Polycystic ovary syndrome: A threat to appearance, menstruation, and fertility

Affecting approximately 1 in 10 females in the United States, polycystic ovary syndrome (PCOS) is the most common endocrine abnormality in women of childbearing age. But it can strike at younger ages as well, occurring as early as age 11. PCOS alters a woman’s men­strual cycle and appearance and can increase her risk of developing other health problems. What’s more, it’s the most common cause of infertility.

Pathophysiology

Normally as an egg grows in the ovary, fluid builds up in the follicle. When the egg matures, the follicle breaks open and the egg
is released; it then travels through to the uterus for fertilization (ovulation). But in PCOS, eggs don’t mature fully and the ovulation process isn’t complete. (See Comparing a normal ovary to a polycystic ovary by clicking on the PDF icon above.)

Theories about the causes

The cause of PCOS is unknown. A recent study found that in women with polycystic ovaries, the small follicles have an increased density, possibly from a genetic cause; the authors theorize that women with PCOS initially may have a greater follicle pool. Other researchers likewise believe PCOS has a genetic component, since some women who have the condition have a mother or sister who also has it.

Another theory links PCOS to excessive insulin production, which can increase levels of androgen—a hormone that stimulates development of male characteristics. Females normally produce androgens, but in smaller amounts than males. In women, increased androgen levels can cause such problems as excessive hair growth and ovulatory abnormalities.

Signs and symptoms

Clinical effects of PCOS vary. The most common problem is an altered menstrual cycle, which may manifest as an infrequent menstrual cycle, no menstrual cycle, or abnormal uterine bleeding.

Patients may have coarse hair on the face, chest, lower abdo­men, back, and upper arms or legs related to increased androgen levels. Other signs of increased androgen levels include acne, oily skin, dandruff, baldness, and thinning hair. Weight gain may occur (especially around the abdomen), and skin tags may appear on the neck or in the armpits. Some patients have darkened skin around the neck, armpits, inner thighs, vulva, or breasts.


These problems may cause anxiety or depression, which can alter the patient’s coping abilities, strain her relationships, and decrease her quality of life. Studies show that mood swings, increased body hair, weight gain, and infertility are the top concerns of women with PCOS, and that these concerns affect their experiences. Some report feeling isolated and different from other women, along with the desire to be “normal.”

Studies of women with menstrual problems (though not specifically PCOS) found lower scores in physical and social functioning and overall health perception in women with dysmenorrhea. Women with menstrual problems are more likely to report psychological distress, insomnia, and pain as well as feelings of sadness, hopelessness, and worthlessness. Also, they’re more likely to smoke, drink heavily, and be overweight.

Diagnosis

PCOS is diagnosed from a combination of history, clinical, and diagnostic findings. History and physical examination can uncover signs and symptoms; a pelvic examination may be done to detect ovarian abnormalities. Transvaginal ultrasound can detect ovarian enlargement and cysts and evaluate abnormal thickness of the uterine lining related to irregular menstrual cycles. Blood tests may be done to measure tes­tosterone and progesterone levels; elevated testosterone and decreased progesterone levels are typical in PCOS. Serum insulin levels may be measured as well; these may be high if PCOS is linked to excessive insulin production.

Treatment

With no cure available, treatment for PCOS focuses on controlling symptoms and preventing associated diseases. Being familiar with available treatment options enhances your ability to support the patient and help her adhere to treatment.

Excessive hair growth may be controlled with drugs or various hair-removal methods, including over-the-counter waxes or creams, electrolysis, and laser therapy. Electrolysis removes hair permanently by applying an electric current to the hair follicle via a fine needle. Laser therapy may permanently remove a portion of the unwanted hair, but some regrowth may occur even after multiple treatments.

Pharmacologic options

Various drugs can be used to control symptoms. (See Drug therapy for patients with PCOS.)

Surgery

For some patients, surgery may be done to promote ovulation. In a laparoscopic procedure called ovarian drilling, the surgeon uses electrical energy to burn holes in the enlarged follicles. The goal is to stimulate ovulation by reducing androgen levels. Risks include scar tissue formation on the ovaries.

Nursing care

Besides teaching your patient about PCOS signs and symptoms and their management, be sure to address the emotional stress caused by the condition. Inform her that PCOS may lead to complications across the lifespan, including an increased risk of hypertension and diabetes mellitus type 2, high cholesterol levels, and cardiovascular disease. Tell her that the constant estrogen elevation may raise the risk of endometrial cancer. Advise her that medications, a healthy diet, and exercise are important in controlling symptoms and preventing other serious health problems. If she smokes, urge her to stop.

Regardless of her age, advise the patient to have annual physical exams as well as routine screenings for increased blood pressure and high cholesterol and glucose levels. Inform her that these exams and screenings are available in various settings, such as hospitals, clinics, and workplace or community settings. As appropriate, encourage her to take part in routine health fairs offered in the community or employee wellness programs; this free or low-cost service is fast and can yield important information.

Encourage the patient to learn about the condition on her own as appropriate, using reliable websites, books, and healthcare journals. The more educated she is about PCOS, the greater her ability to cope with symptoms and the more empowered she’ll be to control the condition.

Diet and exercise

Teach the patient to eat a healthy diet that’s low in simple carbohydrates and processed foods (such as cookies) but high in fiber (as from whole grain breads and cereals, beans, rice, fruit, and vegetables) and lean meats. Advise her to exercise to manage symptoms. Inform her that a healthy diet and exercise promote blood glucose management, which in turn helps manage insulin levels and male hormone production. Diet and exercise also promote weight control, helping to regulate the menstrual cycle.

Emotional support

To address the emotional stress caused by PCOS, refer the patient to a support group, which can provide a sense of belonging and encouragement for treatment and symptom management. One source of support is the Polycystic Ovarian Syndrome Association (www.pcosupport.org).

Most of all, listen to the patient with compassion and understanding. In my practice, I’ve found this can make a crucial difference in outcome, helping to manage the patient’s current concerns and pave the way for a healthy future.

Selected references

American College of Obstetricians and Gynecologists (ACOG). Polycystic ovary syndrome. Washington, DC: ACOG; 2009 October 14. (ACOG Practice Bulletin #108). www.guideline.gov/content.aspx?id=15200&search=polycystic+ovary+syndrome. Accessed August 2, 2010.

Legro RS, Barnhart HX, Schlaff WD, et al. Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med. 2007;356(6):551-566.

Mayo Clinic Staff. Polycystic ovary syndrome. December 8, 2009. www.mayoclinic.com/health/polycystic-ovary-syndrome/DS00423. Accessed August 2, 2010.

Nestler JE. Metformin for the treatment of the polycystic ovary syndrome. N Engl J Med. 2008;358(1):47-54.

Norman RJ, Dewailly D, Legro RS, Hickey TE. Polycystic ovary syndrome. Lancet. 2007;370(9588):685-697.

Polycystic ovary syndrome (PCOS)—topic overview. http://women.webmd.com/tc/polycystic-ovary-syndrome-pcos-topic-overview. Accessed August 2, 2010.

Snyder BS. The lived experience of women diagnosed with polycystic ovary syndrome. J Obstet Gynecol Neonatal Nurs. 2006;35:385-392.

Strine TW, Chapman DP, Ahluwalia IB. Menstrual-related problems and psychological distress among women in the United States. J Women’s Health. 2005;14(4):316-323.

Talbott EO, Zborowski JV, Rager JR, Kip KE, Xu X, Orchard TJ. Polycystic ovarian syndrome (PCOS): a significant contributor to the overall burden of type 2 diabetes in women. J Women’s Health. 2007;16(2):191-197.

U.S. Department of Health and Human Services, Office on Women’s Health. Polycystic ovary syndrome. April 2007. www.womenshealth.gov/faq/polycystic-ovary-syndrome.cfm. Accessed August 2, 2010.

Webber LJ, Stubbs S, Stark J, et al. Formation and early development of follicles in the polycystic ovary. Lancet. 2003;362:1017-1021.

Gina L. Purdue is an assistant professor of nursing at Eastern Kentucky University in Richmond, Kentucky.

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