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  Obesity
 Oligo- or amenorrhea  Dyslipidemia
 Anovulatory infertility  Metabolic syndrome
 Hirsutism  Insulin resistance
 Male pattern baldness  Type 2 diabetes
 Acanthosis nigricans  Sleep apnea
 Acne  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
 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

Normal/ 6 yrs ago 4 yrs ago 2 yrs ago present

units
Bilirubin ≤0.3mg/dl 0.4 H 0.4 H 0.4 H 0.41 H

 Monitor for steatohepatitis

 LIPID PANEL
Positive diagnostic profile
 Low HDL, high LDL and cholesterol, elevated triglycerides

Normal/ 6 yrs ago 4 yrs ago 2 yrs ago present

units
Chol 120-199 189 187 207 H 197
mg/dL
HDL-C >55 mg/dL 60 58 52 L 51 L
LDL <130 mg/dL 95 85 141 H 132 H
TG 35-135 174 H 224 H 211 H 184 H
mg/dL
 THYROID PANEL

 Thyroid Panel with TSH

 R/O thyroid dysfunction presenting with similar
symptoms
Normal/ 6 yrs ago 4 yrs ago 2 yrs ago present
units
T4 4-12 11.4 11.2 9.3 10.1
mcg/dL
T3 uptake 75-98 24 28 30 32
mcg/dL
TSH 0.35-5.50 3.50 2.174 2.515 2.68
mcIU/dL

 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)
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 Normal 6 yrs ago 4 yrs ago 2 yrs ago present
Glucose mg/dL
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 Protein Fat

(g) (g) (g)
Calcium-fortified 8 oz 110 28 2 0
orange juice
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 Protein Fat
(g) (g) (g)
Wendy’s 1 440 35 27 22
Cheeseburger
Wendy’s™ French Small 350 45 4 16
fries order
Diet Coke™ 18 oz 0 0 0 0
Total Energy 790 80g 31g 38g
 24-HOUR RECALL (EVENING)
Food Quantity Calories CHO Protein Fat
(g) (g) (g)
Ham and beans 1½ 420 75 18 5
cups
Corn muffins 2 680 108 8 18

Diet Coke™ 12 oz 0 0 0 0

Skinny Cow ™ ice 1 160 30 4 2

cream sandwich
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??