Managing Polycystic Ovary Syndrome

Mary Elizabeth DuRant, WHNP-BC, CNMNan S. Leslie, PhD, WHNP-BCElizabeth A. Critch, MBA

Polycystic ovary syndrome (PCOS) is the most common endocrine

disease of women of reproduc-tive age (Dunaif, Givens, Haseltine,

& Merriam, 1992; Hart, Hickey, & Franks, 2004). It’s a complex endo-crine disorder that affects between 5 percent and 10 percent of women of reproductive age world wide (Broek-mans et al., 2006; Dunaif et al.; Hart et al.; Siassakos & Wardle, 2007).

A Cognitive Behavioral Strategy Managing Polycystic Ovary Syndrome

PCOS is a group of symptoms and biochemical features that

occur in various combinations and with varying degrees of se-

verity. Presenting with a single finding is not diagnostic of the

problem. The clinical, biochemical and diagnostic features of

PCOS are known, yet the etiology remains unknown (Elghb-

lawi, 2007). Three-fourths of women with secondary amenor-

rhea meet the diagnostic criteria for PCOS (Hill, 2003). PCOS

is a chronic condition that has a major impact on the health of

affected women. Women with PCOS are at risk for developing

type 2 diabetes mellitus, hyperlipidemia, reproductive system

cancers, sleep apnea and infertility problems (Ehrmann, 2005;

Guzick, 2004; Sherif, 2006; Taylor, 1998).

Nurse practitioners (NP) and certified nurse-midwives

(CNM) often see women with PCOS and are well-positioned

to diagnose the condition, address patient concerns and create

a program of care tailored to each individual. Multiple health

complications associated with PCOS affect the patient’s qual-

ity of life and bring her to the health care system. These trou-

blesome symptoms include hirsutism, inability to lose weight,

irregular menstrual cycles, infertility and prolonged bleeding

when menses occur. PCOS, a precursor for long-term meta-

bolic risks, can facilitate the onset of insulin-resistant diabetes

mellitus, cardiovascular disease, metabolic syndrome and re-

productive system cancers.

PCOS, like other chronic conditions, requires continual

management. The best outcomes are achieved when both the

health care provider and the patient actively manage the dis-

ease. The health care plan needs to focus on obtaining and

maintaining an optimum state of health (Wagner, Austin, &

Von Korff, 1996a, 1996b). The primary treatment of choice for

PCOS is lifestyle management aimed at maintaining a healthful

weight through a diet and increased activity to either prevent

or improve the symptoms of PCOS. This paper introduces a

cognitive behavioral strategy that was designed for and is used

by the West Virginia National Center of Excellence in Women’s

Health to assist women with such lifestyle changes.

Who Develops PCOS?The etiology of PCOS is not clearly understood, but current

research suggests a genetic (autosomal-dominant) component.

The disease occurs predominantly in families rather than in

isolated individuals. Studies attempting to define the specific

genetic cause suggest that PCOS is a complex, multigenic disor-

der with a clinical and biochemical presentation that is also in-

fluenced by environmental factors (Abbott, Dumesic, & Franks,

2002; Diamanti-Kandarakis & Piperi, 2005). PCOS should be

suspected in girls during childhood if other women in the fam-

ily have been diagnosed with the disease or are obese and have

been diagnosed with type II diabetes mellitus. Symptomatic

care is often sought initially in pediatric, family medicine or

gynecology care settings for help regulating menstrual cycles or

treating acne or infertility.

Irregular menstrual cycles may be the first presenting

symptom to suggest the existence of PCOS. Oligo-ovulation

manifests as menstrual irregularity and occurs in 70 percent of

women with PCOS. Women with PCOS who report more regu-

lar menstrual patterns experience varying degrees of ovulatory

dysfunction. Often the menstrual formula (i.e., three to five

days of menstrual flow every 28 to 35 days) occurs for the first

one to two years after menarche (which occurs at the normal

age), but then menses become less frequent, occurring every

45 to 365 days (Richardson, 2003). After the onset of puberty,

75 percent of women with secondary amenorrhea meet the di-

agnostic criteria for PCOS (Azziz et al., 2006; Hill, 2003; King,

2006). Menstrual irregularity and/or secondary amenorrhea are

reasons the diagnosis tends to be made after puberty occurs.

EtiologyBased on animal studies, Abbott et al. (2002) suggest that

PCOS is a linear process that begins in utero. They postulate

that either or both hyperandrogenic fetal ovaries or the hyper-

androgenic adrenal cortex is the cause of excess fetal andro-

gen production, beginning in the second trimester. Androgens

are potent gene transcription factors and induce other critical

transcription factors effecting gene expression. This implies fe-

tal androgen excess in female fetuses may reprogram coding

in multiple organ systems that will later appear as the varying

phenotypes of PCOS (Abbott et al.). Though not proven, there

is evidence to support the idea that a genetic defect causes the

fetal ovary theca cells to overproduce androgens, causing the

cascade of changes in utero that lead to the syndrome (Urbanek

et al., 2000).

294 © 2009, AWHONN http://nwh.awhonn.org

Mary Elizabeth DuRant, WHNP-BC, CNM, is a doctoral student and assistant clinical professor; Nan S. Leslie, PhD, WHNP-BC, is a professor; Elizabeth A. Critch, MBA, is the executive director of the West Virginia National Center of Excellence in Women’s Health; all authors are at West Virginia University in Morgantown, WV. Address corre-spondence to: edurant@hsc.wvu.edu.

DOI: 10.1111/j.1751-486X.2009.01439.x

• PCOS is a complex, chronic condition that often requires lifelong management.

• Health behaviors including diet, exercise and weight control are first line strategies for management.

• A cognitive behavioral tool can help women with PCOS achieve and maintain positive behavior changes.

Bottom Line

August September 2009 Nursing for Women’s Health 295

PathophysiologyDefects in reproductive endocrine pathways create a cycle of

abnormal hormonal secretions that cause the range of ob-

served phenotypes. Androgen excess explains defects that cause

the cascade of symptoms. Most women with PCOS have some

degree of insulin resistance. The overproduction of androgens

by theca cells is a response to increased stimulation of the ovary

by luteinizing hormone (LH). Theca cells in women with PCOS

more efficiently convert androgenic precursors to testosterone

than do normal theca cells (Ehrmann, 2005). Follicle-stimu-

lating hormone (FSH) is responsible for regulating aromatase

activity of granulosa cells. The level of FSH determines the

amount of estrogen that is made from androgen precursors

(Ehrmann). FSH levels are often decreased in PCOS (Marrinan

& Stein, 2007).

Insulin is both a direct and indirect contributor to hyper-

androgenemia. It acts synergistically with LH to enhance theca

cell androgen production. Hepatic synthesis of sex hormone–

binding globulin (SHBG) is inhibited by insulin. Elevated levels

of insulin decrease SHBG so that it’s not available to bind with

testosterone, thus increasing circulating levels of free testoster-

one (Ehrmann, 2005). The increased androgens also inhibit

the production of SHBG (Marrinan & Stein, 2007). Elevations

of free testosterone cause worsening clinical signs of hyper-

androgenism. Higher androgen levels contribute to central/

android obesity, which increases insulin resistance and worsen-

ing PCOS symptoms (Azziz, Marin, Hoq, Badamgarav, & Song,

2005; Ehrmann).

The cause of insulin resistance and hyperinsulinemia re-

mains uncertain. Abnormalities in post-insulin signaling and

abnormal insulin secretion have been identified in women with

PCOS. The insulin-signaling defect in adipocytes and skeletal

muscle is specific to PCOS. Insulin resistance in women with

PCOS occurs by a different mechanism than in women who

are obese or have type 2 diabetes mellitus without PCOS (Cor-

bould, Zhao, Mirzoeva, Aird, & Dunaif, 2006). Androgens are

believed to contribute to peripheral insulin resistance in PCOS

by acting directly on the insulin-signaling pathways (Diamanti-

Kandarakis, 2008); as many as 45 percent of women with PCOS

will develop type 2 diabetes by their fourth decade of life.

Normal menstrual cycles occur when the hormone levels

and feedback pathways of the hypothalamic-pituitary-ovarian

axis function appropriately. In PCOS, the hypotha-

lamic-pituitary-ovarian axis is disturbed. The defect

that causes this disturbance is unknown. There is an

abnormality of the gonadotropin-releasing hormone

pulse generator of the hypothalamus. It’s unclear if this

defect is primary or secondary (Marx & Mehta, 2003).

Elevated LH levels and normal or decreased FSH lev-

els are found in PCOS. In addition, there are increased

levels of free estrogen, primarily in the form of estrone

and estradiol. Elevated estrogens cause a feedback effect

on the pituitary that leads to further suppression of FSH

and increased frequency and amplitude of pulsating re-

lease of LH. This hormonal environment increases the

production and release of androgen precursors by theca

cells. These androgen precursors are converted periph-

erally to primarily estrone, which in turn enhances the

feedback to the pituitary, perpetuating the cycle of el-

evated LH, decreased FSH and increased androgen pro-

duction, all of which culminates in abnormal menstrual

cycles and hyperandrogenemia (Ehrmann, 2005; Mar-

rinan & Stein, 2007).

Clinical Consequences of PCOS Detecting health status changes early is an important

part of prevention and management. Preventing or

delaying the progression of PCOS requires ongoing

secondary prevention aimed at early disease detec-

tion, which increases opportunities for interventions

to prevent progression of the disease and emergence

of symptoms.

Endocrine and Gynecologic ConsequencesThirty percent to 40 percent of women with PCOS

have impaired glucose tolerance and 10 percent to

45 percent will develop type 2 diabetes by their 40s.

Obesity is present in more than 50 percent of women

with PCOS. Insulin resistance and hyperinsulinemia

are common findings in both obese and nonobese

women with PCOS. Independently, obesity also leads

to insulin resistance. Therefore, obese women with

PCOS have two contributing factors causing them a

greater degree of insulin resistance than do nonobese

Irregular menstrual cycles may be the first presenting symptom to suggest the existence of PCOS

296 Nursing for Women’s Health Volume 13 Issue 4

women with PCOS (Tsilchorozidou, Overton, & Conway, 2004).

Endocrine disturbances in PCOS lead to increased blood pres-

sure, increased low-density lipoprotein (LDL) cholesterol and

decreased high-density lipoprotein (HDL) cholesterol. These

are known risk factors for developing cardiovascular disease and

metabolic syndrome (Ehrmann, 2005; Sheehan, 2004).

Sixty percent to 80 percent of women with PCOS have

hyperandrogenemia (Diamanti-Kandarakis, Papailiou, & Pal-

imeri, 2006). Elevated androgens cause hirsutism in 60 percent,

acne in 15 percent to 25 percent and androgenic alopecia in an

estimated 5 percent of women with PCOS. Hirsutism is a most

reliable index for elevated androgens (Azziz et al., 2006).

Psychosocial Consequences In Snyder’s (2006) study, women with PCOS recognized them-

selves as different from other women without the disease. High-

er than average weight gain, lack of regular menstrual cycles,

heavy or continuous bleeding with occasional menses, growth

of excessive unwanted facial and body hair and severe mood

swings were identified as the characteristics that made PCOS

sufferers feel different. They also expressed that feeling differ-

ent created a sense of insecurity and isolation (Snyder). Women

with PCOS stated that hirsutism and infertility problems made

them feel less feminine, as though their womanhood had been

stolen (Kitzinger & Wilmot, 2002; Snyder).

Obesity also contributed to a sense of being not normal

or not looking like the media portrayal of femininity (Snyder,

2006). Women with PCOS define a normal female as one who

looks more feminine (without hirsutism), possesses a beauti-

ful complexion and has regular menstrual cycles (Snyder). A

1998 study by Cronin and colleagues of 100 women with PCOS

found that while some women were concerned about irregu-

lar menses and infertility, weight or hirsutism caused a greater

negative impact on quality of life.

There is an association between obesity in young girls and

PCOS. Childhood obesity may be the initial symptom of PCOS

(ACOG, 2002). Trent, Rich, and Austin (2002), using a health-

related quality of life inventory, determined that adolescent girls

with PCOS self-reported a statistically significant reduction in

general health perceptions, behavior, physical function and fam-

ily activities compared with adolescent girls without PCOS.

Cancer RisksEndometrial hyperplasia and endometrial, ovarian and breast

cancer are associated with PCOS. Endometrial hyperplasia and

cancer are attributed to the continuously estrogen-stimulated

endometrium that goes unopposed by progesterone due to

anovulation. Endometrial cancer is also associated with obesity

and type 2 diabetes mellitus, which is prevalent in women with

PCOS (Hardiman, Pillay, & Atiomo, 2003). Determining the

cause of the increased prevalence of breast and ovarian cancer

is difficult. Obesity, anovulation and infertility are independent

risk factors associated with breast and ovarian cancer and they

are common problems in PCOS (Balen, 2001).

Sleep ApneaAn increased prevalence of obstructive sleep apnea that cannot

be explained by obesity alone has been found in women with

PCOS. A study by Fogel et al. (2001) found that, after control-

ling for body mass index (BMI), the risk of sleep-disordered

breathing was increased by a factor of 30. Fogel et al. deter-

mined that insulin resistance seems to be a stronger predictor

of sleep-disorder breathing than age, BMI or elevated free tes-

tosterone.

Women with PCOS stated that hirsutism and infertility problems made them feel less feminine, as though their womanhood had been stolen

August September 2009 Nursing for Women’s Health 297

vidual’s needs and designed to delay or prevent long-

term morbidity from reproductive, metabolic and

cardiovascular diseases can be jointly formulated by

client and practitioner.

Management Diet, exercise and weight loss are the best first-line in-

terventions to improve PCOS (American College of Ob-

stetricians and Gynecologists [ACOG], 2002; Guzick,

2004; Sheehan, 2004). Weight control improves many

aspects of PCOS and leads to more regular menstrual

cycles, reduced androgen levels, lowered lipid levels and

better glucose metabolism. Weight control increases

the potential for spontaneous pregnancy. For an obese

patient, even a small percentage of weight loss has been

found to bring relief from PCOS symptoms (American

Association of Clinical Endocrinologists, 2005). Weight

loss decreases metabolic complications associated with

PCOS and decreases the risk of developing diabetes mel-

litus in later life (Khan, 2007). However, women with in-

sulin resistance often find weight loss to be very difficult.

NPs or CNMs who suspect that their patient has PCOS

should consider screening for glucose intolerance, espe-

cially in obese patients, and referring patients to a regis-

tered dietitian for nutrition counseling and education.

Cognitive Behavioral StrategiesLifestyle changes are often difficult for patients to

achieve and compliance levels are often low. Martin

et al. (2008) identified three components to achieving

behavioral changes required to meet physical activity

goals: (1) overcoming barriers to physical activity, (2)

taking the time necessary for the activity and (3) stick-

ing with the activity over a sustained period of time.

Martin et al. describe placing emphasis on the broad

benefit of positive changes in social relations and not

just focusing on the individual benefit.

Using the theories of cognitive behavior therapy

(CBT) combined with applied behavioral science, the

West Virginia National Center of Excellence in Wom-

en’s Health developed a tool to help women overcome

the barriers to adopting lifestyle changes required in

order to improve one’s health or prevent the develop-

ment of metabolic diseases. CBT is a widely practiced

individual change process that has been validated

through extensive research and offers an action plan

aimed at modifying deleterious behaviors. CBT

combines two very effective approaches for helping

people make positive changes in their lives—cog-

nitive therapy (CT) and applied behavioral science

(Dobson, 2001). CT helps individuals examine

their thoughts (cognitions) to see if their thinking

Infertility, Pregnancy and LactationA common reason women with PCOS seek care is infertil-

ity. Anovulation is a hallmark of the disorder. Anovulation is

due to the increased number and the disturbed maturation of

recruited ovarian follicles resulting from androgen excess, in-

creased LH and decreased FSH stimulation of the ovary (Dia-

manti-Kandarakis, 2008; Diamanti-Kandarakis et al., 2006).

Women with PCOS who desire pregnancy are usually referred

to a gynecologist or reproductive endocrinologist for infertil-

ity treatment. Obesity is a factor that contributes to infertility.

Increasing BMI (especially greater than 35) yields a decrease in

fecundity (Legro, 2007).

There is conflicting evidence about the increased risk of

early spontaneous pregnancy loss in women with PCOS. The

role of obesity as a cause of early pregnancy loss is a confound-

ing independent risk factor. Early pregnancy loss is associated

with hyperinsulinemia, which is present in both obese and

nonobese women with PCOS. It’s thought that reduced insulin

sensitivity may cause an endometrial inflammation reaction,

which prevents implantation and leads to early pregnancy loss

(Siassakos & Wardle, 2007).

Antenatal complications associated with PCOS include

impaired glucose tolerance, gestational diabetes, pregnancy-

induced hypertension and preeclampsia. Iatrogenic premature

birth and increase cesarean birth are also associated with PCOS

(Marx & Mehta, 2003; Siassakos & Wardle, 2007). A postnatal

complication for large babies of obese women is the tendency

to become obese adults. There is concern that in utero fetal

programming of growth hormone and insulin growth factors

may influence postnatal growth and insulin sensitivity of indi-

viduals (Siassakos & Wardle).

Endocrine issues such as PCOS can affect milk production.

Case studies by lactation consultants report that some women

with PCOS have successfully become pregnant and success-

fully initiated breastfeeding. However, such women are often

unable to produce a sufficient volume of milk to nourish a

growing infant (Amir, 2006; Betzold, Hoover, & Snyder, 2004).

Although some women with PCOS have no problems breast-

feeding, there appears to be a group of women with PCOS who

have underdeveloped mammary tissue that cannot produce an

adequate milk supply (Marasco, Marmet, & Shell, 2000). Amir

(2006) discussed that the inability to successfully lactate may be

related to hormonal imbalances or increased serum androgen

levels. Elevated androgen levels are associated with decreased

breast cell proliferation and lack of sufficient breast tissue de-

velopment to maintain milk production. Causes of delayed or

failed lactogenesis result from one of many endocrine errors or

from insufficient mammary tissue (Betzold et al.; Marasco et

al.). Because presenting symptoms vary among women, initial

therapy should largely be directed at the immediate present-

ing chief concern (Guzick, 2004). After the immediate health

concern is addressed, a management plan tailored to the indi-

298 Nursing for Women’s Health Volume 13 Issue 4

change process to help corporations and individuals become

“change resilient.” Change is an inevitable part of life, and

Smith’s book (2002) explicates a behavioral change model de-

signed to help individuals and corporations develop the tools

they need to enact change (see Box 1). The West Virginia Na-

tional Center of Excellence in Women’s Health adapted Smith’s

behavioral change model to help women implement individu-

is distorted. Many people have used this method successfully to

eliminate self-limiting thoughts and to learn to look at situa-

tions rationally and productively (Arkowitz & Hannah, 1989).

It’s especially important for people to examine their thinking

during times of change. When a life change occurs, previous

beliefs and assumptions might no longer be accurate. In fact,

the beliefs and assumptions that worked before the change

might be irrational, counterproductive or maladaptive in the

new situation. By using methods of CT, a person can achieve a

more positive outlook on the opportunities that change might

bring (Arkowitz & Hannah, 1989).

Applied behavioral science helps people turn their good in-

tentions into action. During change, people often fail simply

because they continue to perform their usual activities, and they

continue to get the same results. Change requires new behav-

iors. A person who desires change might try a new behavior but

quickly become discouraged and revert to old ways because the

new behavior feels “unnatural,” or because it doesn’t immedi-

ately achieve the desired results. Methods of applied behavioral

science help an individual create and implement manageable

plans of action. As a person sees that she can be successful with

small steps, she learns how to sustain her momentum by ar-

ranging encouraging consequences for behaviors that help her

move forward (Arkowitz & Hannah, 1989).

Cognitive behavioral change theory is based on three main

principles. The first is teaching problem-solving skills. This

cognitive behavioral intervention can be effective for patient

self-management. The next principle is based on perception.

A woman’s perception about living with a chronic illness af-

fects her behavior and beliefs regarding her ability to control

her disease process (Dobson, 2001). CBT-based interventions

that emphasize self-care behaviors can produce positive adapt-

ed lifestyle changes for effective self-management of PCOS

(D’Zurilla & Nezu, 2001). Finally, cognitive reframing allows

patients to change the way they perceive a situation. Changing

a woman’s perspective can improve her ability to control her

disease effectively (Dobson, 2001).

A Model for Becoming “Change Resilient”Smith (2002), a behavioral psychologist whose focus is on CT

and applied behavioral science, developed a six-step behavioral

For an obese patient, even a small percentage of weight

loss has been found to bring relief from PCOS symptoms

Box 1 Six Concepts For Becoming Change Resilient

1. The phrase “it happens!” refers to any change that affects me. It can be expected or unex-pected, welcome or unwelcome, planned or unplanned, under my control or out of it, caused by nature or by people.

2. My feelings are the emotions I experience when going through a change.

3. My thoughts are ideas that run through my head about change; they are private and known only to me. My beliefs are opinions that I hold deep inside as absolute truths.

4. My behaviors are everything I say or do when I am affected by a change.

5. Consequences to me are things that occur as a result of my behaviors, and either encour-age or discourage me from repeating the same behaviors.

6. My impact on others is about the effect my behaviors have on others.

August September 2009 Nursing for Women’s Health 299

ally tailored health care changes to improve not only their lives

but also the lives of their families.

To provide a manageable process of lifestyle changes to im-

prove health, Smith and the West Virginia National Center of

Excellence in Women’s Health created a workbook entitled Make

“It” Happen For You (West Virginia National Center of Excel-

lence in Women’s Health, 2006), which incorporates five action

steps that can be initiated to bring about behavioral changes that

will help women self-manage a chronic problem. The five action

steps are a proactive way a woman can initiate lifestyle chang-

es. The five areas ask the individual to address (1) feelings, (2)

thoughts and beliefs, (3) behaviors, (4) personal consequences

and (5) the positive impact of the changes on others. The work-

book includes a four-week log laid out as a guidebook for start-

ing a journey to better health. The beginning of the journey is

to accept that an individual’s path will be different from any-

one else’s. This process will help individuals make sustainable

changes or will help them accept themselves the way they are.

The log contains various ways of reframing thoughts to support

the desired changes. More than 300 women across West Virginia

have used the workbook as part of a program to improve health

of women across the state. Follow-up surveys indicate that more

than 50 percent of women who used this tool have made lifestyle

changes. This workbook is an example of a tool that can be used

to help initiate the behavioral changes required to obtain opti-

mum health while living with PCOS.

ConclusionBecause PCOS is a chronic condition that requires lifestyle

modifications, nurses are ideal care providers to help PCOS pa-

tients create an individualized plan to implement and manage

lifestyle changes. Use of the workbook described in this arti-

cle (see Box 2) or of a similar tool could assist the health care

provider to help a woman with PCOS shift her focus

from being a victim of disease to becoming a person

who has achieved an optimum level of wellness. When

women meet their health goals as a result of their own

efforts, they’re empowered as active managers of their

physical and mental well-being. NWH

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