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??