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??