Martha Dannenbaum MD FACOG Gladys Gibbs MD MS FACOG Meghan Windham RD LD MPH Joe Dannenbaum MS ATC CSCS Disclosures We have NO actual or potential conflict of interest in relation to this educational activity or presentation ID: 914490
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Slide1
Polycystic Ovary Syndrome: The Spectrum of Evaluation and Management in the College Health Setting
Martha Dannenbaum, MD, FACOG
Gladys Gibbs, MD, MS, FACOG
Meghan Windham, RD, LD, MPH
Joe Dannenbaum, MS, ATC, CSCS
Slide2Disclosures
We
have NO actual or potential conflict of interest in relation to this educational activity or presentation
.
Slide3Objectives
1. Identify the characteristics of PCOS.
2. Identify the types of testing options available.
3. Describe the non-pharmacologic management of
PCOS.
4. Describe the pharmacologic management of PCOS.
Slide4Slide5History and Basic Science
Slide6Polycystic Ovary Syndrome
History
Multicystic ovaries first described in the mid 1800s
Irving F. Stein, MD and Michael L. Leventhal, MD-first described the symptom complex of amenorrhea, hirsutism and enlarged ovaries in 1935- “Stein-Leventhal Syndrome”
Ovarian wedge resection improved menstrual pattern and pregnancy rates
While the pathophysiology
that leads to the polycystic ovary is difficult to define, it is clear that it develops when a chronic anovulatory state exists for a sufficient length of time
There are many causes of anovulation; therefore there are many causes of polycystic ovaries.
PCOS affects about 8-10% of women of reproductive age
Slide7Diagnostic Criteria
Slide8Slide9Polycystic Ovary Syndrome Basic Science
Fundamental pathophysiologic defect unknown
Familial clustering suggests a genetic component
Endocrine state in women with chronic anovulation is characterized by a “steady state” in which hormone concentrations vary relatively little when compared to normal cycling women.
Increased serum LH concentrations, low normal FSH, increased LH:FSH ratio
Hyperandrogenism
is the key feature of PCOS; increased androgens predominantly come from the ovary
Slide10“Current perspectives view PCOS as a complex disorder,….wherein numerous genetic variants and environmental factors interact, combine, and contribute to the pathophysiology”
Slide11Clinical Manifestations
Oligo-anovulation
Irregular menstrual bleeding/
oligomenorrhea
Infertility
Androgen ExcessAcne
Hirsutism
Ovarian Morphology
Obesity
Insulin Resistance/Diabetes Mellitus
Acanthosis
N
igricans
Cardiovascular Disease
Slide12Screening, Evaluation and Diagnosis
History and Physical Exam
Irregular periods since menarche
Hirsutism (may not be clinically evident)
Family history
AcneOverweight/obese
Laboratory Studies
Variable benefit, but….
Radiology
Ultrasound not mandatory, but….
Slide13Lab studies to consider
HCG (based on history)
Testosterone-total and free
FSH/LH
Fasting glucose/insulin
17 alpha progesterone
Slide14Slide15Slide16Slide17Management
Variable based on patient goals and presenting symptoms
All will benefit from
lifestyle management
Slide18Lifestyle Management-Nutrition
Slide19Nutrition Modifications- Insulin Resistance
Image from: http
://www.ethoshealth.com.au/announcements/confused-by-diabetes-heres-a-simple-explanation
Slide20Image from: http
://www.ethoshealth.com.au/announcements/confused-by-diabetes-heres-a-simple-explanation
Slide21Image from: http
://www.ethoshealth.com.au/announcements/confused-by-diabetes-heres-a-simple-explanation
Slide22How can my diet help?
The TYPE and TIMING of food can help normalize hormone levels in the body
Slide23Types of food
Lean protein
F
ish, chicken, low fat cheese, lean ground beef
Healthy fats
Nuts, seeds, nut butter, olives, avocado, flaxseed, olive or canola oil
Trout, halibut, salmon, sardines, or herring (2x a week)
Vegetables and fruit
Have at least one every time you eat!
High in antioxidants, good sources of fiber and anti-inflammatory
Complex Carbohydrates
Whole grain breads, brown rice, quinoa, oatmeal
Limit added sugars to 25 grams per day
Syrup, glucose, sugar, honey, evaporated cane juice,
etc
Slide24Timing
Eat consistently- this will help regulate blood sugars
3 meals a day
2 snacks- mid-morning, afternoon
No longer than 4 hours between meals
Slide25Current Practices- TAMU
Initial nutrition assessment
Weight history
and background information
Evaluate current eating patterns for trends
Barriers for making a change/ challenges with compliance Discuss carbohydrate content and specify needs based on individual
Address exercise patterns
Follow up visits
Assess weight changes
Further discuss eating patterns and any changes made
Continued collaboration with physicians and counselors
Slide26Best Practices- TAMU
Group setting
Sense of belonging
10-12 participants
Grocery store tours
Label reading for carbohydrate contentShopping while on a budget
Cooking Classes
H
ow to modify recipes
Quick and easy meal ideas
Healthy snacking
Interdisciplinary Team
Counseling
Physician
Dietitian/Nutrition
Additional Resources
Use of Bod Pod for concrete thinkers
Slide27Lifestyle Management-Exercise
Slide28Exercise and its benefits for underlying conditions of PCOS
Research in the last 10 years
Exercise or Physical activity and effects on obesity 23,876 articles
Exercise or Physical activity and effects
on diabetes 16,762 articles
Exercise or Physical activity and effects
on insulin resistance 4,642 articles
Exercise or Physical activity and effects
on metabolic syndrome 3,971 articles
Exercise or Physical activity and effects
on cardiovascular disease 7,139 articles
Source: EBSCO/Medline complete
Slide29Exercise-physical activity
We have to get them moving
Cardiovascular exercise, resistance exercise, and flexibility
Utilize student recreation centers
Make it fun!!!!!!!!!!!!!!
Body weight exercising can be done anywhere and shortens the workoutAquatics: walking, running in the pool, water aerobics
Scavenger hunts on campus
Dancing
Yoga
30 minutes a day is great but get them to start with 5 or 10 minutes
Slide30Process of exercise
Once moving again.
Teach proper progressions
Warm-up
Something to get blood flowing, increased HR, increased breathing
Dynamic stretchingActivityCool-down (walking, light jogging) Never overlook this step
Stretch
Static stretching
Slide31Management: Irregular bleeding
Confirm pregnancy status
Cyclic progesterone (medroxyprogesterone acetate)
Combination Hormonal Contraceptives (pills, patches, rings)
LARC
Slide32Audience Questions
True or False
?
Polycystic
ovary syndrome is a leading risk factor for metabolic syndrome, obesity, insulin resistance, and type 2 diabetes mellitus
.
The risks associated with Polycystic ovary syndrome can be mitigated through what treatment(s
)?
A
. Weight
loss
B
. Hormonal
contraceptives
C
.
Spironolactone
D
. All of
the
above
True or
False?
Treatment
of PCOS depends on symptoms and whether the patient is planning a pregnancy
.
Slide33Case Study #1:
21 year old female student visits the health center reporting increasingly irregular menstrual periods and new dark hair growth on her upper lip, chin and the inner aspect of her thighs. She is not sexually active currently, but has been in the past with her last intercourse 8 months ago. Her last 2 “normal” periods were 4 and 6 months ago. She experienced menarche at age 13, with initial irregular cycles every 2-3 months. She had mild to moderate facial acne as a teenager, which was treated successfully with minocycline. In high school, she was a cheerleader and ran cross-country on the varsity track team. During this time, she would occasionally have regular cyclic periods. Since coming to college, she no longer engages in sports other than occasional visits to the campus rec center. She is a student worker (16-20 hours per week) and is a Junior Accounting major with a 3.6 GPA. She is 5’6” and weighs 165 pounds (BMI 26.6) , having gained 25 pounds since her freshman year.
Slide34Management: Hirsutism
Cosmetic
Plucking, waxing, shaving, threading
Electrolysis
Laser
Medical
Hormonal contraceptives
Spironolactone (aldosterone antagonists)
Finasteride (5 alpha-reductase inhibitors)-*off label use*
Flutamide
Insulin sensitizers (Metformin)
Glucocorticoids
Slide35Slide36Management: Infertility
The great majority of women with PCOS will be able to get pregnant and have a baby with fertility treatment.
Address Overweight/Obese
Ovulation Induction
Clomiphene Citrate
Aromatase inhibitors (
letrozole
)-*off label use*
Injectable Gonadotropins
Advanced Reproductive Technology
Artificial Insemination
In-vitro Fertilization
Look for other reasons for inability to conceive if these methods do not achieve pregnancy.
40% of couples will have more than one factor impacting fertility
Slide37Case Study #2:
28 year old female doctoral student visits the health center to discuss infertility. She has been married for 4 years and not using contraception for 18 months. Her husband is also a doctoral student and accompanies her to the visit. She reports irregular menses since menarche (age 13) which was treated successfully with oral contraceptives starting at age 15. She continued on OCPs until 18 months ago. Since stopping her OCPs she has only had 3 spontaneous menses. She has also noticed an increase in facial hair and acne. On physical exam she is 5’ 5” and weighs 219 pounds (BMI 36.4). Her blood pressure is 135/85 mm Hg. She states she has been overweight since childhood and has had intermittent success with diets, always regaining the weight she lost. She does not regularly engage in exercise. Her waist circumference is 46 inches, suggestive of central obesity.
Slide38Management: General Health Risks
Address Overweight/Obese
Insulin Resistance
Insulin sensitizers (Metformin)
Cardiovascular
Statins
Mental Health
Screen for and treat depression
Cancer
Long term untreated
oligomenorrhea
increases endometrial cancer risk
Ovarian cancer
Slide39Pregnancy considerations:
Increased incidence of Gestational Diabetes
Increased incidence of Pregnancy Induced Hypertension (PIH) and Preeclampsia
Risks related to obesity
Hypertension
ThromboembolismIncreased maternal mortality
Increased risks of pre-term birth and perinatal mortality, even when controlling for multiple gestation resulting from infertility treatment
Slide40The older woman
Normal to Impaired glucose tolerance to Diabetes
Hypertension
Dyslipidemia
“Metabolic Syndrome”
Endometrial CancerOvarian Cancer
Slide41Case study #3
A 46 year old female graduate student, gravida 2, para 2, presents to the health center for a general health visit. She has been working as a high school science teacher and is returning to complete a Masters in Education program. She reports a history of irregular menses since menarche. She reports that she required Clomiphene citrate to achieve pregnancy. Her children, ages 12 and 14, were delivered at full term. Her second pregnancy was complicated by gestational diabetes. She had follow up diabetes testing about 6 months after she delivered and reports everything was normal. She is taking combination oral contraceptives, but because of her age is wanting to discontinue them. She reports she has been seeing her gynecologist annually and states she has always been told everything was fine. Her other personal and family history is negative. On examination, she is 5’4” and her weight is 168 pounds (BMI 28.8). Blood pressure is 134/90. She is noted to have a slight amount of dark hair on her upper lip and around the areola of each breast. Fasting lab results are as follows:
Slide42Fasting Glucose: 96mg/
dL
2 hour (75 gm) OGTT: 162 mg/
dL
Total cholesterol: 218 mg/
dLHDL cholesterol: 39 mg/dL
LDL cholesterol: 163 mg/
dL
Triglyceride: 166 mg/
dL
Slide43Slide44Questions?