ppt pcos group
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CASE STUDY #1POLYCYSTIC 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 vellusHair 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 followingFasting
Glucose Normalmg/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 progressEncouragement and check regularly on what is /is not working
QUESTIONS??
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