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From Novice to Knowing: A Primer on PCOS. Kay M. Czaplewski, BSN, RN, BC, CDE, NHA. Press to begin. What is PCOS?.

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from novice to knowing a primer on pcos

From Novice to Knowing: A Primer on PCOS

Kay M. Czaplewski, BSN, RN, BC, CDE, NHA

Press to begin

what is pcos
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
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

this tutorial will focus on four aspects of pcos click on an area of interest

(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
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
Normal Menstrual Cycle

Four Main Phases

Phase 1: Menses

Phase 2: Follicular Phase

Phase 3: Ovulation

Click on

the daisies to

learn more!

Phase 4: Luteal Phase

home

(Hole, 1989)

phase 1
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!

home

(Hole, 1989)

phase 2 follicular
Phase 2: follicular

Hypothalamus

pituitary

Follicular stimulating hormone

(FSH)

Luetinizing Hormone (LH)

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

OVULATION

(Hole, 1989)

home

phase 3 ovulation
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!

Take me home

(Hole, 1989)

phase 4 luteal
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

phase 1 question
Phase 1 question

Average blood shed during menstruation is 300ml.

  • True
  • False

back to menstrual cycle

back home

that s correct
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
Oops! Try again
  • Blood shed in that amount may be detrimental!

Let me try again!

multiple choice press on the correct answer
Multiple choicePress on the correct answer

In the follicular phase, the endometrium:

Phase 2 question

A. Thickens

C. Dissolves

B. Thins

C. Sheds

home

Take me to menstrual cycle

correct
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

slide17
no…

A dissolving endometrium

That’s just silly

Ha…ha…ha…

Return to test

Next question

slide18
no…

thinning

would

be

Menstruation!!!

(Hole, 1989)

Back to test

slide19
No…

shedding

Would

be

menstruation

Back to test

(Hole, 1989)

phase 3 question
Phase 3 Question

During Ovulation

Egg is released

No egg released

home

Menstrual cycle

correct21
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
Not quite…

Remember, during ovulation, the mature egg is released.

Back to test question

home

phase 4 question
Phase 4 Question
  • After ovulation, what do the follicles form?
  • Corpus luteum

2. Corpus Christi

slide24
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

slide25

No Ya…all…

Back to test

slide26

Great job on getting through

the normal menstrual cycle,

nowlet’s talk about PCOS…

Next slide

home

slide27

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 increased LH and decreased FSH

Disordered

GnRH Release

Pituitary secretion of LH increases

Treatments are directed at

Increased

LH release

Hyperinsulinemia stimulates

ovarian and adrenal androgen synthesis

Restoring gonadotropin

secretion (clomiphene)

Increased androgen and

Insulin levels decrease levels

of circulating binding proteins

that limit androgen bioactivity

Increased

Ovarian

Androgen

biosynthesis

Decreasing androgen levels

(follicle-stimulating hormone

Or ablative surgery)

Decreasing insulin levels

(metformin, insulin sensitizers,

weight loss, exercise

Next slide

home

(Adapted from Legro ,R.S. JAMA 2007 used with permission)

menstrual dysfunction
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
Bonus question…

What is the problem with endometrial

Proliferation?

answer

home

Previous

endometrial cancer
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
Treatment of Menstrual Dysfunction

Oral contraceptives and

progesterone withdrawal

Lifestyle modification/weight loss

Metformin (Barbieri & Ehrmann, 2007)

continue

home

slide32

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

slide33

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

Time!

home

test time
Test Time

The purpose of a progesterone withdrawal is to cause

A. No Menses

B. Menses

c o r r e c t
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.

next

(Barbieri & Ehrmann, 2007)

home

Back to test

ooops try again
Ooops!…try again

(hint…it’s just the opposite!)

Back to question

Back to menstrual dysfunction

Back to home

anovulation and infertility
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

slide38

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

slide39

Lifestyle Changes

Weight Loss reduces hyperinsulinemia

And subsequently, hyperandrogenism (Hill, 2003).

weight

hyperinsulinemia

hyperandrogen

next

home

slide40

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 infertility41
Anovulation and Infertility

For practical purposes, anovulation and infertility are the same thing.

  • True
  • False

Next slide

home

for practical purposes true
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

slide43

Normal

Menstrual

Cycle

Press for test

(Wikipedia, 2007)

insulin resistance ir
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
Treatment of Insulin Resistance

METFORMINdecreases 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 resistance46
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 time47
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

slide48

Yes, genesis is

the first book in the bible

No, genesis

is not

gluconeogenesis

Back to test

you are a rock star
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

slide50

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
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

slide52

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
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)

Test time

(Barbieri & Ehrmann, 2007)

in pcos spironolactone is used for it s effect as press on the correct answer
In PCOS, spironolactone is used for it’s effect as(press on the correct answer)

1. Aldosterone antagonist

2. Aldosterone protagonist

Next slide, please

slide55

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

slide56

Not quite…

We want to decrease androgen secretion and action

Back to test

summary
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

summary58
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.

next

home

slide59

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

slide60

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

slide61

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