Substantial Effects on Health of Polycystic Ovarian Syndrome - Essay Example

Polycystic Ovarian Syndrome: Substantial Effects on Health and Fertilization Shannon C de Castro Teachers 07 November 2009 Loyola University Chicago Polycystic Ovarian Syndrome: Prevalence and Impact on Women's Health and Fertility Polycystic Ovarian Syndrome (PCOS) is the leading cause of infertility in women of child-bearing age. It is a complex and multifaceted endocrine disorder with substantial number of symptoms. Etiology of PCOS is not well understood, and with much variability in symptoms and diagnosis, this syndrome presents as a predicament to both patient and care administrator. PCOS is known as an abnormal physiological condition which causes abnormal hormonal imbalances which affect, among other things, a woman's fertility. There is no universally accepted definition of PCOS, as observed by the ACOG, although most definitions cite the common symptoms of the disorder. In general, PCOS is characterized by absence of or irregular menstruation, hirsutism, anovulation, infertility, obesity, acne, metabolic disorders, insulin insensitivity and hyperinsulinemia, to name a few symptoms. The patient's ovaries in classical cases show the presence of multiple small cysts. The primary cause of this disorder is not known. However, three factors are known to play important roles in the development and progression of PCOS. These are hyperandrogenism, hyperinsulinemia, and high levels of Luteinizing hormone (LH). PCOS is easily diagnosed in the clinical setting through history and physical examination. This is then accompanied by laboratory results of hormonal levels, for the sake of differential diagnoses with similar illnesses, such as congenital non-classical adrenal hyperplasia. Infertility related to PCOS is caused by anovulation. The high level of LH associated with PCOS is responsible for this anovulation. It causes increased production of androgens from the adrenal gland and the ovaries. These androgens cause typically masculine characteristics in the female and inhibit maturation of the ovum. Secondly, high levels of LH also inhibit maturation and release of dominant follicles (Hill, 2003). Scope of the Problem Young women and adolescent girls are the age group susceptible to contracting PCOS. The percentage of that age group who are diagnosed with PCOS is an astounding 5-10 percent. (Kidson, 1998) For women of child-bearing age, PCOS is the most common endocrine disorder. Statistics show that 4 to 6 percent of all women in America have hyperandrogenic chronic anovulation (Schroeder, April 2003). This prevalence increases sharply in women with chronic anovulation and hyperinsulinemia. This illness not only robs the affected patient of the ability to have children, but it also increases her susceptibility to other disorders, such as diabetes type 2 (DM type 2) and CVS diseases. The psychological part of it must also be considered. These patients commonly suffer from depression due to the inability to have children and the other symptoms associated with PCOS, such as hirsutism and androgenic alopecia. The risk factors for PCOS are increased levels of LH secretion due to hyperproduction of gonadotropin releasing hormone, hyperinsulinemia and hyperandrogenism. A concern which must be addressed is the increasing cases of ovarian hyperstimulation, pregnancy loss, gestational diabetes and hypertension due to ovulation induction in these patients (Schroeder, April 2003). Since the actual cause of PCOS is not known, there is very little that can be done to prevent the disorder. However, it is important to screen for the disorder and other differential diagnoses of similar illnesses in all patients presenting with irregular menstruation, infertility and hirsutism. All identified cases should also be screened for risks of DM type 2, CVS conditions and the metabolic syndrome. The rise in the prevalence of PCOS and the fact that diabetes and CVS conditions are among the leading causes of morbidity and mortality in today's clinical setup, should make the contribution of PCOS to these two conditions a cause of concern when looking at ways of reducing their prevalence. Review of selected literature Though many references were researched, this paper focuses on five selected nursing journal articles regarding PCOS, its diagnosis and management guidelines. These articles were selected through Pubmed and ScienceDirect databases. These databases are reliable in providing scholarly materials from accredited journals in the medical and nursing fields. Some of the key search terms used were "Polycystic ovarian syndrome", "Polycystic ovary syndrome + fertility" and "Polycystic ovary syndrome + nursing" among others. The first criterion used for picking an article was the date of publication. I confined my search to publications done after the year 2000. Then, PCOS had to be the main focus of the article. In addition, for an article to be chosen, it had to have mentioned the infertility issues associated with PCOS. The last criterion for choosing an article was that the article be published in a nursing journal or highlight the role of nursing in the management of PCOS. We will begin with Joyce King's article, she has covered the issue of PCOS well with detailed facts on what it is, its pathogenesis, manifestations, diagnosis and management. She has mentioned the high prevalence of the disorder and the lack of complete understanding of its pathophysiology due to heterogeneity. The article explains the three proposed mechanisms of pathophysiology. It also gives a clear understanding of the symptoms associated with PCOS in order of their significance in diagnosis. These symptoms have been accompanied by statistics of their prevalence in patients with this disorder. The article does not fail to mention the relationship between PCOS and the cardio vascular system. It also emphasizes differential diagnosis of related disorders such as nonclassical hypogonadism. Outlined in the article are possible ways of treating PCOS. It gives the goal of treatment as management of symptoms and allowing the patient to return to normal life. This includes possibilities of conceiving. The author emphasizes that midwifery nurses must understand the symptoms, diagnosis and management of PCOS due to its high prevalence. However, the article does not clearly address the role of the nurse in management of this disorder and its complications. The author ends with a good conclusion highlighting all the important points in her subtopics. PCOS: Recognizing Polycystic Ovary Syndrome in the Primary Care Setting. By Mary Pat Bartoszek, RN, MSN. Mary Pat Bartoszek's article on recognizing polycystic ovary syndrome in the primary care setting begins with statistics of prevalence of PCOS. However, it does not give any definition of PCOS. The article mentions briefly the pathogenesis of the disorder followed by detailed definitions and explanations of the presentation of PCOS. As for diagnosis, the article begins by emphasizing that differential diagnosis must be done using the "red flags" signaling a suspected alternate diagnosis (Bartoszek, 2009). Besides the common diseases considered in the differential diagnosis, the author also includes hyperthyroidism, Cushing's syndrome and hyperprolactinemia in this list. Among the long term implications of the disorder, this article addresses the risks of developing DM type 2, cardiovascular risks, and endometrial cancer. Interestingly, the article introduces a new fact that women with PCOS also experience sleep disorders such as OSA. All these long-term implications are well supported with results from other studies. Like the previous article, diagnosis in this article emphasizes clinical history and physical examination. However, unlike the previous article, this article point outs out that if a final diagnosis of PCOS is made, a patient may be treated by her regular physician. The need for an endocrinologist only comes in when the diagnosis is not clear (Bartoszek, 2009). This article gives detailed information of the type of therapies which target different manifestations of the disorder. These interventions are more or less similar to those named in Joyce King's article. Among key points for the success of these interventions Bartoszek names early diagnosis, lifestyle changes, and management of complications. The article includes very good pictures showing the highlighted symptoms. The article recommends further studies but does not give a conclusion. Update: The Pathogenesis and Treatment of PCOS. By Kathryn M. Hill, RNC, WHCNP, MS. The third article I chose mainly deals with the pathogenesis and treatment of PCOS. This article gives essential guidelines on how a nurse can take careful medical history, perform a proper examination and the necessary laboratory tests which should be ordered during the diagnosis of PCOS (Hill, 2003). It also addresses the management of this disorder highlighting when to seek a specialist's advice. The article first gives an elaborate review of the menstrual cycle before discussing the pathophysiology of PCOS. It then discusses the significance of elevated LH levels in the pathogenesis of PCOS. It also mentions the possibility of genetic defects resulting in insulin insensitivity and hyperinsulinemia (Hill, 2003). This is a new topic which had not been discussed in the previous two articles. The article then defines and explains the clinical manifestations of PCOS with accompanying statistics. Unlike, the previous two articles, infertility is discussed on its own in this article. The section on history taking includes additional symptoms which should either be present or absent in addition to the common symptoms. For example, the article mentions that PCOS-associated bleeding lacks preceding symptoms such as bloating and breast tenderness (Hill, 2003). This is attributed to lack of ovulation. Diagnosis is similar to that seen in Mary Pat Bartoszek's article. Interestingly, pregnancy is mentioned in this article as one of the differential diagnoses. Treatment goals listed, in this article, include reduction of hyperandrogenism, recovery of fertility, protection of the endometrium and reduction in risks of Diabetes type 2, cardiovascular disease and other complications. As in the previous articles, the management of hirsutism, acne, menstrual abnormalities, hyperinsulinemia and dyslipidemia, obesity and infertility is discussed exhaustively. The article gives very important information which could help a nurse in patient education including commonly asked questions. New Approach to Polycystic Ovary Syndrome and Other Forms of Anovulatory Infertility. By Joop S. E. Laven, MD, PhD, Babak Imani, MD, Marinus J. C. Eijkemans, MSc and Bart C. J. M. Fauser, MD, PhD. This article begins by acknowledging the confusion surrounding the classification, definition, pathophysiology and criteria for diagnosis of PCOS. The article then describes the history of PCOS. This is followed by a discussion of the old method of classification of inovulatory infertility. The article cites three classes namely WHO I, WHO II and WHO III depending on the levels of circulating gonadotropin and estrogen levels. It goes on to give a detailed account of the criteria for classification characteristics such as cycle history, body weight and composition, LH levels and hyperandrogenism among others. The limitations of this classification are highlighted. The article then looks at new approaches to classification which are prognosis rather than diagnosis-oriented. Polycystic Ovarian Syndrome: What Nurses Need to Know About This Misunderstood Disorder By Missy L. Jackson, RNC, WHNP. This article shows how PCOS does not spare even those in the medical profession through the moving story of a nurse who is diagnosed with the disorder and how it has affected her life. It describes the history of PCOS, its clinical manifestations, diagnosis and management. Of all the articles analyzed, this is the only one which looks at the emotional effects of this disorder. These include stress and depression, a feeling of not being a real woman and low self-esteem. It is also the only article which gives clear nursing implications of the disorder. These include the important role of patient education and counseling and the supportive role in emotion management. This is to help the patient understand the disorder and to help her identify and cope with the negative emotions associated with PCOS. None of the articles analyzed have ventured into establishing alternative forms of treatment. The guidelines outlined in these articles are similar those given by federal organizations such as the Agency for Healthcare Research and Quality (AHRQ) and Professional bodies such as ACOG. Unlike the common practice of rushing to reduce symptoms with drugs, AHRQ and ACOG guidelines recommend that patient and family education should be the first step (AHRQ, 2006). This is followed by non-pharmacological interventions such as diet and cosmetic therapies. Pharmacological therapies should the last in line. However, it was noted that mainstream medicine has chosen to ignore some of the steps in diagnosis as not helpful whereas these steps are still in the said guidelines. An example of such a step is the trans-vaginal ultrasound of the ovaries. All the articles above said this is not an important diagnostic step but it is still in the guidelines for diagnosis according to AHRQ and ACOG (AHRQ 2006, Schroeder, April 2003). It was also noted that the guidelines do not advocate the use of insulin sensitizers such as metformin for ovulation induction. Actually, unlike common practice, these guidelines do not advocate ovulation induction in patients with PCOS as this increases their risk of DM type 2. This analysis has opened my mind to the difficulties and challenges which patients of PCOS face. I believe that the insight I have gotten into the accompanying complications of PCOS will help me in designing appropriate treatment plans which are all inclusive and supportive. I have also learned there are many choices for interventions which can be chosen depending on the patient's preference. This area requires a lot of research. Therefore, I will embark on learning more about PCOS so that I can serve my clients in the best way possible. References AHRQ. (2006, November). Diagnosis and Management of Polycystic Ovarian Syndrome. Retrieved October 23, 2009 from http://www.guideline.gov/summary/summary.aspxdoc_id=9438 Bartoszek M. P. (2009). PCOS: Recognizing polycystic ovary syndrome in the primary care setting. The Nurse Practitioner, 34(7), 22-29 Hill K. M, (2003). Update: The pathogenesis and treatment of PCOS. The Nurse Practitioner, 28(7), 8-23 Jackson M. L. (2005). Polycystic ovarian syndrome: What nurses need to know about this misunderstood disorder AWHONN Lifelines, 8(6), 512-518. King J. (2006). Polycystic Ovary Syndrome. J Midwifery Womens Health 5; 415- 422. Laven J.S.E., Imani B., Eijkemans M.J.C., & Fauser B.C.J.M.. (2002). New approach to polycystic ovary syndrome and other forms of anovulatory infertility. Obstetrical and Gynecological Survey, 57(11); 755-756. Schroeder B. M., (2003, April). Practice guidelines: ACOG releases guidelines on diagnosis and management of polycystic ovary syndrome. Retrieved October 23, 2009 from http://www.aafp.org/afp/20030401/practice.html Franks et al (2008). Follicle dynamics and anovulation in polycystic ovary syndrome. Hum Reprod Update , 14 (4):367-78. Epub 2008 May 22 Kidson, W. (2008). Polycystic ovary syndrome: a new direction in treatment. Med J Aust. (10):537-40. Read More