Tag Archives: adolescence

Promoting self-esteem in overweight and obese girls

Childhood obesity has reached epidemic rates in the United States, affecting all socioeconomic classes. At the same time, girls in this country are being bombarded with media images of the ideal female body, which is likely more slender and more muscular than their own. Preadolescence and adolescence are tumultuous periods of development for any girl, but they present a particular challenge for girls who are overweight or obese (OW/O) and who are at risk for experiencing a loss of self-esteem because their own shape and size do not match those of the media portrayed ideal. Providers of healthcare to girls in these age groups are in a position to identify those girls at high risk and guide them and their parents to available interventions and resources to help enhance their self-worth and possibly control their weight or lose weight in the process.

The American Academy of Pediatrics defines obesity as an excess percentage of body weight due to fat that puts persons at risk for many health problems.1 Among children aged 2-19 years, 31.7% are at or above the 85th percentile of body mass index (BMI)-for-age growth charts in weight, defining them as overweight or obese.2Nearly 17% of children in this age range are defined as obese—that is, they have BMIs greater than the 95th percentile. Among children and adolescents in the United States, OW/O prevalence is most concentratedin African American(AA) females, Hispanic males, and Native Americans.1-8

Statement of the problem

A direct link between OW/O and the development of health problems later in life, including cardiovascular, endocrine, pulmonary, renal, and orthopedic disorders, has been well established.1-8 In addition, OW/O can have adverse effects on children’s current physical and emotional health. In pre-adolescent and adolescent girls, for example, OW/O is strongly correlated with low self-esteem, which can lead to depression, anxiety, disordered eating, substance abuse, social isolation, and even suicidal ideation.4,9-11 Jasik and Lustig4 identified the ages of 9-12 years in girls as being key for development of excess adiposity. During this age period, many girls tend to be less active than when they were younger, and they tend to eat less healthy foods, causing the to gain weight. Higher levels of adiposity translate to higher systemic levels of estrogen and to an earlier onset of thelarche. A vicious cycle is set in motion:  Early breast development leads some girls to become self-conscious  and isolate themselves,  perhaps avoiding physical activities and eating extra food to soothe themselves, thereby aggravating the situation. To add to the complexity, this age period can be a challenging one in which to stage interventions because of these girls’ rapidly  changing cognitive and emotional development.

Factors that lower self-esteem or preserve it in girls

According to McClure et al,12 self-esteem represents one’s capacity to feel worthy of happiness. Self-esteem is an important determinant of adolescent mental health and development. One in three girls has a distorted interpretation of her appearance— either that she feels she is overweight when she is normal or that she feels she is normal when she is overweight.10 McClure et al12found that obesity was the most strongly correlated, modifiable risk factor for low self-esteem in pubescent girls.

Documented risk factors for low self-esteem include adolescence itself, female gender, low socioeconomic status, non-traditional family structure, having healthcare/special needs, exposure to school bullying, parental aggravation and family stress, elevated BMI, sedentary behavior, and higher rates of television viewing.13 During pre-puberty, a girl’s self esteem is not significantly tied to BMI; however, by age 13-14 years, the shift to a significant negative correlation exists.13

Low self-esteem does not appear to be a significant contributor to the development of obesity but, rather, a primary result of it.14 Factors that help preserve a girl’s self-esteem include physical activity, perception of good health, family communication and closeness, authoritative parenting, perceived teacher support, being part of a religious community, and feeling safe at school.12

Effects of maternal and societal factors

The initial and most powerful influence on a girl’s self-esteem is her mother.10As a girl enters late childhood/early adolescence, though, an increased desire to fuse with her peer group often takes precedence—with increased attention paid to the media. Pop culture bombards girls with “ideal” female images on television, in movies, in magazines, and on the Internet— girls of today have a much higher exposure to advertising than did previous generations. Girls are also exposed to mixed messages by the media; they are encouraged to love themselves the way they are, but they are also told that being OW/O is undesirable. Susceptibility of an adolescent to all these peer and pop culture pressures largely depends on both her mother’s values and actions and on the relationship she has with mother. For example, if a girl has a strong bond with a mother who has a good image of herself, she is less likely to be vulnerable to outside influences.15

Other factors that increase the risk for psychosocial complications of OW/O are race and ethnicity.15In general, AA girls do not experience as extreme downward spiral in self-esteem as do their Caucasian peers.14Identifying oneself with an ethnic group has been thought to be protective against low self-esteem.14 This theory is demonstrated in the study by McClure et al,12 which showed that even though female Hispanic and AA populations in the U.S. had higher rates of OW/O than their white counterparts, they had higher self-esteem and a more positive body image. AA girls also reported less desire for thinness. This difference ma have been due to a cultural acceptance by AAs, even an admiration, of “curvy” women. These findings warrant further investigation to determine whether the values of a particular ethnic group can overcome the negative self-esteem typically related to being OW/O.

Raising self-esteem in overweight/obese girls

Several studies have shown that programs with a primary focus on exercise as a means to increase self-esteem are detrimental to participants’ body image and have not produced a sustained, significant reduction in BMI.9,14,16 O’Dea9 theorized that the most effective model would focus primarily on building self-esteem itself, with secondary promotion of a healthy attitude toward diet and exercise. As the time period of greatest potential for weight gain coincides with psychological immaturity, the best course of action in girls ma be an early intervention to promote self-esteem and positive body image—starting just before the onset of thelarche, at age 8 or 9.8As these girls enter middle adolescence after menarche at age 12-14, the focus on nutrition and physical activity can gradually increase.11 At this point, the girls’ weight gains will have stabilized and they will have become more emotionally mature.9

According to Piaget’s developmental stages, young adolescents cannot grasp the concept that OW/O may lead to obesity related health problems during adulthood.17These individuals will not understand this concept until their late teenage years, when most of the psychological stigma of obesity has already occurred. This notion reinforces O’Dea’s theory that the most important concern to address in young adolescents is the adverse psychosocial effects of OW/O.9,17In other words, a therapeutic approach should focus on raising self-esteem, not on weight loss or exercise or the potential adverse health consequences of OW/O in the distant future.

Selected approaches

Available programs to address low self-esteem in OW/O girls vary in intensity, strategy, and primary focus. Nurse practitioners must ascertain each patient’s values and goals before recommending a specific approach for her. Options range from patient-centered, motivational interviewing to participation in community- wide programs.

Motivational interviewing— Use of this approach is based on the idea that OW/O is maintained by faulty cognitions and beliefs.18The motivational interviewer must identify, evaluate, and restructure the patient’s maladaptive cognitions and beliefs. In this approach, the NP identifies factors contributing to the patient’s poor self-image and works with both the patient and parents (as indicated) to create an environment to foster a positive body image. Success of this type of intervention depends heavily on a desire to change. Motivational interviewing has been shown to work with adults, but little research has been conducted with younger patients. This intervention may be beneficial for older adolescents, who tend to be more independent and self-motivated. In dealing with pre-adolescent to early adolescent patients, NPs might want to include the parents in the process. Motivational interviewing is a code-able intervention for primary care practitioners, does not require referral and outside expenses to the family,and is minimally invasive.

School-based programs— Many school programs address self-esteem and body image at around the fifth-grade level.19,20In a survey by Wilson,19 adolescents indicated that an ideal obesity prevention program at school would include their peers, take place during school hours, involve “fun” physical activities, and not require family members to participate directly—although they stated that they valued family support outside the program. The Nutrition and Enjoyable Activity for Teen Girls (NEAT Girls) study targeted girls in disadvantaged secondary schools who had been identified as being less active.20No parental involvement was included in the program. The researchers found that the program helped improve participants’ body image, although no significant reduction in BMI was noted between the intervention and control groups. The researchers theorized that parental involvement in the program might have had a significant impact on BMI while preserving the observed improvement in body image.

Female-specific extracurricular programs—Programs such as Girl Scouts of America, Girls on the Run, New Moves, the Memphis Girls Health Enrichment Multi-site Studies (GEMS), GoGirlGo, and Loozit have had a significant positive impact on adolescent participants’ self-esteem. 6-8,10,16,21 Compared with school-based programs, these programs are more tailored to participants’ needs and have a lower leader-to-participant ratio. The main emphasis of many of these programs is to address the issue of low self-esteem and poor body image, with a secondary emphasis in some groups on increased physical activity. Many studies have shown that noncompetitive physical activity improves feelings of self-worth; girls who participate in any kind of physical activity report feeling good about themselves, regardless of their weight.6,16,20 The curricula vary in content and length, for example, from weeklong summer camp (GoGirlGo) to longer, regular involvement through age 17, such as is available in Girl Scouts of America.7,10

According to Walker’s theory of intentionality, a program will have the best outcome if it is tailored to the essential needs and the inherent nature of a particular child.22 Even though the GoGirlGo program lasted only a week, participants stated that they felt empowered and had fun in the process.7 The authors of this report ascribed the program’s success to tailoring discussion topics to participants’ needs and to the mentor having a pre-existing relationship with the participants—establishing a level of trust prior to the camp.7

The GEMS programs were specific to AA girls aged 8-10 years, took place at local YMCAs, and were led by AA women, who were the adults most likely to foster a mother–daughter-type relationship with the girls.16Participants met weekly for 14 weeks and then monthly for the remainder of the 2 years. The intervention group’s goals were to follow a balanced diet, to decrease sedentary behaviors, and to increase physical activity. Psychological interventions included positive reinforcement, social support, and goal setting. The girls’ parents/guardians were encouraged to participate by increasing the availability of healthy foods at home. In the control group, the goal was to improve self-esteem and social efficacy; the family unit was not involved. Despite a rather intensive and well-planned study, the researchers found no significant prevention of weight gain among intervention participants versus the controls.

Family-driven and community-wide programs—NEAT girls, Girl Scouts, and the GEMS are family-oriented programs that rely on a child’s parents, who are often the ones preparing meals, to lead by example with positive attitudes regarding body image and increased physical activity. 10,16,20Perhaps the largest program is Let’s Move, a comprehensive national health initiative spearheaded by First Lady Michelle Obama5 Let’s Move addresses preventive measures for childhood obesity, starting with the mother’s prenatal care and progressing through encouragement of breastfeeding and childrearing practices (e.g., following a healthful diet, limiting exposure to digital media). This program does not specifically address interventions for the social stigma of obesity; rather, it aims to decrease the psychosocial side effects by eliminating the cause.

The U.S. Department of Health and Human Service Office on Women’s Health has constructed websites such as womenshealth.orgA that address body image in children.23This resource offers simple recommendations for parents/ guardians to promote both a healthy body image and a healthy relationship with food. Recommendations from this resource include maintaining open lines of communication, discussing media images, praising the child’s accomplishments, and avoiding negative comments regarding dieting and body shape.

In an effort to combat poor self-image in New York City, the organization New York City Girls placed posters of girls in areas of high visibility (e.g., subways, buses) proclaiming “I’m a Girl; I’m beautiful the way I am.”24The program aimed to counter the media bombardment of stick thin fashion models. The posters featured normal-appearing girls of all ethnic backgrounds. The second phase of the program included outreach, with several in-school and after-school programs as well as free fitness classes for further promotion of a healthful lifestyle.

Role of the nurse practitioner

Most NPs do not have adequate time during a typical well-patient visit to both identify low self-esteem in an OW/O girl and counsel her appropriately. NPs may need to schedule additional appointments with the patient and parents to focus discussions on self-esteem and body image or to make a referral to a mental health specialist when deemed necessary. NPs also need to consider the family’s social background, financial constraints, and goals. Above all, the most successful intervention is one in which the patient feels invested. By encouraging girls’ participation in early interventions, NPs are not only curbing the risk for future health problems, but also helping shape the ideas and attitudes of the future generation by creating strong role models and mothers.

Conclusion

The inverse relationship between BMI and self-esteem escalates as girls enter puberty. Although this phenomenon does not affect all ethnic groups equally, plummeting self-esteem is a widespread occurrence in this age group and, without intervention, may lead to problems such as substance abuse, depression, anxiety, social isolation, and suicidal ideation. Although low self-esteem in the presence of OW/O is common, a higher BMI is more socially acceptable in some cultural subgroups. Participation in motivational interviewing or in school or community programs can lead to improvements in self-esteem and body image. Preadolescent and adolescent girls may also develop a healthy attitude toward nutrition and physical activity. Reduction of BMI should not necessarily be emphasized in this age group unless a patient’s BMI poses immediate risks to her health; she may experience more psychological damage through intense intervention during this fragile period of social uncertainty. Because NP are often trusted primary points of contact within the healthcare field, they are in an ideal position to provide guidance to both the child and parent(s).

Meaghan Eddy is a family nurse practitioner at Cape Fear Center for Digestive Diseases in Fayetteville, North Carolina. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

References

1. American Academy of Pediatrics. Prevention and Treatment of Childhood Overweight and Obesity. 2013. http://www2.aap.org/obesity/about.html

2. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA. 2010;303(3):242-249.

3. Raj M, Kumar RK. Obesity in children & adolescents. Indian J Med Res. 2010;132(5):598-607.

4. Jasik CB, Lustig RH. Adolescent obesity and puberty: the “perfect storm.” Ann N Y Acad Sci. 2008;1135:265-279.

5. White House Task Force on Childhood Obesity. Solving the problem of childhood obesity within a generation. Report to the President. May 2010.

6. Neumark-Sztainer DR, Friend SE, Flaitum CF, et al. New Moves—preventing weight-related problems in adolescent girls: a group-randomized study. Am J Prev Med. 2010;39(5):421-432.

7. Warner S, Dixon, MA, Schuman C. Enhancing girls’ physical activity and self-image: a case study of the GoGirlGo program. Women Sport Phys Activ J. 2009;18(1):28-41.

8. Shrewsbury VA, O’Connor J, Steinbeck KS, et al. A randomized controlled trial of a community-based healthy lifestyle program for overweight and obese adolescents: the Loozit Study protocol. BMC Public Health. 2009;9(119):1-12.

9. O’Dea JA. Self-concept, self-esteem, and body weight in adolescent females: a three-year longitudinal study. J Health Psychol. 2006;11(4):599-611.

10. Girl Scout Research Institute. Weighing In: Helping Girls Be Healthy Today, Healthy Tomorrow: Research Review. New York, NY: Girl Scouts of the United States of America; 2004.

11. Rojas A, Storch EA. Psychological complications of obesity. Pediatr Ann. 2010;39(3):174-180.

12. McClure AC, Tanski SE, Kingsbury J, et al. Characteristics associated with low self-esteem among U.S. adolescents. Acad Pediatr. 2010;10(4):238-244.

13. Strauss RS. Childhood obesity and self-esteem.  Pediatrics. 2000;105(1):1-5.

14. Wang F, Veugelers PJ. Self-esteem and cognitive development in the era of the childhood obesity epidemic. Obes Rev. 2008;9(6):615-623.

15. Franklin J, Dener G, Steinbeck KS, et al. Obesity and risk of low self-esteem: a statewide survey of Australian children. Pediatrics. 2006;118(6):2481-2487.

16. Klesges RC, Obarzanek E, Kumanyika S, et. al. The Memphis Girls Health Enrichment Multi-site Studies (GEMS): an evaluation of the efficacy of a two-year obesity prevention intervention in African-American girls. Arch Pediatr Adolesc Med. 2010;164(11):1007-1014.

17. Piaget J. Inhelder B. Memory and Intelligence. London, UK: Routledge and Kegan Paul; 1973.

18. Walpole M, Dettmer E, Morrongiello B, et al. Motivational interviewing as an intervention to increase  adolescent self-efficacy and promote  weight-loss: methodology and design. BCM Public Health. 2011;11:1-9..

19. Wilson LF. Adolescents’ attitudes about obesity and what they want in obesity prevention programs. J School Nurs. 2007;23(299):229-238..

20. Luban DR, Morgan PJ, Dewar D, et al. The Nutrition and Enjoyable Activity for Teen Girls (NEAT girls) randomized controlled trial for adolescent girls from disadvantaged secondary schools: rationale, study protocol, and baseline results. BMC Public Health. 2010;10:1-14.

21. Girls on the Run website. 2014. http://www.girlsontherun.org/

22. Walker J. Intentional youth programs: taking theory to practice. New Dir Youth Dev. 2006;Winter(112):75-92.

23. U.S. Department of Health and Human Services Office on Women’s Health. Body Image and Your Kids. Last updated September 22, 2009. http://www.womenshealth.gov/bodyimage/kids/

24. Dockterman, E. Bloomberg v. Pop Culture: NYC’s Campaign to Boost Girls’ Self-esteem. October 2, 2013. http://healthland.time.com/2013/10/02/bloombergs-quixotic-campaign-to-boost-girls-self-esteem/?iid=sr-link1

Web resource

A. http://www.womenshealth.gov/bodyimage/kids/

 

It’s not just physical: The adverse psychosocial effects of polycystic ovary syndrome in adolescents

 

Management of polycystic ovary syndrome (PCOS) in adolescents entails dealing not only with the physical manifestations but also the troubling psychosocial effects related to these physical manifestations. The author conducted a literature review to ascertain the adverse psychosocial effects of PCOS in adolescents, as well as what nurse practitioners can do to mitigate these effects.

Key words: polycystic ovary syndrome, PCOS, adolescence, psychosocial effects

Polycystic ovary syndrome (PCOS) is a common endocrine disorder that affects 5%-10% of women and typically begins during adolescence.1-5 Common physical manifestations of PCOS—acne, obesity, hirsutism, and anovulation—can have adverse effects on adolescents’ self-image and mood.6,7 As a result, many of these girls may withdraw from their peers because of emotional distress or embarrassment. In addition to lowering self-esteem, obesity and the features of metabolic syndrome can increase the risk for future health complications,8,9 which in turn can provoke anxiety in adolescents who are aware of these risks. With all of these negative forces at play, adolescents with PCOS are also at increased risk for depression.10 In this article, the author shares the results of a literature search on the psychosocial concerns related to PCOS in adolescents and what nurse practitioners can do to address these concerns.

Literature review

The author searched the PubMed, Google Scholar, CINAHL, and JSTOR databases to find articles published between 2002 and 2013 that pertained to the adverse psychosocial effects of PCOS in adolescents, including management of these effects. Key words in the search were polycystic ovarian syndrome, PCOS, adolescence, teens, quality of life,
psychosocial, psychosocial issues, depression, anxiety, eating disorders, hirsutism, obesity, and metabolic syndrome. Other articles were found by hand-searching relevant studies cited in the articles initially found.

Articles met inclusion criteria if they covered psychosocial concerns related to PCOS in adolescents. Articles describing the physical effects of PCOS were included if they served to provide relevant background information. Studies focusing only on adults were excluded unless, again, they provided useful background information or they compared PCOS-related psychosocial concerns in adolescents versus adults.

Psychosocial concerns related to PCOS

Table 1 lists selected studies related to psychosocial concerns in adolescents with PCOS. These concerns include anxiety and depression,1,4 social interaction,11,12 body image,11 body weight,1,11,13,14 eating disorders,15 hirsutism,13 fertility,2,11,13 and decreased quality of life (QOL) related to sexual behavior.2,11 Health-related QOL (HQOL) scores in adolescents have been correlated with the level of PCOS symptomatology.14 A qualitative study showed that a PCOS diagnosis had an adverse impact on HQOL, with emotional and social functioning being more affected than physical health.11

Psychological problems

According to a report by Dowdy,10 adolescents with PCOS commonly use words such as nerd or freak to describe themselves; PCOS changes their bodies, which makes them feel different from other adolescents. A small study showed that adolescents with PCOS, compared with healthy adolescents, had higher anxiety scale scores.4 Dowdy10 reported that anxiety among adolescents with PCOS was related to their appearance, body-image concerns, and fear of future infertility.

Insulin resistance and increased levels of insulin in the bloodstream, which are common in patients with PCOS, have been thought to cause problems with mood.16 Insulin levels in the blood can affect serotonin levels in the brain and vice versa, so it is unclear whether insulin abnormalities initiate depressive symptoms or are the result of them.10

Body weight and body-image disturbances

Overweight/obesity (OW/O) and an elevated body mass index (BMI) are more common in adolescents with PCOS than in those without PCOS.8,14 Excess weight, among all the physical manifestations of PCOS in adolescents, has the greatest adverse impact on HQOL.17,18 One study showed that HQOL scores were inversely proportional to BMI values in teens with PCOS and high BMIs.14 PCOS-related OW/O has been linked to decreased academic achievement and lower income, even after controlling for socio­economic status and intelligence. In addition, many females with OW/O are the recipients of hurtful comments and actions from peers, family members, colleagues, strangers, and even some healthcare providers,19 which can lower their self-esteem.

Other body-image concerns in adolescents with PCOS involve male-pattern hair on the face and body and acne.10 Adolescents with hirsutism, versus those without the condition, have lower HQOL scores and self-esteem and an increased prevalence of anxiety disorders.20 Some adolescents report feeling that hirsutism has robbed them of their female identity.10 PCOS-related insulin resistance increases the risk for developing acanthosis nigricans (a brown to black, poorly defined, velvety hyperpigmentation of the skin),21 another body-image concern because of its physical visibility.

Femininity, fertility, and sexuality concerns

According to the dictionary, feminine means “having the qualities traditionally ascribed to women.”22 Menstruation is an important symbol of femininity; menarche and a normal menstrual cycle serve as rites of passage that prove that a female has the ability to reproduce.4 Adolescents with PCOS, versus their healthy peers, are more likely to have concerns about their future fertility because of their menstrual irregularities.2 Fear of potential infertility has an adverse impact on HQOL.

Adolescents with PCOS, compared with adolescents who do not have PCOS, may feel more self-conscious, less desirable, and less inclined to be outgoing with persons to whom they are attracted.10 A teen with PCOS may feel unsexy or unwomanly because her body has “let her down,” and she may have less sexual interest because of the many PCOS-related stressors with which she must cope.10Eating disorders
Results of a retrospective study showed that adolescents with menstrual disturbances were at greater risk of having an eating disorder.23 Adolescents with OW/O may develop unhealthy eating habits such as binge eating, purging, dieting, and using diuretics or laxatives to lose weight.24 Some adolescents with PCOS feel that their efforts to lose weight are not as successful as those of their peers who do not have PCOS.10

Screening for adverse psychosocial effects of PCOS

Screening for psychosocial concerns related to PCOS should start early in adolescence. Table 2 lists screening tests available for identification of psychosocial problems.25 An evaluation of the Polycystic Ovary Syndrome Questionnaire (PCOSQ) by Jones et al26 found this tool reliable for determining HQOL in women with PCOS. Validity of the tool could be improved with the addition of acne to the questionnaire because of acne’s identification as an important factor involved in HQOL. Although the PCOSQ was first developed based on research conducted on women,27 it has been used in adolescents to assess psychosocial concerns related to PCOS.13

NP role in managing psychosocial effects of PCOS

Goals of therapy for adolescents with PCOS—amelioration of psychological problems, weight loss, reduction of the manifestations of hyperandrogenism, and improvement in body image and self-esteem—are best achieved by a multidisciplinary team that includes NPs.3,4,28 The physical and psychosocial aspects of treatment go hand in hand. Meeting physical management goals (e.g., weight loss, reduction in hyperandrogenism manifestations) can lessen some of the troubling psychosocial effects, and enhancing self-esteem can motivate weight-loss efforts and perhaps even improve adherence to the pharmacotherapeutic regimen. One of the best ways that NPs can help is to supply adolescent patients with information about PCOS and its treatment that they can understand.

Mental health approaches

An open trial of weekly cognitive behavioral therapy sessions and family sessions has shown that these modalities may help treat both depressive symptoms and obesity in adolescents with PCOS.1 Participating in individual and family sessions can help patients develop positive methods of coping with PCOS and find constructive ways to manage their feelings. Support groups that meet in person or online can help motivate adolescents to make and maintain healthy lifestyle choices.29,30 NPs can recommend any or all of these psychotherapeutic approaches.

Lifestyle changes

Weight loss of 5%-10% may not only decrease cardiovascular risks and insulin resistance but also help improve HQOL.8,14,31 NPs should ascertain which weight-loss strategies have worked or not worked in the past, and identify any unsafe weight-loss strategies and eating patterns in which patients may be engaged.24,29 In these cases, NPs should offer patients safe alternatives for losing weight.24

A case–control study showed that, compared with controls, girls with PCOS engaged in physical activities less often (if they did exercise, they did so with less frequency and intensity), and they were less likely to be aware of the beneficial effects of exercise on their health.32 NPs should encourage patients to exercise regularly, which may help increase their self-esteem and overall health.13,19 Yoga may be even more beneficial; results of a recent randomized, controlled trial indicated that yoga effectuated a significantly greater increase in HQOL than did traditional exercise.33

With regard to approaches to counter the effects of hyperandrogenism, unwanted hair can be removed temporarily via shaving, waxing, and/or plucking (which unfortunately may cause other unwanted effects such as irritation, scarring, or folliculitis). Laser treatments can provide more permanent results, but many treatments may be needed and the treatments may be costly.34

Medications

Oral contraceptives (OCs) regulate menstrual cycles and treat hirsutism and acne.28,34 Insulin sensitizers such as metformin can be used to treat underlying insulin resistance.34,35 However, a randomized, placebo-controlled trial showed that adding metformin to a regimen of lifestyle changes and OC use did not lead to a significant improvement in HQOL.13 Anti-androgens such as spironolactone can help manage the hyperandrogenism effects.34,36 Statins are first-line treatments for lowering low-density lipoprotein cholesterol levels.37 Antidepressants and anxiolytics can be used to treat psychiatric disorders related to PCOS; in these cases, NPs may want to consult with a mental health specialist.

Further research

An important topic for future study is the efficacy of implementing a HQOL survey at every primary care visit for adolescents with PCOS. The purpose of this survey would be to assess for psychosocial co-morbidities common in individuals with PCOS. The studies should ascertain whether implementing such a screening would make providers more aware of the adverse psychosocial effects of PCOS, help identify psychosocial symptoms, and facilitate more comprehensive treatment when needed. Additional research should determine the outcomes of losing weight, how other PCOS-specific interventions affect overall HQOL, how to address infertility concerns, and how primary care practitioners can best manage adolescents holistically to help improve HQOL. More research is needed regarding how providers should teach and communicate with adolescents with PCOS.

Conclusion

Polycystic ovary syndrome in adolescents involves a myriad of physical manifestations that can compromise psychosocial health. These adverse psychosocial effects may have a major impact on HQOL. Early diagnosis of PCOS, screening for adverse psychosocial effects, and treatment that reduces physical manifestations of PCOS are important. Lack of attention to these problems can force adolescents to endure adverse psychosocial effects that can lead to further unhealthy behaviors. NPs have an opportunity to educate adolescents about the disease process of PCOS and to implement strategies to treat these patients’ physical and psychosocial problems to improve their HQOL for a lifetime.

Joyce S. Lee is a certified pediatric nurse practitioner who graduated from Columbia University School of Nursing in New York, New York. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

Acknowledgment

The author thanks Rita Marie John, DNP, EdD, CPNP-PC, DCC, for her help, editing, and counsel during the preparation and writing of this article.

References
1. Rofey DL, Szigethy EM, Noll RB, et al. Cognitive–behavioral therapy for physical and emotional disturbances in adolescents with polycystic ovary syndrome: a pilot study. J Pediatr Psychol. 2009;34(2):156-163.

2. Trent ME, Rich M, Austin SB, Gordon CM. Fertility concerns and sexual behavior in adolescent girls with polycystic ovary syndrome: implications for quality of life. J Pediatr Adolesc Gynecol. 2003;16(1):33-37.

3. Bekx MT, Connor EC, Allen DB. Characteristics of adolescents presenting to a multidisciplinary clinic for polycystic ovarian syndrome. J Pediatr Adolesc Gynecol. 2010;23(1):7-10.

4. Laggari V, Diareme S, Christogiorgos S, et al. Anxiety and depression in adolescents with polycystic ovary syndrome and Mayer-Rokitansky-Küster-Hauser syndrome. J Psychosom Obstet Gynaecol. 2009;30(2):83-88.

5. Rachmiel M, Kives S, Atenafu E, Hamilton J. Primary amenorrhea as a manifestation of polycystic ovarian syndrome in adolescents: a unique subgroup? Arch Pediatr Adolesc Med. 2008;162(6):521-525.

6. Perrin JM, Gnanasekaran S, Delahaye J. Psychological aspects of chronic health conditions. Pediatr Rev. 2012;33(3):99-109.

7. Leventhal H, Leventhal EA, Contrada RJ. Self-regulation, health, and behavior: a perceptual-cognitive approach. Psychol Health. 1998; 13(4):717-733.

8. Coviello AD, Legro RS, Dunaif A. Adolescent girls with polycystic ovary syndrome have an increased risk of the metabolic syndrome associated with increasing androgen levels independent of obesity and insulin resistance. J Clin Endocrinol Metab. 2006;91(2):492-497.

9. Snyder BS. Polycystic ovary syndrome (PCOS) in the adolescent patient: recommendations for practice. Pediatr Nurs. 2004;31(5):416-422.

10. Dowdy D. Emotional needs of teens with polycystic ovary syndrome. J Pediatr Nurs. 2012;27(1):55-64.

11. Jones GL, Hall JM, Lashen HL, et al. Health-related quality of life among adolescents with polycystic ovary syndrome. J Obstet Gynecol Neonatal Nurs. 2011;40(5):577-588.

12. Trent ME, Rich M, Austin SB, Gordon CM. Quality of life in adolescent girls with polycystic ovary syndrome. Arch Pediatr Adolesc Med. 2002;156(6):556-560.

13. Harris-Glocker M, Davidson K, Kochman L, et al. Improvement in quality-of-life questionnaire measures in obese adolescent females with polycystic ovary syndrome treated with lifestyle changes and oral contraceptives, with or without metformin. Fertil Steril. 2010;93(3):1016-1019.

14. Trent M, Austin SB, Rich M, Gordon CM. Overweight status of adolescent girls with polycystic ovary syndrome: body mass index as mediator of quality of life. Ambul Pediatr. 2005;5(2):107-111.

15. Wiksten-Almstromer M, Linden-Hirschberg A, Hagenfeldt K. Menstrual disorders and associated factors among adolescent girls visiting a youth clinic. Acta Obstet Gynecol Scand. 2007;86(1):65-72.

16. Weiner CL, Primeau M, Ehrmann DA. Androgens and mood dysfunction in women: comparison of women with polycystic ovarian syndrome to healthy controls. Psychosom Med. 2004;66(3):356-362.

17. Adali E, Yildizhan R, Kurdoglu M, et al. The relationship between clinico-biochemical characteristics and psychiatric distress in young women with polycystic ovary syndrome. J Int Med Res. 2008;36(6):1188-1196.

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