Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Polycystic Ovary
E28.2: Polycystic ovarian syndrome
I. DEFINITION
Polycystic ovary syndrome (PCOS), formerly known as Stein–Leventhal syndrome, is an endocrinologic condition with complex pathophysiology and various clinical presentations. It is one of the most common problems in women of reproductive age. Typical clinical and biochemical manifestations are anovulatory cycles, infertility, and hyperandrogenicity, but many women do not exhibit these characteristic signs. Some women with PCOS have ovaries with a thickened capsule and multiple follicular cysts (polycystic ovaries [PCO]). Women with PCO do not necessarily have PCOS, and those with PCOS do not always have PCO.
II. ETIOLOGY (UNKNOWN BUT POSITED)
A. Genetic factors
B. Possible autosomal transmission of responsible genetic sequences
C. A gene or gene series may render the ovary susceptible to insulin stimulation of androgen secretion and block follicular maturation.
III. HISTORY
A. What the patient may present with (only 20%–30% symptomatic)
1. Anovulatory cycles
2. History of infertility
3. Oligomenorrhea
4. Amenorrhea
5. Prolonged erratic menstrual bleeding
6. Signs of hyperandrogenism, including hirsutism, acne, and alopecia (especially crown pattern baldness)
7. Galactorrhea
8. Increased waist-to-hip ratio: greater than 0.85
9. Hyperpigmentation: nape of neck, axillae, and inguinal areas (acanthosis nigricans)
B. Additional information to be considered
1. Menstrual cycle history or patterns (onset, length, duration, amount of bleeding)
2. Pregnancy history
3. Contraceptive history
4. History of weight gain, hirsutism
5. Voice changes, frontal balding, increased muscle mass, acromegaly
6. Any chronic diseases, especially diabetes
7. Family history of PCOS, infertility, or diabetes
8. Medication history
IV. PHYSICAL EXAMINATION
A. Complete physical examination, including height, weight, and blood pressure
B. Pelvic examination: speculum and bimanual to check for enlarged PCO
C. Breast examination to rule out galactorrhea
POLYCYSTIC OVARY SYNDROME 255
D. Full-body scan for hirsutism, acanthosis nigricans, body shape, waist-to-hip ratio, and hair growth patterns
V. LABORATORY AND OTHER DIAGNOSTICS
A. Follicle-stimulating hormone (FSH)
B. Luteinizing hormone (LH)
C. LH/FSH ratio → prolactin
D. Androstenedione
E. Glucose (fasting)
F. Testosterone (total and free)
G. 17-Ketosteroids
H. Dehydroepiandrosterone sulfate (DHEAS)
I. Sex hormone–binding globulin
J. Comprehensive metabolic panel
K. Transvaginal ultrasound preferably on cycle days 3, 4, or 5
L. Thyroid-stimulating hormone (TSH)
M. Lipid profile
N. Insulin (fasting)
O. Human chorionic gonadotropin (hCG)
VI. DIFFERENTIAL DIAGNOSIS
A. Late manifestation of congenital adrenal hyperplasia
B. Adrenal adenoma
C. Adrenal carcinoma
D. Hyperthecosis
E. Ovarian carcinoma
F. Cushing’s syndrome
G. Acromegaly
H. Idiopathic hirsutism
I. Hyperprolactinemias
J. Thyroid disorders
K. Disorders of adrenal and pituitary glands
VII. TREATMENT
A. Weight-loss and exercise program
B. Low-dose, low-androgenic combination of oral contraceptives to restore cyclic menses
C. Possibly use of antiandrogens for hirsutism and acne
D. Insulin-sensitizing agents: metformin and troglitazone (not generally recommended as first-line, single therapy for infertility)
E. Electrolysis, depilatories
F. Ovulation induction
VIII. COMPLICATIONS
A. Insulin resistance and development of type 2 diabetes, metabolic syndrome
B. Miscarriage
C. Infertility
D. Hysterectomy
E. Endometrial cancer
F. Ovarian cancer (not significantly increased)
G. Cardiovascular disease (atherosclerosis, hypertension, increased triglycerides, stroke)
H. Depression (symptoms of PCOS can affect confidence and self-esteem)
I. Weight gain
J. Nonalcoholic fatty liver disease (particularly if obesity is present)
IX. CONSULTATION AND REFERRAL
A. For infertility treatment
B. For nonpharmacologic treatment of hirsutism
X. FOLLOW-UP
A. Education about PCOS and lifestyle alterations
B. Education about pharmacologic interventions
C. Education about fertility
See Bibliographies.
Website: www.pcosupport.org