Polycystic Ovarian Disease - NRSG 835

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NOTE:  Information Updated 9/04

POLYCYSTIC OVARY SYNDROME - Rose Mary Russell, Women’s Health NP

 

Functional Ovarian Hyperandrogenic Disorders

Hyperandrogenic Disorders

 

CHARACTERISTICS

    1. PCO characterized by excessive production of androgens & estrogen
    2. H-P-0 axis intact
    3. Ovary intrinsically without defects
    4. Ovary affected by excess androgens and conversion of androgens in periphery to estrogens.
    5. No known cause

PATHOPHYSIOLOGY

A. ANDROGENS

  1. Androgenic steroids
    1. testosterone - most potent
    2. dihydrotestosterone - potent tissue metabolite from skin and skeletal muscle.
    3. androstenedione, dehydroepiandrosterone (DHEA) & free DHEA - S.
  2. Women secret testosterone equally from adrenal (25%) ovaries (25%) 50% is peripheral conversion. This is 5-20% of men.
  3. Testosterone and other circulate bound to SHBG and other binding proteins ie. albumin, so that ^ amts. of SHBG results in less free bioavailable hormone.
  4. SHBG produced in liver, ^ by estrogens and decreased by androgens and insulin, so less SHBG ^ amount of circulating testosterone.
  5. Thus, free testosterone level are a better marker of androgenic activity than total testosterone.
  6. Androgens aromatized to estrogen in peripheral fat, why women who are hyperandrogenic tend to have normal total estrogen levels.
  7. Decrease in (SBG) leads to increase active testosterone.

B. HYPERINSULINEMIA

  1. Hyperandrogenic women are significantly more insulin resistant, independent of obesity.
  2. Increased insulin stimulates ovarian androgen production.
  3. High insulin levels cause hyperandrogenemia in women with severe insulin essence.
  4. It is not clear if insulin leads to increased androgens or increased androgens contribute to hyperinsulinism.
  5. The degree of resistance correlates with the presence of acanthosis nigrican - darkening of rugal folds.
  6. Acanthosis nigricans associated with the highest fasting insulin.
  7. The greater the obesity the greater the fasting insulin.

INCREASED ESTROGEN, ANDROGEN, LH

  1. Increased estrone from:
    1. obesity ( conversion of ovarian and adrenal androgens to estrone in body fat)
    2. excessive levels of androgens seen in women of normal weight.
  2. High estrone causes suppression of pituitary FSH and increase of LH.
  3. Constant LH leads to anovulation, multiple cysts, theca cell hyperplasia with excess androgen output from ovary and adrenal gland.
  4. May see physical findings like Cushing's Syndrome ^ androgen levels.
  5. This leads to ^ androgen secretion by ovaries which contributes to
  6. premature follicular atresia and persistent anovulation, leading to
  7. PCO. There is an increased risk for breast and endometrial CA due to ^ estrogen.

DEFINITION

    1. Secondary amenorrhea; hyperandrogenic and menstrual irregularity in premenopausaul women.
    2. Amenorrhea/ Oligiomenorrhea
      1. LH>FSH 3:1
      2. LH.35 mIU/ml. 9% of infertility.

CHARACTERISTICS / DEMOGRAPHICS

    1. Hirsutism - 70%, androgen responsive skin zones. Coarse terminal
    2. hair. Virilization <1% of women with hirsutism. -distinguish from hypertrichosis, fine vellus hair, not androgen dependent.
    3. Obesity - 40%
    4. Virilization - 20%
    5. Secondary amenorrhea 50%
    6. Abnormal uterine bleeding - 30%
    7. Normal periods - 20%
    8. May be daughters who fathers balded early
    9. Onset teen years.
    10. Acne varies with race
      1. Asian and Am. Indians - no hair.
      2. Mediterranean - heavy facial and body
      3. African Am. and Hispanic- Acanthosis Nigricans
      4. Asians - increased acne.
    11. 38% of women with diffuse alopecia have evidence of hyperandrogene mia.
    12. 50% of women with acne have ^ androgen.
    13. Hyperandrogenemia women tend to have ^ chol, lower HDL, ^ waist to hip ratio.

DIFFERENTIAL DIAGNOSIS

    1. DC OCP
    2. Premature menopause - FSH & LH ^
    3. Rapid wt. loss, extreme exercise, or obesity
    4. Hyper/hypo thyroid
    5. Cushing syndrome
    6. Pituitary tumor - ^ prolactin
    7. Ovarian or adrenal tumors - suspect when onset is abrupt and not assoc. with puberty.
    8. Hyperprolactinemia - assoc. with ^ DHEA-S levels and hirsutism.
      1. ^ are mild
      2. no tumors on scan
      3. prolactin may ^ adrenal androgen.

LABORATORY EVALUATION

    1. UA Preg test/serum
    2. Menses calendar/ BBT
    3. LSH/FSH ratio
    4. Prolactin level
    5. TSH
    6. Serum testosterone (total and free)
    7. DHEA-S
    8. Pelvic US
    9.  

 

GOALS OF MANAGEMENT

    1. effect of hirsutism/acne or self-concept
    2. regulate menses, decrease unopposed estrogen effect
    3. Decrease insulin resistance
    4. determine risk factors
    5. fertility

 

S: Chief Complaint - Hirsutism (70%)  or Infertility

    1. Menses/OB/ Contraceptive Hx
      • Menses hx including menarche, freg.. duration, past conception, use of OCP, symptoms of ovulation. Any abnormal bleeding, normal periods, c/o infertility.
    2. PMH - Medication hx - use of danazol for endometriosis
      • use of androgenic OCP, Norgestrel
      • Dilantin
      • Minoxidil use
    3. FMH - Family h/o hair growth, diabetes, thyroid, adrenal diseases
    4. ROS - male pattern baldness
      • ^ oil production
      • deepening of voice
      • ^ muscle mass or proximal muscle weakness darkening of rugal folds skin changes, acne, straie, bruising fat areas of neck supraclavicular
      • ^ abd. girth, central obesity
      • galactorrhea
      • wt. gain

0:

    1. VS - A B/P
    2. Wt. Ht.
    3. Skin - distribution of androgen terminal hair, quantity
      1. acne, ^ oil production
      2. presence of straie - cortisol production, bruising, fat dist.
      3. acanthosis nigricans
    4. Hair - temporal balding
    5. HEENT –
      1. deepening of voice
      2. moon face
      3. eye exam
    6. Breast - decreased size, galactorrhea
    7. Pelvic -
      1. external - amt. of terminal hair; clitormegaly; ambiguous genitalia
      2. internal - presence of cervical mucus, character, ferning
      3. ovaries - palpable, equal, tender, smooth

P:

    1. Obesity, lose wt.
    2. If no fertility desired-
      1. OCP
        • pills to ^ SHBG
        • keep on 6-12 months
        • Ovcon/Modicon 0.4 - 0.5 norethidrone
        • Ortho cept, Desogen & Orthotricyclen least andronergic effect on lipids.
        • Women whose ovaries work may need BTB and increased estr/proges, Demulen 1/35
        • Avoid androgenic - levonorgestrol, Nordette, Lo-ovral, and Lo-estrin
        • Do not use if PRL levels increased
      2. Medroxyprogesterone 10 mg./day for 10 days of month.
      3. Spironolactone 50 - 100 mg BID
    3. Refer if fertility desired or ^ PRL
      1. Bromocriptine
      2. Clomiphene citrate
      3. GNRH
      4. Laser drilling
      5. Wedge resection
      6. Low dose dexamethasone suppression
    4. Mild hirsutism
      1. shaving
      2. bleach
      3. tweezing
      4. depilatories
      5. electrical epilators
      6. lasers

 

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