and amenorrhea, indicative of Polycystic Ovary Syndrome (PCOS). The presentation details the patient's history, physical exam findings, and endocrine lab results, highlighting key symptoms such as irregular periods, hirsutism, and acne. It defines PCOS as a metabolic dysfunction characterized by hyperandrogenism, insulin resistance, and anovulation, discussing its signs, symptoms, and potential barriers to effective management. The presentation explores overcoming these barriers through awareness, behavioral management, and healthcare professional education. It outlines evidence-based treatment approaches, including first-line therapy with combined oral contraceptives (COC) and metformin, and second-line therapy with spironolactone, along with their adverse effects. Alternative therapies, such as lifestyle changes involving weight loss through diet and exercise, are also emphasized. The presentation concludes by outlining optimal outcomes of obesity management and includes a list of references supporting the information presented. Additionally, the presentation answers a series of questions related to PCOS treatment and diagnosis.

Polycystic Ovary
Syndrome (PCOS)
BY KETEVAN APTSIAURI
NR 508
PROFESSOR RUCK
02/16/2020

CASE STUDY
• 17 YEAR OLD FEMALE ADOLESCENT PRESENTS AT THE PRIMARY CARE CLINIC FOR
EVALUATION OF OBESITY AND AMENORRHEA. PATIENT HAS A HISTORY OF NORMAL PUBERTY
AND ONSET OF MENARCHE AT 11 YEARS OF AGE. SHE REPORTS HAVING IRREGULAR
PERIODS SINCE THE ONSET OF MENSES. PERIODS INITIALLY OCCURRED EVERY 2-3 MONTHS
BUT FOR THE PAST YEAR, MENSTRUAL INTERVALS STRETCH UP TO 4 MONTHS. MENSES LAST
FOR 4-5 DAYS AND ARE DESCRIBED AS LIGHT BLOOD FLOW. PATIENT ALSO REPORTS THE
GROWTH OF COARSE DARK HAIR ON HER FACE AND LOWER ABDOMEN ALONG WITH A
PERSISTENT FACIAL ACNE UNRESPONSIVE TO TOPICAL THERAPY
• PREVIOUS MEDICAL HISTORY INCLUDES RAPID WEIGHT GAIN OVER THE LAST 5 YEARS
• PATIENT DENIES ANY MEDICATION OR FOOD ALLERGIES
• PHYSICAL EXAM FINDINGS CONFIRM ACNE AND HIRSUTISM OTHERWISE THE ASSESSMENT IS
UNREMARKABLE. PATIENT’S HEIGHT (68 INCHES), WEIGHT OF (113 KG), BP138/90
• ANALYSIS OF ENDOCRINE LAB TESTING REVEALS: 17 HYDROXY PROGESTERONE 110 NG/DL;
TOTAL TESTOSTERONE 70 NG/DL FREE TESTOSTERONE 12 NG/DL, DHEAS 225 MCG/DL, LH
20 MIU/ML, FSH 12 MIU/ML; HEMOGLOBIN A1C 6.1%

WHAT IS PCOS
• THIS IS A METABOLIC DISFUNCTION CHARACTERIZED BY:
• HYPERANDROGENIC STATE (EXCESSIVE PRODUCTION OF BOTH ANDROGEN AND ESTROGEN
• INSULIN RESISTANCE
• HYPERINSULINEMIA
• ANOVULATION
• SUSPECTED TO HAVE GENETIC BASES
• STEROID BIOSYNTHESIS
• ANDROGEN BIOSYNTHESIS
(MCCANCE & HUETHER, 2019)

SIGNS & SYMPTOMS OF PCOS
•DYSFUNCTIONAL BLEEDING OR AMENORRHEA
•HIRSUTISM D/T INCREASED TESTOSTERONE LEVELS
•ACNE
•OBESITY
•ACANTHOSIS NIGRICANS (INSULIN RESISTANCE AND SPIKES CAUSE THE SKIN TO
TURN BLACK AND BROWN IN THESE PLACES)
•INFERTILITY
(MCCANCE & HUETHER, 2019)

POTENTIAL BARRIERS
• THE MAJOR BARRIER IS THE UNABLE TO CHANGE THE LIFESTYLE
• UNCONTROLLED WEIGHT MANAGEMENT
• LACK OF AWARENESS IN UNDERSTANDING THE CONDITION OF PCOS
• UNABLE TO ANALYZE THE SIGNS AND SYMPTOMS
• FAILURE IN IMPLEMENTING THE EVIDENCE-BASED PRACTICE IN THE HEALTH
SYSTEM

OVERCOMING POTENTIAL BARRIER
• CREATING AWARENESS BY EDUCATING THE MAJORITY OF POPULATION.
• IT CAN BE DONE WITH THE HELP OF CONFERENCES, CAMPING IN MULTIPLE LOCATION
AND SUCH OTHER ASPECTS THAT LEADS COMMUNICATION FOR CREATING AWARENESS.
• BEHAVIORAL MANAGEMENT IS NECESSARY FOR CHANGING THE LIFESTYLE OF THE
PEOPLE
• HEALTHCARE PROFESSIONALS CAN EDUCATE THE EXISTING PATIENT TO ANALYZE THE
SIGNS AND SYMPTOMS FOR FURTHER DELIVERING OF QUALITY CARE.
• THEY CAN ALSO PROVIDE THE EFFICIENT DIET THAT WILL HELPS THEM IN OVERCOMING
OBESITY
• EFFICIENT WEIGHT MANAGEMENT STRATEGY SUCH AS INCLUDIENG PHYSICIAL ACTIVITY
AND MULTIPLE INTEGRATED CARE TOWARDS IT.

MEDICATION MANAGEMENT
FIRST LINE THERAPY
• COMBINED ORAL CONTRACEPTIVES
(COC)
• METFORMIN
• THIS MEDICATION IS AVAILABLE
UNDER MULTIPLE TRADE NAME
• SUCH ARE : GLUCOPHAGE, RIOMET,
FORTAMET AS WELL AS
GLUCOPHAFE XR
• THIS DRUGS COMES UNDER THE
CLASS OF BIGUANIDES
SECOND LINE OF THERAPY
• SPIRONOLACTONE (GENERIC NAME)
• IT CAN BE USED IN CASE THE
PATIENT HAVE ALLERGY TO THE
FIRST LINE MEDICATION.
• TRADE NAME : ALDACTONE

ADVERSE EFFECTS
METFORMIN
• IT REDUCES THE INSULIN LEVEL IN THE BODY
• INSULIN RESISTANCE IS THE MOSTLY MUTUAL
TRAIL TO DISEASE AMONGST FEMALES WITH
PCOS
• IT HAS ALSO BEEN SEEN THAT METFORMIN
HAS EFFECTIVE IN INDUCING OVULATION
• HOWEVER, IT IS IMPORTANT TO CHANGE THE
LIFESTYLE FOR EFFECTIVE RESULTS
• ACCORDING TO HASHIM (2016), THERE IS AN
INCREASE IN CLINICAL PREGNANCY RATE
WITH LOWER RISK IN THE HEALTH.
SPIRONOLACTONE
• IT IS VERY MUCH EFFECTIVE IN
REDUCING THE GROWTH OF MALE HAIR.
• HOWEVER, THE EFFECTIVENESS CAN BE
SEEN IN 5-6 MONTHS
• IT WILL HELP IN REDUCING THE
IRREGULAR MENSTRUAL BLEEDING
HOWEVER. FAILURE IN TAKING REGULAR
MEDICATION CAN RESULTS IN IRREGULAR
MENSTRUAL CYCLE
• THERE CAN BE LITTLE DISCOMFORT
SUCH AS TIREDNESS OR HEADACHE

ALTERNATIVE THERAPY
• LIFESTYLE CHANGES:
• WEIGHT LOSS (DIET & EXERCISE)
• OBESITY MANAGEMENT
PCOS PATIENT FINDS DIFFICULT TO USE THE INSULIN IN THE BODY, AND HENCE
FINDS DIFFICULT IN CONVERSION OF FOOD(SUGAR AND STARCHES) INTO ENERGY.
THEREFORE, RESULTING IN INSULIN RESISTANCE IN THE BLOODSTREAM.
OBESITY MANAGEMENT AS WELL AS WEIGHT LOSS PROCESS IS VERY CRUCIAL IN
OVERCOMING THE POLYCYSTIC SYNDROME. IT IS ESTIMATED THAT ONLY A
REASONABLE FRACTION OF BODY WEIGHT CAN NORMALIZE THE MENSTRUAL
CYCLE.
• IT CAN BE ACHIEVED BY EATING HIGH FIBER AS WELL AS LOW SUGAR DIET.
• PHYSICAL ACTIVITY IS VERY MUCH CRUCIAL TO IMPLEMENT THE BETTER
LIFESTYLE.

OPTIMAL OUTCOME OF OBESITY
MANAGEMENT
• IT WILL IMPROVE THE BEHAVIORAL AS WELL AS IMPROVED THE LIFESTYLE.
• IT HAS INCREASED THE EVENTS OF OVULATORY
• THE REDUCTION IN WEIGHT WITH 5- 10 PERCENT WILL REDUCE THE INSULIN
LEVEL ALONG WITH THE HYPERANDROGENISM

REFERENCES
BARBER, T. M., JOHARATNAM, J., & FRANKS, S. (2018). PATHOGENESIS AND
MANAGEMENT OF ADIPOSITY AND INSULIN RESISTANCE IN POLYCYSTIC OVARY
SYNDROME (PCOS). IN PEDIATRIC OBESITY (PP. 629-642). HUMANA PRESS, CHAM.
DIRI, H., KARABURGU, S., ACMAZ, B., UNLUHIZARCI, K., TANRIVERDI, F., KARACA, Z.,
& KELESTIMUR, F. (2016). COMPARISON OF SPIRONOLACTONE AND
SPIRONOLACTONE PLUS METFORMIN IN THE TREATMENT OF POLYCYSTIC OVARY
SYNDROME. GYNECOLOGICAL ENDOCRINOLOGY, 32(1), 42-45.
DUMITRESCU, R., MEHEDINTU, C., BRICEAG, I., PURCĂREA, V. L., & HUDITA, D.
(2015). METFORMIN-CLINICAL PHARMACOLOGY IN PCOS. JOURNAL OF MEDICINE
AND LIFE, 8(2), 187.
HASHIM, H. A. (2016). TWENTY YEARS OF OVULATION INDUCTION WITH METFORMIN
FOR PCOS; WHAT IS THE BEST AVAILABLE EVIDENCE?. REPRODUCTIVE
BIOMEDICINE ONLINE, 32(1), 44-53.

KOTHARE, A., JAISINGHANI, C., RANE, S., & HARSHAL, A. (2015). INTER-RELATIONSHIP
OF PCOS WITH BMI, OBESITY AND EXERCISE. IJHSR, 5(6), 545-546.
LEELAPHIWAT, S., JONGWUTIWES, T., LERTVIKOOL, S., TABCHAROEN, C., SUKPRASERT,
M., RATTANASIRI, S., & WEERAKIET, S. (2015). COMPARISON OF
DESOGESTREL/ETHINYL ESTRADIOL PLUS SPIRONOLACTONE VERSUS
CYPROTERONE ACETATE/ETHINYL ESTRADIOL IN THE TREATMENT OF POLYCYSTIC
OVARY SYNDROME: A RANDOMIZED CONTROLLED TRIAL. JOURNAL OF
OBSTETRICS AND GYNAECOLOGY RESEARCH, 41(3), 402-410.
MCCANCE, K. L., & HUETHER, S. E. (2018). PATHOPHYSIOLOGY-E-BOOK: THE BIOLOGIC
BASIS FOR DISEASE IN ADULTS AND CHILDREN. ELSEVIER HEALTH SCIENCES.
TZIOMALOS, K., & DINAS, K. (2018). OBESITY AND OUTCOME OF ASSISTED
REPRODUCTION IN PATIENTS WITH POLYCYSTIC OVARY SYNDROME. FRONTIERS IN
ENDOCRINOLOGY, 9, 149.