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PCOS From Novice to Knowing

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PCOS From Novice to Knowing Powered By Docstoc
					From Novice to Knowing: A
    Primer on PCOS
Kay M. Czaplewski, BSN, RN, BC,
          CDE, NHA

                          Press to begin
     What is PCOS?
PCOS (polycystic ovary disease) is a
condition most often characterized by
irregular or absent periods; abnormal
hair growth; obesity and insulin
resistance. It affects 5-10% of women
of reproductive age, without regard to
ethnicity (Legro, 2007)
PCOS can lead to long term complications
like diabetes, endometrial cancer,
dyslipidemia and cardiovascular disease, if
left untreated (MayoClinic, 2007; Hill, 2003)
                                  NEXT SLIDE
                 Why do we Care?
Nurses need to understand the basic
   physiology and treatment
   modalities of PCOS in order
   provide education, guidance, and
   support.
Patients chief concerns with PCOS
   may change over time, and many
   will seek advice from different
   health care providers, including
   nurses.
Nurses need to understand how
   PCOS is managed and the
   potential health risks associated
   with this common condition.
                                       next, please
                    (There’s no place like )
                       HOME PAGE
This tutorial will focus on four aspects of PCOS
               (click on an area of interest)

Menstrual Dysfunction

Anovulation/Infertility


Hyperandrogen

Insulin Resistance


    (click here for a refresher on normal menstrual function)
              Click here for pathophysiology of PCOS Or press next
How do we know what is abnormal
     until we know normal?
            Menstruation 101

      TAKE ME ON A QUICK REVIEW




       NO TIME FOR REVIEW, JUST TELL ME ABOUT
       PCOS AND MENSTRUAL DYSFUNCTION




                                     Back to home page
                                          next
   Normal Menstrual Cycle
Four Main Phases




          Click on
      the daisies to
        learn more!

         home          (Hole, 1989)
                       Phase 1
       Day 1-5
       Shedding of
       endometrium
       Average blood shed
       10-80 ml
       Plasmin enzyme
       released by
       endometrium inhibits
       clotting
                                 Take me to phase 2!
(Hole, 1989)                         home
                          Phase 2: follicular
                                         Hypothalamus


                                             pituitary
                 Luetinizing Hormone (LH)                  Follicular stimulating hormone
                                                                         (FSH)
                                        Follicles mature


                                       Releases estrogen

                                 Causes lining of uterus to thicken

               Hypothalamus releases luteinizing hormone releasing factor (LHRF) which
                                        causes increased LH

                           Triggers most mature follicle to burst and release egg
                                                                    Phase 3, please
(Hole, 1989)                                OVULATION                     home
               Phase 3: Ovulation
                         Blood supply to ovary increases

                         Surge of LH weakens ovary wall

               Ligaments contract pulling ovary closer to fallopian tube


                                 Egg released

                     Cervix develops clear stringy mucous


                  Facilitates movement of sperm toward egg


                     Unfertilized egg dissolves in uterus


                                                      Take me to phase 4!
(Hole, 1989)                                                Take me home
                 Phase 4: Luteal




After ovulation, residual follicles form corpus luteum, a solid
 body that produces progesterone and estrogen for about 2
    weeks. Progesterone make uterine lining receptive to
 implantation. In absence of pregnancy, progesterone levels
            fall, this leads to menstrual shedding.

                                         Next slide
  (Hole, 1989)                           home
  For a summary of
menstruation in graph
form, Please press me!



         Kay,RN




                  Otherwise, proceed
                      With test
         Phase 1 question
Average blood shed during menstruation
   is 300ml.
A. True
B. False




                  back to menstrual cycle
                   back home
                    That’s Correct!
• The average blood
  loss is 10-80 ml
        (Wikipedia, 2007)




    Back to test
    Take me to question 2
     home
                Oops! Try again
• Blood shed in that
  amount may be
  detrimental!




     Let me try again!
             Phase 2 question
             Multiple choice
           Press on the correct answer


  In the follicular phase, the
          endometrium:

               A. Thickens

B. Thins                           C. Dissolves

                 C. Sheds

                                     Take me to menstrual cycle   home
                 Correct!
Increasing levels of estrogen
  would produce thickening of
  endometrium in preparation of
  a potential fertilized egg.




                                  Back to test
 (Hole, 1989)                     Phase 3 question
                  no…

A dissolving endometrium
That’s just silly
Ha…ha…ha…




                           Return to test
                             Next question
                no…

thinning
 would
    be
           Menstruation!!!


                             (Hole, 1989)
                              Back to test
No…
shedding


 Would


         be
                menstruation

                               Back to test

 (Hole, 1989)
         Phase 3 Question
During Ovulation



Egg is released


No egg
  released




                             home
                            Menstrual cycle
           correct
Under the influence of
 FSH secreted by the
 anterior pituitary, the
 follicle matures, a
 rush of LH cases the
 mature follicle to
 rupture. This is called
 ovulation (Tabers, 2006).


                             Next question
                             Back to test
                                 home
 Not quite…

Remember, during
 ovulation, the mature
 egg is released.




                    Back to test question
                         home
           Phase 4 Question
• After ovulation, what
  do the follicles form?


    1. Corpus luteum


     2. Corpus Christi
                            Yes…
After ovulation residual follicles form
  corpus luteum, a solid body that
  produces progesterone and estrogen for
  about 2 weeks. Progesterone makes the
  uterine lining receptive to implantation. In
  absence of pregnancy progesterone
  levels fall, this leads to menstrual
  shedding  (Hole, 1989).



                                   Next
                                          home
No Ya…all…


             Back to test
Next slide

  home
                      Pathophysiology of PCOS
      Polycystic ovary syndrome is characterized by inappropriate gonadotropin secretion,
      Androgen excess and often hyperinsulinemia, all of which contribute to anovulation
Impaired estrogen feedback leads to      Disordered
   increased LH and decreased FSH
                                         GnRH Release      Pituitary secretion of LH increases

  Treatments are directed at                                 Hyperinsulinemia stimulates
                                      Increased              ovarian and adrenal androgen
                                      LH release                         synthesis
    Restoring gonadotropin
  secretion (clomiphene)

                                                                Increased androgen and
  Decreasing androgen levels           Increased
                                                             Insulin levels decrease levels
  (follicle-stimulating hormone          Ovarian
                                                             of circulating binding proteins
  Or ablative surgery)                  Androgen
                                                             that limit androgen bioactivity
                                      biosynthesis

     Decreasing insulin levels
  (metformin, insulin sensitizers,
       weight loss, exercise                                                       Next slide

                                                                                       home
                                       (Adapted from Legro ,R.S. JAMA 2007 used with permission)
     Menstrual Dysfunction
• Problem: Endometrium is in an
            unopposed estrogen
            state resulting in
            anovulation. This results
            in suppression of FSH
            and increase of LH
            leading to endometrium
            proliferation. (Hill, 2003)

       Press here for a refresher on normal menstrual function   next
                                                                 home
Bonus question…

 What is the
 problem with
 endometrial
Proliferation?
                  answer
                   home Previous
       Endometrial Cancer
• For women with PCOS, chronic
  unopposed estrogen is a risk factor for
  endometrial carcinoma.
• Four menses per year are recommended
  to to help control this risk. Sheehan, 2004




                                            continue

                                            home
  Treatment of Menstrual
       Dysfunction
Oral contraceptives and
progesterone withdrawal
Lifestyle modification/weight loss
Metformin  (Barbieri & Ehrmann, 2007)




                                        continue
                                          home
Oral Contraceptives and Progesterone Withdrawal



  Oral contraceptives (OCs) affect the ovary by
    maintaining a constant level of estrogen and
    progesterone. This prevents fluctuation of estrogen
    and progesterone. Thus OCs manage oligomenorrhea
    and reduce the risk of endometrial cancer (Kelly, 2003).

   Provera (progesterone withdrawal) results in
     menses. Four menses per year are recommended
      to decrease risk of development of uterine
      cancer from endometrial proliferation.
                               (Sheehan, 2004, Hill, 2003)




                                                             Next page
                                                              home
 Lifestyle Modification and Weight Loss


Weight loss can lead to resumption of
ovulation within weeks.
Improving insulin resistance through
Diet and exercise can result in improvement
In menstrual function (Stankiewicz & Norman, 2006).

weight     hyperinsulinemia   hyperandrogen   menstruation

                                                       Test
                                              home     Time!
           Test Time
The purpose of a
progesterone
withdrawal is to
cause

A. No Menses

 B. Menses
                            C-o-r-r-e-c-t
• Progesterone levels are
  elevated during the luteal
  phase of the menstrual
  cycle. As they fall,
  menstrual shedding
  occurs.
• For a woman with PCOS,
  it is necessary to induce
  menstrual shedding for
  the prevention of cervical
  cancer. This done with
  progesterone withdrawal
  course, taken about four
  times per year.

     (Barbieri & Ehrmann, 2007)             next     home

                                            Back to test
   Ooops!…try again




(hint…it’s just the opposite!)
                         Back to question
                         Back to menstrual dysfunction
                         Back to home
Anovulation and Infertility
 Normally in the follicular phase, follicles
in the ovary begin developing under the
influence of a complex interplay of
hormones, and after several days, the
dominant follicle releases an egg in an
event known as ovulation. (Hole, 1989). In
PCOS, LH remains elevated, ovulation
cannot occur (Sheehan, 2004).

                                     home
                                     next
Treatment of Anovulation and Infertility

In most patients, Clomiphene and extended
release metformin are used alone or
together to induce ovulation.
 (Legro, Barnhardt, Schlaff, Carr, Diabmond, et al, 2007)




                                                            Next page
           Lifestyle Changes

         Weight Loss reduces
          hyperinsulinemia
         And subsequently,
          hyperandrogenism             (Hill, 2003).




weight       hyperinsulinemia   hyperandrogen


                                     next
                                     home
Treatment of Anovulation and Infertility
                            Metformin…
…decreases hepatic glucose production
 thus reducing the need for insulin
 secretion. This helps suppress androgen
 production and improves ovulation
                                    AND

…decreases intestinal absorption of
 glucose and improves insulin resistance
 (Legro, Barnhardt, Schlaff, Carr, Diamond, et al, 2007)
                                                                  TEST TIME!
                                                           back    home
    Anovulation and Infertility
For practical purposes, anovulation and
 infertility are the same thing.

• True

• False


                                 Next slide
                                    home
 For practical purposes, true
When the egg has matured, it secretes
 enough estradiol to trigger the release
 of LH. The surge of LH matures the
 egg and weakens the wall of the
 follicle in the ovary. This process leads
 to ovulation. (Wikipedia, 2007)



A woman must ovulate to be fertile.
                                    (Hole, 1989)


                                   Back to test

                                    Next slide
                                       home
Normal
Menstrual
Cycle




(Wikipedia, 2007)   Press for test
         Insulin Resistance (IR)
   (IR) is a condition in which the cells of the body become resistant to the
   effects of insulin. The normal response to a given amount of insulin is reduced.
    As a result, higher levels of insulin are needed in order for insulin to have the
   desired effect   (Franz, 2003; Stankiewicz & Norman, 2006).




• Fasting glucose 100-125
• Impaired 2 hour glucose tolerance test 140-199
• Fasting insulin ratio <4.5 (Stankiewicz & Norman, 2006)

 (Acanthosis nigricans, a dark, velvety pigmentation seen on back
   of neck, axilla, or skin folds is symptom of insulin resistance
    (Franz, 2003)


                                                                 Next slide
                                                                     home
Treatment of Insulin Resistance
METFORMIN decreases hepatic glucose
 production thus reducing the need for insulin
 secretion. This helps suppress androgen
 production and improves ovulation. Metformin
 also decreases intestinal absorption of glucose
 and improves insulin resistance
  (Legro, Barnhardt, Schlaff, Carr, Diamond, et al, 2007).




                                                             Next slide
   Treatment of Insulin Resistance


Metformin also lowers fatty acid concentrations,
thus reducing gluconeogenesis (The formation of
glucose, especially by the liver, from non-
carbohydrate sources, such as amino acids and the
glycerol portion of fats)

                            (Barbieir & Ehrmann, 2007; Franz, 2003)




                                     Test time!
             Test-time

What is glyconeogenesis?

       The first book of the bible?

       The formation of glucose from
       non-carbohydrate sources?
       The formation of free fatty
        acids?
                                  Previous slide
                                   Home
Yes, genesis is     No, genesis
the first book in   is not
   the bible        gluconeogenesis




                           Back to test
You are a rock star!!

     As you know, gluconeogenesis
       is the formation
     of glucose, especially by the
       liver, from non-
     carbohydrate sources, such as
       amino acids and
     the glycerol portions of fats
                 (Barbieri & Ehrmann, 2007)



                                              Back to test
                                              Back home
                                              next
            Close, but no cigar!
Free fatty acids are an
  important source of fuel
  for many tissues since
  they can yield relatively
  large quantities of energy.
  Many cell types can use
  either glucose or fatty
  acids for this purpose (Franz,
   2003).

Metformin inhibits this
  process (Barbieir & Ehrmann, 2007).

                                        Back to test
                Hyperandrogen
Hirsutism is one bothersome aspect of PCOS, often seen as
Distribution of hair on the face, chest, abdomen, back, thumbs
Or toes. It is also seen as male-pattern balding or thinning hair.


  The goals of medication therapy are to lower
    androgen levels, increase sex hormone
    binding globulin (SHBG) levels to allow
    less circulating testosterone, and if the
    patient wants, hair removal.
                                          (Hill, 2003)




                                                           next
                                                          home
Q. How does circulating
     androgens
   contribute to hirsutism?

A. The anagen (growth) phase
     of the hair cycle is
     prolonged in
     hyperandrogenic states,
     resulting in increased
     male pattern hair
     distribution (Hill, 2003)

                      next
     Treatment of Hirsutism
       Spironolactone is often used for its
        aldosterone antagonist side effect
                          (Barbieri & Ehrmann, 2007)




         Mechanical Hair Removal
          shaving
          plucking
          electrolysis
          waxing
          bleaching (Hill, 2003)

Vaniqua (inhibits an enzyme for normal hair growth)
                (Barbieri & Ehrmann, 2007)             Test time
2. Aldosterone protagonist

                             Next slide, please
     Hey learner, it’s your birthday, hey, learner, it’s your birthday…
                                     you are correct!

Spironolactone inhibits the effect of aldosterone by
  competing for intracellular aldosterone
  receptors.
Spironolactone has anti-androgen activity by
  binding to the androgen receptor and thus
  preventing it to interact with dihydrotestosterone.
  This blocks the action of testosterone and
  reduces hirsutism
  (Sheehan, 2004; Hill, 2003, Wikipedia, 2007)



                                                        next
             Not quite…


We want to decrease androgen secretion and action




                                       Back to test
                Summary
PCOS is a chronic condition, most often
  characterized by irregular or absent periods;
  abnormal hair growth; obesity and insulin
  resistance. It affects 5-10% of women of
  reproductive age (Legro, 2007).
PCOS can lead to long term complications
 like diabetes, endometrial cancer,
 dyslipidemia and cardiovascular disease, if
 left untreated (MayoClinic, 2007; Hill, 2003).


                                                  Next slide
                    Summary
Treatment of PCOS is
  focused on areas that
  cause the patient the
  most distress, however,
  as nurses, we need to be
  familiar with the
  complexity of PCOS and
  potential health risks
  associated with this
  common condition, to
  better help our patients.

                              home   next
      I would like to thank
 Kimberly Woyach, MSN, APNP,
    CDE for inspiring me with
   her knowledge and passion of
               PCOS



Start tutorial over   references   home
                                              References

Barbieri, R. L., Erhmann, D. A. (2007) Patient information: Treatment of polycystic
   ovary syndrome. Retrieved February 4, 2007 from UpToDate, licensed by the Medical
   College of Wisconsin, Milwaukee, WI.

Franz, M. J. (Ed.). (2003). A core curriculum for diabetes educators, fifth edition: Diabetes in the life
    cycle.American Association of Diabetes Educators. Chicago: American Association of Diabetes
    Educators.

Hill, K. M. (2003). Update: The pathogenesis and treatment of PCOS. The nurse practitioner. 28 (7):
       8-23

Hole, J. W. (1989). Essentials of human anatomy and physiology (3rd ed.). Dubuque, IA: Wm. C. Brown

Legro, R.S. (2007) A 27-year-old woman with a diagnosis of polycystic ovary syndrome. JAMA. 297 (5):

    509-519
Legro, R. S., Barnhardt, H. X., Schlaff, W. D., Carr, B. R., Diabmond, M. P., Carson, et al (2007)
    Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. The new england
    journal of medicine. 346 (6): 551-566.

MayoClinic (nd) Women's health: Polycystic ovary syndrome. Retrieved February 18, 2007 from
    http:www.mayoclinic.com/health/polycystic-ovary-syndrome/DSS00423/DSCETION=6




                                                                                                   next
                                                 References

Stankiewicz, M., Norman, R. (2006) Diagnosis and management of polycystic ovary disease: A practical guide. Drugs
    2006. 66 (7): 903-912

Sheehan, M.T.(2004). Polycystic ovary syndrome: Diagnosis and management. Clinical medicine & research.
    2 (1): 13-27.

Taber’s cyclopedic medical dictionary (20th ed) (2005). Philadelphia. F. A. Davis company.

Wikipedia: The free encyclopedia. (2006) FL: Wikimedia Foundation, Inc. Retrieved February 14, 2007 from
    http.www.wikipedia.org

Womenshealth.gov (2007) Polycystic ovarian syndrome. retrieved February 2, 2007
 from http://www.4woman.gov/faq/pcos.htm




                                                                                     Start tutorial again

				
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