WHAT IS PCOS?
PCOS = polycystic ovarian syndrome
Characterized by polycystic ovaries and abnormalities in the metabolism and control of androgens and estrogen in women of reproductive reproductive age
Etiology of PCOS is not known, although there is likely a genetic component causing hyperinsulinemia and increased testosterone testosterone production
WHAT IS PCOS?
Polycystic ovaries:
Defined by the presence of at least eight small (2 to 8 mm) follicles (cysts) in each ovary with ovarian ovarian enlargement
WHAT IS PCOS? Typical symptoms include any of the following:
Polycystic ovaries
Obesity
OligoOligo- or ameno amenorrh rrhea ea
Dyslipidemia
Anovul Anovulat atory ory infertil infertility ity
Metabolic syndrome
Hirsutism
Insulin resistance
Male pattern baldness
Type 2 diabetes
Acant Ac anthos hosis is nigric nigrican ans s
Sleep apnea
Acne
Fatty liver
PHYSICAL SYMPTOMS SYMPTOMS
HOW IS PCOS DIAGNOSED?
No specific diagnostic criteria established
Diagnosed by physical and biochemical evidence and exclusion of other disorders
Physical symptoms: symptoms: menstrual disturbance, hirsutism, acanthosis nigricans, acne, obesity
Biochemical tests: abnormalities in androgens, LH, FSH, glucose, insulin, cholester choles terol, ol, triglycerides
Ultrasound: presence of polycystic ovaries
PCOS MEDICAL COMPLICATIONS COMPLICATIONS
Type 2 diabetes
Caused by hyperinsulinemia and obesity
Cardiovascular Cardiovascular disease disea se Caused by elevated blood pressure, cholesterol, triglycerides
Infertility/spontaneous Infertility/spontaneous abortion abor tion
Caused by androgen (e.g. excess testosterone) and estrogen abnormalities
Endometrial cancer
As a consequence of increased estrogen production
THE PATIENT
Gracie Moore
Race/Sex: white female
Age: 34 years
Education: graduate student working on doctoral degree
Occupation: graduate teaching assistant
Hours of work: 8a-5p
Household members: husband and adopted infant daughter
PATIENT BACKGROUND
Medical history: onset of PCOS 6 years ago
Stopped menstruating in college
Placed on oral contraceptives to regulate cycle
40 pound weight gain since college
Exacerbated Exacerbated hirsutism hirsutism and PCOS symptoms symptoms
2 previous miscarriages Family history history of type 2 diabetes Current medications: oral contraceptives
Lifestyle history: symptoms exacerbated exacerbated by stress of juggling career, school, and family
Prompted to seek medical attention
CHIEF COMPLAINT AND PHYSICAL EXAM
Chief complaint: unintentional weight gain
“I just keep gaining weight, no matter what I do!” Also: hirsutism, sleep apnea
Physical exam within normal limits except:
Skin: dry/pale, acne, skin tags, acanthosis nigricans
DIAGNOSIS AND TREATMENT TREATMENT PLAN
Dx: polycystic ovarian syndrome
Treatment plan
Biochemical tests: CBC, metabolic panel, lipid panel, thyroid panel, testosterone level, 2-hr GTT
Medications: Medications: Yaz Yaz (oral contraceptiv contraceptive), e), Glucophage Glucophage (hypoglycemic (hypoglycemic agent), Aldactone (antihyper (antihypertensiv tensive), e), Vaniqua (reduces excessive excessive hair growth)
Nutritional Consultation
ANTHROPOMETRICS
Current height and weight: 65”, 180 lbs
Current BMI: 30.0 kg/m2
Current waist circumference: 36 in.
Class I obesity
>35 in. = increased risk
Weight history: college weight = 140 lbs
College BMI: 23.3 kg/m2
Normal weight
IBW= 125 lbs, current %IBW= 144%
LAB VALUES
LAB VALUES
Status of kidneys and liver
Electrolyte and acid/base balance
Blood sugar
Blood protein
Bilirubin
≤0.3mg/dl 0.4 H
0. 4 H
Monitor for steatohepatitis
0.4 H
0.41 H
LIPID PANEL Positive diagnostic profile
Low HDL, high LDL and cholesterol, elevated triglycerides
Chol
120-199 mg/dL
189
187
207 H
197
HDL-C
>55 mg/dL
60
58
52 L
51 L
LDL
<130 mg/dL
95
85
141 H
132 H
TG
35-135 mg/dL
174 H
224 H
211 H
184 H
THYROID PANEL
Thyroid Panel with TSH
R/O thyroid dysfunction presenting with similar symptoms
T4
4-12 mcg/dL
11.4
11.2
9.3
10.1
T3 uptake
75-98 mcg/dL
24
28
30
32
TSH
0.35-5.50 mcIU/dL
3.50
2.174
2.515
2.68
Low T3 uptake consistent w/oral contraceptives
LAB VALUES
Testosterone estosterone Level
Affected by:
5 alpha-reductase enzyme at vellus Hair follicles and sebaceous gland
Clearance rate increase with production rate
Testosterone
promotes acne and terminal hair
Any elevation indicates excess androgen production
Free testosterone measured by available Sex Hormone Binding Globulin (SHBG) 20-76 mg/dL
56
75
87 H
25
LAB VALUES
Glucose Tolerance Test (GTT)
Monitors for insulin resistance
Risk for type 2 diabetes
Drink 75g glucose solution
GTT 75g
Blood draw at beginning (base line) q2h following following
70-115
96
<200
149
<200
134
<200
116
MEDICATIONS (Dr (Drospi ospire reno none ne an and d Ethin Ethinyl yl estr estradi adiol ol))
Oral contraceptive Suppresses the pituitary's production of LH, FSH Suppresses the ovarian production of androstenedione
Is an androgen
Estrogen in birth control increases testosterone binding protein in the blood stream
Less available testosterone to be converted to dihydrotestosterone by 5 alpha-re alpha-reductas ductase e enzyme
Reduces hirsutism
Regulates menstrual cycle
Increase serum K
Should limit dietary intake
MEDICATIONS
Increases insulin sensitivity
Hyperinsulinemia increases free testosterone
Reduces ovarian androgen production Decreases hepatic glucose production
Decreases conversion of testosterone to dihydrotestosterone
Reduces insulin secretion
Reduces hirsutism and acne
Nutritional concerns
B12 absorption, adequate fluid intake, monitor lactic acidosis, GI upset
MEDICATIONS
Diuretic used to treat hypertension
Excretion of sodium relaxes blood vessels
Most widely prescribed anti-androgen in the United States At high doses Aldactone blocks cytochrome P-450 system Reduces capacity of the ovary and adrenal glands to make androgens Alters the conversion of testosterone to dihydrotestosterone (DHT) by 5 alpha-reductase
K sparing diuretic Increases serum K Limit dietary intake
MEDICATIONS
Does not inhibit the production or action of androgens
Interferes with 5 alpha-reductase enzyme
Reduces terminal hair formation
Topical cream used twice daily
No nutritional implications
GRACIE’S ENERGY NEEDS
Current TEE (180lbs.) = 1858.25 x (1.0 to 1.39 1858 - 2583 2583 kcal kcal/da /dayy sedentary) = 1858
Previous TEE (140 lbs.) = 1676.25 x (1.0 to 1.39 sedentary) = 1676 – 2330 kcal /day
Gracie’s energy intake should be consistent with her requirements at her previous normal weight to achieve weight loss
24-HOUR FOOD FOOD RECALL (MORNING)
Food
Calcium-fortified
Quantity
Calories
CHO
Protein
Fat
(g)
(g)
(g)
8 oz
110
28
2
0
Coffee (black)
6 oz
2
0
0
0
Mixed nuts (salted)
1 cup
760
24
20
68
Ice tea (unsweet)
10 oz
0
0
0
0
872
52g
22g
68g
orange juice
Total Energy
24-HOUR RECALL (LUNCH) Food
Wendy’s
Quantity
Calories
CHO
Protein
Fat
(g)
(g)
(g)
1
440
35
27
22
Wendy’s™ French
Small
350
45
4
16
fries
order
Diet Coke™
18 oz
0
0
0
0
790
80g
31g
38g
Cheeseburger
Total Energy
24-HOUR RECALL (EVENING) Food
Ham and beans
Quantity
1½
Calories
C HO
Protein
Fat
(g)
(g)
(g)
420
75
18
5
cups Corn muffins
2
680
108
8
18
Diet Coke™
12 oz
0
0
0
0
1
160
30
4
2
1260
213g
30g
25g
Skinny Cow ™ ice cream sandwich Total Energy
GRACIE’S CURRENT CURRENT ST STA ATUS
1676-2330 676-2330 kcal recommended normal no rmal BMI
2922 kcal total current intake
47% CHO
11% Protein
42% Fat
4,255 mg Na
No physical activity reported
PES PES STA STATEME TEMENTS NTS
Excessive energy intake related to consumption of high fat, energy dense foods as evidenced by selfreported intake in excess excess of requirements, 40 pound weight gain in the past 6 years, and current BMI of 30 kg/m2
Excessive Na intake related to frequent consumption of salty convenience convenience snacks and meals as evidenced by a Na intake of 185% of max recommended intake and elevated blood pressure of 139/85 mmHg
SAVING GRACIE
1)Recommend nutrition education and counseling Re-attain a normal BMI (<25kg/m 2) by decreasing total kcal intake by 500-1000 kcals/day
Reduce intake of high fat/energy dense foods
No more than 30% of kcal from fat
Less than 10% of kcal from sat fat
Increase intake of fruits and vegetables
5-9 a day
Monitor K
SAVING GRACIE
2) Reduce Na intake to below 2,300 mg as recommended by by the Dietary Guidelines
Decrease intake of salty convenience convenience snacks and meals
SAVING GRACIE
3) Gradually build to 60 min. moderate intensity physical activity 5 days/wk
Suggest everyday activities that she can incorporate incorporate throughout the day (brisk walking)
4) Keep a diet and physical activity journal Helps pt. see REALITY 5) Meet weekly as needed to check progress
Encouragement and check regularly on what is /is not working
QUESTIONS??