Polycystic Ovarian Syndrome: Putting the Pieces of the Puzzle Together

The diagnosis of Polycystic Ovarian Syndrome (PCOS) “is like putting a puzzle together piece by piece,” said Danielle R. Stratton, DNP, RN, PPCNP-BC, a primary and acute care DNP in a private pediatric practice and assistant professor, Department of Nursing at SUNY Brockport, NY. Dr Stratton spoke on the importance of early diagnosis and management of PCOS at the National Association of Pediatric Nurse Practitioners (NAPNAP) National Conference on Pediatric Health Care held March 15 to 18, 2023, in Orlando, Florida.

The syndrome affects approximately 12% of women in the United States, or 12 million women. “This may not seem like a big percentage, but for each one of those women, PCOS is a life-changing disease that requires life-long treatment,” said Dr Stratton.

The exact cause of PCOS is unknown but is probably a combination of genetic and environmental factors. “People mistakenly think PCOS is caused by an increase in only testosterone levels, but it is not. It is caused by an increase in androgen levels,” Dr Stratton said. The syndrome is often diagnosed a year or 2 after menarche. The signs and symptoms of PCOS include:

• Missed, irregular, or very light periods
• Weight gain around the abdomen after menarche
• Acne and oily skin
• Skin tags around the neck and axillae
• Acanthosis nigricans
• Hirsutism
• Male-pattern baldness
• Infertility

Over time, women with PCOS may develop serious health conditions related to their disease including weight gain around the abdomen, difficulty losing weight, anxiety and depression related to weight, insulin resistance, sleep apnea, and cardiometabolic conditions (hypertension, hypercholesterolemia, nonalcoholic fatty liver disease, and stroke).

The diagnosis of PCOS is “a bit of a puzzle,” noted Dr Stratton. “There is no single test to confirm the diagnosis of PCOS.” Therefore, pediatric clinicians need to obtain a thorough medical history, including family history. This includes a discussion of the patient’s first period, menstrual cycle patterns, and related symptoms. Blood work is performed to identify hyperandrogenism as well as other abnormal findings, including inflammatory markers (Table). Because PCOS is associated with overweight and insulin resistance, hemoglobin A_1c, fasting glucose, fasting lipid panel, and liver function tests are ordered.

Table. Typical Laboratory Tests for Polycystic Ovarian Syndrome

Follicle-stimulating hormone, luteinizing hormone, prolactin, estradiol

Thyroid stimulating hormone

Testosterone (free and total)

Androstenedione (morning fasting) and 1 week before and after menses

Dehydroepiandrosterone (DHEA)-2

Insulin

Hemoglobin A1c

Fasting glucose

Fasting lipid panel

Liver function test

Vitamin D (if fatigued)

A pelvic examination is also required to assess enlargement of the ovaries. This can be done by the clinician or by a pediatric Ob/Gyn. The best imaging tests for examining the ovaries are pelvic and intravaginal ultrasonography, however, the latter may be extremely uncomfortable for many teenagers. Pelvic ultrasonography is the best way to view the swollen ovaries and multiple small follicles on the surface of the ovary, said Dr Stratton, and “may best be performed by a pediatric Ob/Gyn.” Twelve or more ovarian cysts and increasing ovarian volume are hallmarks of PCOS presentation, Dr Stratton explained.

Management of Patients: Educate and Empower

The most important thing a clinician can do is to educate and empower patients, said Dr Stratton. “The diagnosis of PCOS does not define them. Teach them to be proactive about their health and well-being. Patients with PCOS have chronic inflammation; they are tired. It is important to emphasize healthy eating, staying hydrated, and getting enough sleep,” she said. Teenagers may be tempted to drink high-caffeine energy drinks to counter fatigue, “but this will just cause dehydration, raise their heart rate, and make them more tired.”

Starting medication management early after diagnosis can help to manage some of the health concerns related to overweight, insulin resistance, and cardiometabolic issues. Therefore, one of the first medications in the arsenal is metformin, noted Dr Stratton. Metformin is usually started low and titrated up. Working with a pediatric endocrinologist, the dose is usually begun at 500 mg/d and titrated up to 1000 mg to 1500 mg/d. Metformin has been found to improve PCOS symptoms, insulin resistance, and may aide in weight loss over time.

Patients are also started on oral contraceptive pills (OCP). The goal of OCP therapy is to keep testosterone levels low and increase follicle-stimulating hormone, luteinizing hormone, and prolactin levels. “We want to prevent the ovaries from releasing an egg,” noted Dr Stratton, “ovulating only 4 times a year.” Contraceptives that have lower estrogen levels may help with reducing the severity of some PCOS symptoms but they are less effective at managing PCOS overall. Intrauterine devices are not indicated for women with PCOS because they do not reduce testosterone levels, noted Dr Stratton.

Spironolactone is an agent used to block the effects of androgen and helps to reduce the overproduction of testosterone. The benefits of therapy are that it reduces hirsutism, blood pressure, and may cause weight loss over time. Patients will need positive support when starting spironolactone as it can take up to 6 months to take effect.  

Establishing Life-Long Healthy Habits

When PCOS is diagnosed in adolescence, patients can do a number of things to be proactive about their well-being. Clinicians can help patients establish healthy lifestyle habits, such as keeping good sleep hygiene, eating healthy diet, staying active, and reducing stress. It is also important for patients to maintain regular physical/gynecological examinations and establish a referral to an endocrinologist who is knowledgeable in PCOS maintenance.

Visit Clinical Advisor’s meetings section for more coverage of NAPNAP 2023.

Source

Stratton DR. Adolescent health: PCOS and the important of early detection, diagnosis, treatment, and intervention. Presented at: NAPNAP National Conference; March 15-18, 2023; Orlando, FL.