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?
Typ ica lsym p to m s in clu d e a n y o f th e
fo llo w in g :
 Polycystic ovaries  Obesity
 Oligo- or  Dyslipidemia

amenorrhea  Metabolic

 Anovulatory syndrome
infertility  Insulin resistance

 Hirsutism  Type 2 diabetes

 Male pattern  Sleep apnea

baldness  Fatty liver
 Acanthosis
nigricans
 Acne
Physical Symptoms

acanthos
is
nigrican
s

hirsutism

polycystic ovaries
 How is PCOS diagnosed?
 No specific diagnostic criteria
established
 Diagnosed by physical and biochemical
evidence and exclusion of other
disorders
 Physicalsymptoms: menstrual
disturbance, hirsutism, acanthosis
nigricans, acne, obesity
 Biochemical tests: abnormalities in
androgens, LH, FSH, glucose, insulin,
cholesterol, triglycerides
 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
 Lifestylehistory: symptoms exacerbated
by stress of juggling career, school,
and family
 Prompted to seek medical attention
Chief Complaint and Physical Exam
 Chiefcomplaint: unintentional weight
gain
 “Ijust keep gaining weight, no matter
what I do!”
 Also: hirsutism, sleep apnea

 Physicalexam 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

Normal/ 6 yrs ago 4 yrs ago 2 yrs ago present

Bilirubin units
≤0.3mg/d 0.4 H 0.4 H 0.4 H 0.41 H
 l
 Monitor for steatohepatitis
 Lipid panel
 Positive diagnostic profile
 Low HDL, high LDL and cholesterol,
elevated triglycerides


 Normal/ 6 yrs ago 4 yrs ago 2 yrs ago present

units
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

Normal/ 6 yrs ago 4 yrs ago 2 yrs ago present
T 4 units
4-12 11.4 11.2 9.3 10.1
mcg/dL
T 3 uptake 75-98 24 28 30 32
TSH mcg/dL
0.35-5.50 3.50 2.174 2.515 2.68
 mcIU/dL


 Low T3 uptake consistent w/oral

contraceptives
 Lab values
 Testosterone Level
 Affected by:
5alpha-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
Normal/unit 6 yrs ago 4 yrs ago 2 yrs ago present
Testosterone
Sex
20-76 mg/dL 56
Hormone 75
Binding Globulin
87 H 25
(SHBG)



 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 Normal 6 yrs ago 4 yrs ago 2 yrs ago present

Glucose mg/dL
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
 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
 2 4 -H o u r Fo o d R e ca ll ( M o rn in g )

Food Quantity Calories CHO Protein Fat

(g) (g) (g)
Calcium-fortified 8 oz 110 28 2 0
orange juice
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 Protein Fat
(g) (g) (g)
Wendy’s 1 440 35 27 22
Cheeseburger
Wendy’s™ French Small 350 45 4 16
fries order
Diet Coke™ 18 oz 0 0 0 0
Total Energy 790 80g 31g 38g
 24-Hour Recall (Evening)
Food Quantity Calories CHO Protein Fat
(g) (g) (g)
Ham and beans 1½ 420 75 18 5
cups
Corn muffins 2 680 108 8 18

Diet Coke™ 12 oz 0 0 0 0

Skinny Cow ™ ice 1 160 30 4 2

cream sandwich
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
a normal BMI (<25kg/m2) by
 Re-attain
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

 5-9a 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??