PCOS- Case Study 25 Nov. 4

C A S E S T U DY 2 5

POLYCYSTIC OVARIAN SYNDROME

WHAT IS PCOS?

• PCOS is a health problem that can affect a woman’s:• Menstrual cycle • Fertility• Hormones• Insulin production• Heart• Blood vessels• Appearance

• PCOS is the most common hormonal reproductive problem in women of childbearing years. (5- 10%)

ETIOLOGY

• The exact causes are unknown.• Proposed causes:• Patients suffer from a functional abnormality of

cytochrome P450c17, the rate-limiting enzyme in androgen biosynthesis.

• Genetic disorder• Abnormalities in metabolism of androgen and estrogen

and poor control of androgen production.• High levels of androgen production lead to acne and

excessive hair growth.• Peripheral insulin resistance and hyperinsulinemia can

lead to and magnify obesity.• Lower levels of adiponectin in lean and obese PCOS

women.

CRITERIA

ROTTERDAM 2003

• 2 out of the 3 must be present • Oligomenorrhea or

anovulation • Clinical and/or

biochemical signs of hyperandrogenism

• Polycystic ovaries

AES 2006

• All of the following must be present • Oligomenorrhea or

anovulation • Clinical and/or

biochemical signs of hyperandrogenism

• Exclusion of other androgen excess or related diseases

CHARACTERISTICS OF PCOS

• Menstrual disturbances: primary amenorrhea, oligomenorrhea, or secondary amenorrhea

• Elevated androgenic hormones

• Acne• Hirsutism • Male-patterned baldness• Obesity and weight gain • Elevated insulin levels,

insulin resistance, and Type 2 diabetes

• Oily skin

Hirsutism

Male-patterned baldness

CHARACTERISTICS OF PCOS

• Multiple cysts in the ovaries• Dandruff• Acanthosis nigricans• High blood pressure • Elevated cholesterol • Sleep apnea• Skin tags

Acanthosis nigricans

CPAP Machine

COMPLICATIONS ASSOCIATED WITH PCOS

• Endometrial cancer

• Infertility

• Diabetes

• Heart Disease

• Metabolic Syndrome

METABOLIC SYNDROME VS. PCOS

Metabolic Syndrome

WHO 1999One of the following:• Diabetes • Impaired glucose tolerance• Impaired fasting glucose• Insulin resistance

Plus 2 of the following: • Blood pressure ≥ 140/90

mg/dl• Dyslipidemia• Central obesity • Microalbuminuria

PCOS

• Commonly seen with PCOS• Diabetes• Elevated glucose levels• Insulin resistance • High blood pressure • Obesity

GRACIE MOORE

Gracie Moore is a 34 year old female of European American descent. She is currently working as a graduate assistant while going to school for her doctoral degree. She stopped menstruating in college and was put on birth control pills to help control her hormones levels. Gracie was able to control her weight in high school with diet and exercise. When she began graduate school she became too busy to exercise and began to gain an average of 4 lbs per year, now weighting 180 lbs.

GRACIE MOORE

With the weight gain, her hirsutism and PCOS symptoms got worse. Her physician prescribed her another oral contraceptive to keep her testosterone levels down. Since her husband and herself have been married they have tried to conceive a baby. After failing twice, they adopted. With the increasing severity of her symptoms and busy lifestyle, Gracie is seeking further medical intervention.

CHIEF COMPLAINT

• “I just keep gaining weight, no matter what I do! The more weight I gain, the more hair shows up on my body. And I just found out I have sleep apnea and I have to use a CPAP at night!”

CLIENT/FAMILY HISTORY

• Age: 34 yrs

• Gender: Female

• Education: Working on her Doctorate (Ph.D.)

• Ethnicity: European American descent

• Family Medical Hx: Father with diabetes

• Client Medical Hx: History of high blood pressure,

onset of PCOS- 6 years ago

NUTRITION- FOCUSED PHYSICAL FINDINGS

• Oily skin

• Acanthosis

nigricans

• Acne

• Hirsutism

• Male patterned baldness

• Dandruff

• Skins tags

• Obesity

FOOD AND NUTRITION RELATED HISTORY

• Medication and Herbal Supplement Use• Oral contraceptives (YAZ, OrthoNovum)• Controls hormone levels• Regulates menstruations through

providing synthetic estrogen and antiandrogenic properties

• Side effects: hypertension, liver tumors, anaphylactic reactions, changes in glucose that can lead to diabetes

• Glucophage• Treats Type 2 diabetes• Works by decreasing sugar produced by

cells in the liver, increasing sensitivity of muscle cells to insulin, delays absorption of sugar from intestines into the blood stream.

• Side effects: nausea, vomiting, trouble breathing, swelling and rapid weight gain

FOOD AND NUTRITION RELATED HISTORY

• Medication and Herbal Supplement Use• Aldactone • Potassium sparing diuretic• Blocks action of aldosterone, therefore

increasing the amount of salt filtered out of the blood stream.

• Side effects: nausea, upper stomach pain, jaundice, gas, shallow breathing

• Vaniqua• Slows growth of unwanted hair• Irreversible inhibitor of ornithine

decarboxylase (ODC) which plays an important role in cell division and proliferation of hair follicles

• Side effects: acne, swelling of face, tongue and throat, trouble breathing, burning sensation

BIOCHEMICAL DATA, MEDICAL TESTS, AND PROCEDURES

Medication Function of Medication Nutritional Implications

YAZ 1 TAB PO QD Hormonal Contraceptive N/A

Glucophage 850 mg PO QD

Treat Type 2 diabetes Monitor Glucose Levels

Aldactone 100 mg/d PO Treats high blood pressure

No altered diet, just monitor electrolyte levels (Na+ and K+)

Vaniqua (apply thin layer)

Slow growth of unwanted hair

N/A

OrthoNovum 1/35 Contraceptive N/A

Medications

FOOD AND NUTRITION RELATED HISTORY

• Food and Nutrient Intake• Breakfast: • 8 oz calcium fortified OJ• 6 oz black coffee

• Midmorning Snack:• 1 cup mixed (salted) nuts• 10 oz unsweetened iced tea

• Lunch:• Wendy’s Cheeseburger• Small fries• 18 oz Diet Coke

• Dinner: • 1.5 cup Ham & beans • 2 corn muffins• 12 oz diet coke

• Snack:• Skinny Cow ice cream sandwich

Energy and Macronutrient Distribution

• Total Energy Intake: ~2,850 kcals Percent Carbs: 47 % (45-65)

• Percent Fat: 42 % (20-35)• Percent Protein: 11 % (10-35)

FOOD AND NUTRITION RELATED HISTORY

• Knowledge/Beliefs/Attitudes• Basic knowledge on healthy diet and weight

management, but lack time and motivation • Physical Activity and Function • Not currently physically active because of

hectic lifestyle

ANTHROPOMETRIC MEASUREMENTS

• Height: 65 in, 165 cm • Weight: 180 lbs, 81.8 kg• Weight Change: Unplanned increase of 28.5% of

usual body weight• BMI: 30 kg/m2

• Waist Circumference: 36 in• Waist to hip ratio: 36in/49in = 0.73

BIOCHEMICAL DATA, MEDICAL TESTS, AND PROCEDURES

Abnormal Lab Normal Value Reason for Abnormality

Nutritional Implications 

TG: 184 mg/dL (H) 35- 135 mg/dL Obesity Decrease Caloric and Fat intake

LDL: 132 mg/dL (H) < 130 mg/dL Obesity Decrease Caloric and Fat intake

HDL: 51 mg/dL (L) > 55 mg/dL Obesity Decrease Caloric and Fat intake

ALT: 42 U/L (H) 4- 36 U/L Nonalcoholic Steatohepatitis (NASH)

Decrease Caloric and Fat intake

Bilirubin: 0.41 mg/dL (H)

0.3 mg/dL Nonalcoholic Steatohepatitis(NASH)

Decrease Caloric and Fat intake

Abnormal Relevant Biochemical Lab Values

BIOCHEMICAL DATA, MEDICAL TESTS, AND PROCEDURES

Normal Relevant Biochemical Lab Values• 2-hr OGTT• Admin: 75g • Fasting: 96mg/dL (70-115mg/dL)• 0.5, 1.0, 2.0 Hr: 149, 134, 116mg/dL (<200mg/dL)

• Insulin• 14μIU/dL

• Cholesterol• 197mg/dL (120-199mg/dL)

COMPARATIVE STANDARDS

• Recommended TEE: • Female (REE)= 10xWeight(Kg) + 6.25 xHeight(cm) –

5xAge(Yrs) – 161• Activity Factor (Sedentary): 1.0 – 1.39• TEE: 1,520 - 2,113 kcals/day (avg. 1,817 kcals/day)

• Current Energy Intake: • 2,914 kcals/day• Excess of ~1,100 kcals/day

• Body Composition:• Current BMI: 30 kg/m2

• Normal BMI: 18.5-24.9

METABOLIC SYNDROME VS. PCOS

Metabolic Syndrome • WHO 1999One of the following:• Diabetes Х• Impaired glucose tolerance Х• Impaired fasting glucose Х• Insulin resistance Х

Plus 2 of the following: • Blood pressure ≥ 140/90 mg/dl Х• Dyslipidemia √• Central obesity √• Microalbuminuria N/A

Thus, Gracie is not classified as having Metabolic Syndrome according to the WHO’s criteria

NUTRITION DIAGNOSIS

• Overweight/Obesity (NC- 3.3) related to a sedentary lifestyle and excessive caloric intake as evidenced by a BMI of 30.0 kg/m2 and a caloric intake excess of ~1,100 kcals/day.

• Altered Nutrition-Related Laboratory Values (NC- 2.2) related to high dietary fat intake as evidenced by elevated LDL, lowered HDL, and elevated TGs.

NUTRITION PRESCRIPTION

• PES #1: Reduce body weight by 5-10% or to a BMI of <25 kg/m2.

• PES #2: Reduce LDL <130 mg/dL, TGs to <135 mg/dL, and increase HDL > 55 mg/dL.

NUTRITION INTERVENTION

• Comprehensive nutrition education recommended modifications (E-2.2) include lowering total energy to 1200- 1300 kcals/day and dietary fat intake by at least 7%, and choosing an overall healthful diet. • Goal setting (C-2.2) to reduce portion of nuts to ¼

- ½ cup/day or replace nuts with low-energy dense foods (such as fruits and vegetables) at least 5 days a week, choose low-fat food and drink options, and 15- 30 minutes of exercise at least 3 days a week.• Self monitoring (C-2.3) by keeping a food and

exercise log to track progress and compliance.

MONITORING AND EVALUATION

• Monitoring total energy intake (FH-1.2.1.1), total fat intake(FH-1.6.1.1) weight (AD-1.1.2), body mass index (AD-1.1.5),physical activity frequency (FH-6.3.3), cholesterol, HDL (BD-1.7.2), cholesterol, LDL (BD-1.73), and triglycerides (BD-1.7.7).• Monitor weekly for the first 6 months: weight,

BMI, physical activity, energy and fat intake.• Reduce frequency to every other week after the first 6

months.

• Monitor lipid levels every 3 months.

DOCUMENTATION

• A: 34 yo WM living w/ husband and adopted daughter. “I just keep gaining weight, no matter what I do! The more weight I gain, the more hair shows up on my body. And I just found out I have sleep apnea and I have to use a CPAP at night!” Diet hx included juice, coffee, mix nuts, cheeseburger, fires, diet coke, ham and beans, corn muffins, and ice cream. Gets meals from fast food and prepares her own too.

Dx: R/O PCOS PMHx: none other than PCOS symptoms Labs: TG: 184 mg/dL, LDL 132 mg/dL, HDL 51 mg/dL Home Meds: Glucophage, YAZ, Aldactone, Vaniqua, OrthoNovum Ht: 65 cm Adm wt: 180 lbs BMI: 30 kg/m2

Estimated requirements: 1,500 - 2,100 kcals/day

DOCUMENTATION

• D: Overweight/Obesity (NC- 3.3) related to a sedentary lifestyle and excessive caloric intake as evidenced by a BMI of 30.0 kg/m2 and a caloric intake excess of ~1000 kcals/day. Altered Nutrition-Related Laboratory Values (NC- 2.2) related to high dietary fat intake as evidenced by elevated LDL, lowered HDL, and elevated TGs.

• I: Comprehensive nutrition education recommended modifications (E-2.2) include lowering total energy to 1200- 1300 kcals/day and dietary fat intake by at least 7%, and choosing an overall healthful diet. Goal setting (C-2.2) to reduce portion of nuts to ¼ - ½ cup/day or replace nuts with low-energy dense foods (such as fruits and vegetables) at least 5 days a week, choose low-fat food and drink options, and 15- 30 minutes of exercise at least 3 days a week. Self monitoring (C-2.3) by keeping a food and exercise log to track progress and compliance.

• M/E: Monitoring total energy intake (FH-1.2.1.1), total fat intake(FH-1.6.1.1) weight (AD-1.1.2), body mass index (AD-1.1.5),physical activity frequency (FH-6.3.3), cholesterol, HDL (BD-1.7.2), cholesterol, LDL (BD-1.73), and triglycerides (BD-1.7.7).

REFERENCES

• Bart C.J.M. Fauser, et al. Consensus on women’s health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertility and Sterility. Volume 97, Issue 1. 2012 Jan; pg 28-38. E25.

• Calogero AE, Calabrò V, Catanuso M, Condorelli RA, La Vignera S. Understanding Polycystic Ovarian Syndrome Pathogenesis: An Updated of Its Genetic Aspects. J Endocrinol Invest. 2011 Sep;34(8):630-44. Epub 2011 May 23.

• Eflornithine. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000275/. 2010 Sep.• Lucidi, Richard Scott. Polycystic Ovarian Syndrome.

http://emedicine.medscape.com/article/256806-overview#aw2aab6b2b2. 2012 Oct.• Mayo Clinic staff. Metabolic Syndrome. http://www.mayoclinic.com/health/metabolic

%20syndrome/DS00522. 2011 Oct.• Metformin (Glucophage) for Polycystic Ovary Syndrome. http://women.webmd.com/metformin-

glucophage-for-polycystic-ovary-syndrome. 2010 Jan.• Moran LJ, Hutchison SK, Norman RJ, Teede HJ. Lifestyle changes in women with polycystic ovary

syndrome. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD007506. DOI: 10.1002/14651858.CD007506.pub3.

• Nelms, Maria, et al. Nutrition Therapy and Pathophysiology 2/e. Belmont, CA: Yolanda Cossio, 2011. Print.

• Ortho-Novum. www.rxlist.com/ortho-novum-drug.htm 2007 Dec• Spironolactone. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000733/. 2009 Apr. • Yaz. http://www.rxlist.com/yaz-drug/warnings-precautions.htm. 2012 Apr.

QUESTIONS, COMMENTS, OR SUGGESTIONS?