Tag Archives: PCOS

Group visits for management of patients with PCOS: A pilot study

Polycystic ovary syndrome (PCOS), a complex disorder affecting reproductive-aged females, presents challenges for equipping patients with knowledge and tools to manage their condition. The authors examined the feasibility of conducting a group visit program in a college health setting for women with PCOS, and ascertained whether these visits might effectuate favorable changes in these women’s self efficacy and health practices. Continue reading »

The role of anti-Müllerian hormone in diagnosing and managing PCOS

Because multiple subjective factors can cloud the diagnosis of polycystic ovary syndrome, anti-Müllerian hormone (AMH) level, an objective value, has been studied as a potential supplement to polycystic ovarian morphology in diagnosing and managing the syndrome. The author reviews recent evidence demonstrating the role of AMH in this regard.

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder affecting females of reproductive age and the leading cause of anovulatory infertility.1 Lack of correct diagnosis and management of PCOS can lead to reproductive challenges (e.g., infertility, early miscarriage, gestational diabetes), metabolic disorders (e.g., type 2 diabetes mellitus), or cardiovascular disorders (e.g., hypertension, dyslipidemia).2 Advanced practice nurses (APNs) are tasked with correctly diagnosing and managing PCOS in order to prevent these associated morbidities, which can compromise quality of life.

According to the Rotterdam criteria for diagnosing PCOS, at least two of these three elements must be met: clinical and/or biochemical hyperandrogenism, ovulatory dysfunction, and polycystic ovarian (PCO) morphology.3 PCO morphology has been defined as the presence of more than 12 follicles measuring <10 mm and/or an increased ovarian volume (>10 mL) without a cyst or dominant follicle in either ovary.3 According to Lujan et al,the inclusion of ultrasonographic(USG) evidence of polycystic ovaries as a diagnostic marker has substantially broadened the phenotypic spectrum of PCOS, yet much debate surrounds the validity of these newly identified milder variants of the syndrome.

In light of such concerns, the use of anti-Müllerian hormone (AMH) level as a more reliable marker for PCO morphology than follicle size and number on USG has been investigated in recent studies. Results of these studies indicate a consistent relationship between AMH level and USG estimates of antral follicle count (AFC) and ovarian volume.5-7 Research has shown that serum AMH levels are significantly increased in women with PCOS versus those without PCOS.1,5,6 Although further research is needed, serum AMH measurement may prove to be a useful tool for APNs in diagnosing phenotypes of PCOS that satisfy the Rotterdam criteria.

Development of polycystic ovaries

To appreciate the role of AMH in PCOS, APNs must understand the two-cell, two-gonadotropin model of estrogen synthesis, as well as how disruption of this process may lead to development of polycystic ovaries.8 This model describes the working hormonal balance between the outer theca cell layer and the inner granulosa cell layer in the ovarian follicle; the former cell layer secretes androgens and the latter, estrogens. When luteinizing hormone (LH) stimulates cholesterol in the theca cells, androgen is released. Upon exposure to follicle- stimulating hormone (FSH), androgen is converted into estrogens in the granulosa cells.

When this two-cell, two-gonadotropin process is disrupted, a hormonal imbalance ensues, such that circulating LH concentrations exceed FSH concentrations. Ovarian androgen production increases, resulting in serum androgen excess. The increased androgen stimulates the growth of smaller antral follicles yet inhibits later follicular development and maturation.9 Such arrest in follicle growth can lead to PCO morphology. These smaller antral follicles cannot be released via ovulation or subsequent luteinization.

Function of AMH

Anti-Müllerian hormone has been identified as the hormone secreted by sertoli cells in the male testes during embryonic sexual differentiation.10,11 In females, AMH is a glycoprotein produced by the granulosa cells of antral follicles. The highest level of AMH secretion is evident in antral follicles ≥4 mm in diameter and continues to be expressed until the differentiation stage (8-9 mm), in which FSH selects a dominant follicle for future ovulation.12 Evidence suggests that AMH inhibits follicular growth by inhibiting estrogen secretion in the antral follicles prior to FSH selection. As a result, estrogen and AMH have an inverse relationship; AMH exerts a regulatory function by ensuring that not all primordial follicles are released at once.13

Levels of AMH fluctuate only minimally throughout the menstrual cycle, and not to the same extent as FSH and other pituitary and ovarian hormone levels. AMH levels are noted to be lower in women during pregnancy. These levels decline steadily after age 25 and are undetectable after menopause.14 Information on whether AMH levels are affected by the use of hormonal contraception is conflicting.15,16

Current uses of AMH measurement

Because AMH is secreted by antral follicles prior to the differentiation stage, it is most often used as a clinical biomarker for ovarian reserve in infertility diagnosis and management and in detection of premature ovarian aging.17,18 AMH is an excellent predictor of ovarian responsiveness in ovulation induction and in vitro fertilization, as well as a useful tool to help predict ovarian hyper-stimulation, oocyte yield, and ovarian function pathology in an infertility setting.13,19-21 In addition, AMH may be useful in assessing the need for fertility-preservation strategies and detecting post-chemotherapy or surgical damage to the ovarian reserve.13,22

Use of AMH measurement in diagnosing PCOS

A thorough history, physical examination, and select laboratory tests are important elements in determining the presence of androgen excess and ovulatory dysfunction— two of the three Rotterdam criteria used for PCOS diagnosis.As described earlier, polycystic ovaries, the third criterion, are identified via USG by the presence of more than 12 antral follicles measuring <10 mm and/or an increased ovarian volume (>10 mL) without a cyst or dominant follicle in either ovary. However, USG has potential shortcomings, including sensitivity of the machine, less-than-perfect operator technique, and subjective interpretation of the findings. In addition, transvaginal USG imaging may be inappropriate or less accurate in certain patient populations (e.g., obese persons or those who have never been sexually active).3,4

Determination of a patient’s AMH level, an objective laboratory value, may help minimize the subjectivity of the USG findings. In several studies, a serum AMH level >18 pmol/L, when compared with USG, provided better sensitivity and specificity for PCO morphology in women who met Rotterdam criteria for PCOS.5,23,24 Other studies have been performed to determine the optimal cutoff for the AMH value:

• A meta-analysis of data extracted up until January 2013 showed that an AMH value of 33.6 pmol/L was 82.8% sensitive and 79.4% specific in diagnosing PCOS in symptomatic women.25

• In 2013, a study of 60 infertile women with PCOS showed that an AMH value of 23.8 pmol/L was 98% sensitive and 93% specific in diagnosing PCOS.26

• Another 2013 study, conducted on 59 infertile women, 37 of whom had characteristics of PCOS, showed that an AMH level of 33 pmol/L was 95% sensitive and 95% specific in diagnosing PCOS.1

• In a study conducted in 2011 on 240 patients, an AMH value of 35.7 pmol/L was 92% sensitive and 97% specific in identifying PCO morphology.5

These findings notwithstanding, a standard AMH level for diagnosing PCOS has yet to be established. Furthermore, several limitations preclude AMH from becoming widely utilized for PCOS diagnosis. First, lack of a universally accepted method and assay to measure AMH prevents it from becoming an established diagnostic tool for PCOS.27 Second, because AMH declines with advancing age, the threshold for PCOS diagnosis may need to be modified through the life span.28 Third, research involving the use of AMH level to diagnose PCOS in adolescents is limited.27, 29, 30 Finally, the 2013 Endocrine Society guidelines do not include a recommendation for using AMH measurement as a routine diagnostic tool for PCOS.3

Although AMH level and oligoanovulation are correlated, AMH has not been proven to be an acceptable indicator of ovulatory dysfunction or hyper androgenism.23 Hence, AMH level, if used, should be combined with other laboratory or clinical measures of hyperandrogenism and/or ovulatory dysfunction to maximize its diagnostic sensitivity and specificity. Furthermore, the role of AMH is unclear in diagnosing subtypes of PCOS, especially those that do not present with classic symptoms. Studies have suggested that ovulatory PCOS phenotypes, compared with anovulatory types, are associated with differing levels of serum AMH.31

Use of AMH measurement in gauging response to PCOS treatment

The goal of PCOS treatment is managing symptoms and minimizing co-morbidities. Proper management can reduce the risk for certain gynecologic cancers and infertility. Management should be both individualized and holistic and may include weight reduction through lifestyle modification and use of hormonal contraceptives, metformin, and gonadotropin/estrogen modulators. Current methods of monitoring the effectiveness of these management modalities include patient-reported symptom improvement and menstrual regulation, physical examination for reduction in signs of hyperandrogenism, measurement of insulin and glucose levels, and achievement of successful pregnancy outcome.

Many recent studies have been conducted to assess the relationship between various PCOS management modalities and patients’ AMH levels; the Table (pp 3839) lists a representative sample of such studies.15, 16, 32-37 Additional research is needed to demonstrate the utility of these AMH measurements, especially as compared with current methods (e.g., clinical signs, patient-reported symptoms, other lab test findings) in making decisions about and evaluating the effectiveness of treatment.

Discussion

Based on what is known at this time, use of the AMH level is not recommended as a replacement for any component of the Rotterdam criteria in terms of diagnosing PCOS or as an assessment tool for monitoring the success of existing management modalities. However, AMH may be a useful supplemental tool for APNs because it is an objective and more reliable marker for diagnosing PCO morphology. Indeed, AMH can help providers who are not trained in pelvic or transvaginal USG in diagnosing PCOS. Although more research is needed in this area, AMH may be another component of PCOS diagnosis and management in the future.

Conclusion

Although the Rotterdam criteria are the gold standard for diagnosing PCOS, concern regarding the subjective nature of polycystic morphology on USG has been voiced over the years. An AMH value >35 pmol/L may have the highest sensitivity and specificity in terms of indicating polycystic ovaries. However, data supporting the use of AMH levels to make treatment choices or to monitor the effectiveness of such treatments in females with PCOS are inconclusive. At the very least, findings from studies assessing changes in AMH levels related to specific treatment modalities may offer more insight into the pathophysiology of this complex endocrine disorder.

Tiffany A. Tseng is a women’s health nurse practitioner at HRC Fertility in Pasadena, California. 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. Casadei L, Madrigale A, Puca F, et al. The role of serum anti-Müllerian hormone (AMH) in the hormonal diagnosis of polycystic ovary syndrome. Gynecol Endocrinol. 2013;29(6):545-550.

2. Jayasena CN, Franks S. The management of patients with polycystic ovary syndrome. Nat Rev Endocrinol. 2014;10(10):624-636.

3. Legro RS, Arslanian SA, Ehrmann DA, et al. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2013;98(12):4565-4592.

4. Lujan ME, Chizen DR, Pierson RA. Diagnostic criteria for polycystic ovary syndrome: pitfalls and controversies. J Obstet Gynaecol Can2008;30(8):671-679.

5. Dewailly D, Gronier H, Poncelet E, et al. Diagnosis of polycystic ovary syndrome (PCOS): revisiting the threshold values of follicle count on ultrasound and of the serum AMH level for the definition of polycystic ovaries. Hum Reprod. 2011;26(11):3123-3129.

6. Pigny P, Merlen E, Robert Y, et al. Elevated serum level of anti-mullerian hormone in patients with polycystic ovary syndrome: relationship to the ovarian follicle excess and to the follicular arrest. J Clin Endocrinol Metab. 2003;88(12):5957-5962.

7. Piltonen T, Morin-Papunen L, Koivunen R, et al. Serum anti-Müllerian hormone levels remain high until late reproductive age and decrease during metformin therapy in women with polycystic ovary syndrome. Hum Reprod. 2005;20(7):1820-1826.

8. Hillier SG, Whitelaw PF, Smyth CD. Follicular oestrogen synthesis: the ‘two-cell, two-gonadotrophin’ model revisited. Mol Cell Endocrinol. 1994; 100(1-2):51-54.

9. Vendola KA, Zhou J, Adesanya OO, et al. Androgens stimulate early stages of follicular growth in the primate ovary. J Clin Invest. 1998; 101(12):2622-2629.

10. La Marca A, Stabile G, Artenisio AC, Volpe A. Serum anti-Mullerian hormone throughout the human menstrual cycle. Hum Reprod. 2006; 21(12):3103-3107.

11. Vigier B, Picard JY, Tran D, et al. Production of anti-Müllerian hormone: another homology between Sertoli and granulosa cells. Endocrinology. 1984;114(4):1315-1320.

12. Weenen C, Laven JS, Von Bergh AR, et al. Anti-Müllerian hormone expression pattern in the human ovary: potential implications for initial and cyclic follicle recruitment. Mol Hum Reprod. 2004;10(2):77-83.

13. Dewailly D, Andersen CY, Balen A, et al. The physiology and clinical utility of anti-Müllerian hormone in women. Hum Reprod Update. 2014;20(3):370-385.

14. Leader B, Baker V. Maximizing the clinical utility of antimullerian hormone testing in women’s health. Curr Opin Obstet Gynecol. 2014;26(4):226-236.

15. Somunkiran A, Tavuz T, Yucel O, Ozdemir I. Anti-Müllerian hormone levels during hormonal contraception in women with polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol. 2007;134(2):196-201.

16. Panidis D, Georgopoulos NA, Piouka A, et al. The impact of oral contraceptives and metformin on anti-Müllerian hormone serum levels in women with polycystic ovary syndrome and biochemical hyperandrogenemia. Gynecol Endocrinol. 2011; 27(8):587-592.

17. van Rooij IA, Broekmans FJ, Scheffer GJ, et al. Serum antimullerian hormone levels best reflect the reproductive decline with age in normal women with proven fertility: a longitudinal study. Fertil Steril. 2005;83(4):979-987.

18. Lie Fong S, Schipper I, Valkenburg O, et al. The role of anti-Müllerian hormone in the classification of anovulatory infertility. Eur J Obstet Gynecol Reprod Biol. 2015;186:75-79.

19. van Rooij IA, Broekmans FJ, te Velde ER, et al. Serum anti-Müllerian hormone levels: a novel measure of ovarian reserve. Hum Reprod. 2002;17(12):3065-3071.

20. Amer SA, Mahran A, Abdelmaged A, et al. The influence of circulating anti-Müllerian hormone on ovarian responsiveness to ovulation induction with gonadotrophins in women with polycystic ovarian syndrome: a pilot study. Reprod Biol Endocrinol. 2013;11:115.

21. Dąbkowska-Huć A, Lemm M, Sikora J, et al. Anti-Müllerian hormone dynamics during ovulation induction treatment with recombinant follicle-stimulating hormone in women with polycystic ovary syndrome. Endokrynol Pol. 2013; 64(3):203-207.

22. Dunlop CE, Anderson RA. Uses of anti-Müllerian hormone (AMH) measurement before and after cancer treatment in women. Maturitas. 2015;80(3):245-250.

23. Sahmay S, Aydin Y, Oncul M, Senturk LM. Diagnosis of polycystic ovary syndrome: AMH in combination with clinical symptoms. J Assist Reprod Genet. 2014;31(2):213-220.

24. Lauritsen MP, Bentzen JG, Pinborg A, et al. The prevalence of polycystic ovary syndrome in a normal population according to the Rotterdam criteria versus revised criteria including anti-Mullerian hormone. Hum Reprod. 2014;29(4):791-801.

25. Iliodromiti S, Kelsey TW, Anderson RA, Nelson SM. Can anti-Mullerian hormone predict the diagnosis of polycystic ovary syndrome? A systematic review and meta-analysis of extracted data. J Clin Endocrinol Metab. 2013;98(8):3332-3340.

26. Saikumar P, Selvi VK, Prabhu K, et al. Anti mullerian hormone: a potential marker for recruited non growing follicle of ovarian pool in women with polycystic ovarian syndrome. Clin Diagn Res. 2013;7(9):1866-1869.

27. Dewailly D, Lujan ME, Carmina E, et al. Definition and significance of polycystic ovarian morphology: a task force report from the Androgen Excess and Polycystic Ovary Syndrome Society. Hum Reprod Update. 2014;20(3):334-352.

28. Zec I, Tislaric-Medenjak D, Megla ZB, Kucak I. Anti-Müllerian hormone: a unique biochemical marker of gonadal development and fertility in humans. Biochem Med (Zagreb). 2011;21(3):219-230.

29. Cengiz H, Ekin M, Dagdeviren H, et al. Comparison of serum anti-Müllerian hormone levels in normal weight and overweight-obese adolescent patients with polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol. 2014;180:46-50.

30. Pinola P, Morin-Papunen LC, Bloigu A, et al. Anti-Müllerian hormone: correlation with testosterone and oligo- or amenorrhoea in female adolescence in a population-based cohort study. Hum Reprod. 2014; 29(10):2317-2325.

31. Alebić MS, Stojanović N, Duhamel A, Dewailly D. The phenotypic diversity in per-follicle anti-Müllerian hormone production in polycystic ovary syndrome. Hum Reprod. 2015;30(8):1927-1933.

32. Neagu M, Cristescu C. Anti-Müllerian hormone—a prognostic marker for metformin therapy efficiency in the treatment of women with infertility and polycystic ovary syndrome. Med Life. 2012;5(4):462-464.

33. Tomova A, Deepinder F, Robeva R, et al. Anti-Müllerian hormone in women with polycystic ovary syndrome before and after therapy with metformin. Horm Metab Res. 2011;43(10):723-727.

34. Kriseman M, Mills C, Kovanci E, et al. Antimullerian hormone levels are inversely associated with body mass index (BMI) in women with polycystic ovary syndrome. J Assist Reprod Genet. 2015;32(9):1313-1316.

35. Piouka A, Farmakiotis D, Katsikis I, et al. Anti-Mullerian hormone levels reflect severity of PCOS but are negatively influenced by obesity: relationship with increased luteinizing hormone levels. Am J Physiol Endocrinol Metab. 2009;296(2):E238-E243.

36. Thomson RL, Buckley JD, Moran LJ, et al. The effect of weight loss on anti-Müllerian hormone levels in overweight and obese women with polycystic ovary syndrome and reproductive impairment. Hum Reprod. 2009;24(8):1976-1981.

37. Mahran A, Abdelmaged A, El-Adawy AR, et al. The predictive value of circulating anti-Müllerian hormone in women with polycystic ovarian syndrome receiving clomiphene citrate: a prospective observational study. J Clin Endocrinol Metab.

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
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