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Polycystic ovary syndrome evidence based practice essay

Pathophysiology, diagnosis, and management of polycystic ovary syndrome Introduction Polycystic ovary syndrome PCOS was first reported in by Stein and Leventhal who described seven women dealing with amenorrhea, hirsutism, and enlarged ovaries with multiple cysts Stein and Leventhal, This syndrome was given the name Stein—Leventhal syndrome after these two physicians for sometime. In the s, however, the term polycystic ovary syndrome PCOS was first introduced and gradually started to replace its former name.

It is now recognized as a common complex heterogeneous endocrine disorder in reproductive-age women associated with reproductive, metabolic and psychological features. This syndrome is primarily characterized by irregular menses, hyperandrogenism, and polycystic ovaries Azziz et al.

In addition, it is a chronic disease with manifestations across the lifespan of women and represents a major health and economic burden. Therefore, the aim of this research is to review this subject in depth taking in consideration the pathogenesis, clinical features, diagnosis, complications and management.

Epidemiology Polycystic ovary syndrome is the most common endocrine disease in women of child-bearing age.

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Recently, there has been variations of the polycystic ovary syndrome evidence based practice essay of PCOS depending on the diagnostic criteria used. Pathophysiology Normally, females of reproductive age experience cycles of hormonal activity that repeat at about one-month intervals. The term menstruation refers to the periodic shedding of the uterine lining.

Averagely, the menstrual cycle takes about 28 days and occurs in phases: There are four major hormones chemicals that stimulate or regulate the activity of cells or organs involved in the menstrual cycle: As well as triggering an increase in the production of the female hormone estrogen.

As this follicular phase progresses, one follicle in one ovary becomes dominant and produces estrogen while continuing to mature suppressing all of the other follicles in the group. The second phase, or ovulation, begins on the 14th day after the follicular phase started. The rise in estrogen from the dominant follicle triggers a surge in the amount of luteinizing hormone that is produced, which causes the dominant follicle to release its egg from the ovary into the fallopian tube.

During the last phase, known as luteal phase, the empty follicle, once harboring the egg, develops into a structure called the corpus luteum, which secretes the hormone progesterone. Progesterone prepares the uterus for the implantation of a fertilized egg.

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If the egg is not fertilized, it passes through the uterus, and the lining covering it breaks down and sheds, and the next menstrual period begins. The pathophysiology of PCOS results from a primary defect in the pituitary function, as well as, defects in insulin secretion and action, and ovarian function. Raised LH levels will lead to an increase of androgen production and secretion by ovarian theca cells.

The increase in LH seems to be the result polycystic ovary syndrome evidence based practice essay abnormal sex steroid feedback rather than the cause of androgen excess.

Moreover, use of antiandrogen treatment lowers the elevated LH pulse frequency of PCOS to a normal level, suggesting that androgen excess interferes with the hypothalamic inhibitory feedback of female hormones, principally progesterone Rosenfield and Bordini, In spite of this, about half of the patients with PCOS, especially obese patient, do not have elevated LH levels or abnormal gonadotropin response to GnRH agonist testing.

Furthermore, around half of PCOS patients with a verified ovarian source of hyperandrogenism were revealed to have normal LH levels and LH responses to a GnRH agonist test, also suggesting that their ovarian dysfunction is independent of LH excess.

Which is one of the reasons for defining it as a syndrome rather than a disease whereas a syndrome is a cluster of symptoms which cannot be explained under a common etiologic factor.

However, the individual susceptibility probably depends on prenatal androgen exposure, genetic factors, ethnic origin and environmental risk factors Zhang et al. The interaction of a number of genetic and environmental factors determine the heterogeneous, clinical, and biochemical phenotype, which is why PCOS is described as an oligogenic disorder Barber and Franks, Nonetheless, based on the aggregation of cases in families, PCOS is considered a heritable disorder and resembles an autosomal dominant pattern Diamanti-Kandarakis, Kandarakis and Legro, Hence, a family history of PCOS is considered a risk factor.

Environmental risk factors, such as obesity, seem to amplify genetic predispositions Zhang et al. These environmental factors implicated in PCOS e. The reproductive and metabolic features of PCOS are sometimes reversible with lifestyle modifications such as weight loss and exercise Shannon and Wang, These considerably distinctive features, displaying a varying degree of expression in each individual, emphasize the phenotypic variability of PCOS, and is in fact another reason why it is considered as a syndrome.

Women with PCOS may present with an array of serious clinical implications including reproductive manifestations hirsutism, infertility and pregnancy complications Boomsma et al. Generally, PCOS is a chronic condition that usually begins in adolescence then transitions to include infertility and increase metabolic complications over time. Reproductive features of PCOS Hyperandrogenism Clinical hyperandrogenism primarily includes hirsutism, acne and male pattern alopecia.

Hirsutism is defined in females as male type terminal hair growth and distribution Norman et al. Studies have shown that androgen levels are elevated in woman with acne, although the severity of acne has not been positively correlated with any particular hormone with the exception of the adrenal androgen, dehydroepianandrosterone sulfate DHEA-S Karrer-Voegeli et al.

Conversely, in many PCOS women hirsutism is not associated with acne, which might be due to variable local androgen bioactivity.

  1. Studies have shown that androgen levels are elevated in woman with acne, although the severity of acne has not been positively correlated with any particular hormone with the exception of the adrenal androgen, dehydroepianandrosterone sulfate DHEA-S Karrer-Voegeli et al.
  2. Nonetheless, based on the aggregation of cases in families, PCOS is considered a heritable disorder and resembles an autosomal dominant pattern Diamanti-Kandarakis, Kandarakis and Legro,
  3. The other challenge for patients is dealing with psychosocial impact of mood disturbance and reduced psychological well-being on motivation and the ability to implement and sustain successful lifestyle changes that are critical in this condition.
  4. Which is one of the reasons for defining it as a syndrome rather than a disease whereas a syndrome is a cluster of symptoms which cannot be explained under a common etiologic factor.

This enzyme has two isoforms: This explains the different clinical manifestations seen in hyperandrogenic women when the degree of hirsutism is not well-matched with the severity of the acne Archer and Chang, Male pattern hair loss androgenic alopecia is a genetically determined disorder characterized by the gradual conversion of terminal hairs into indeterminate, and finally into vellus hairs.

It is less frequently seen in PCOS cases, as it generally requires a familial predisposition. Oligomenorrhoea occurs usually in adolescence, with onset later in life often associated with weight gain Brassard, AinMelk and Baillargeon, Furthermore, these ovarian abnormalities have been thought to increase the risk for infertility. Infertility was one of the main symptoms originally attributed to PCOS according to the understanding of Stein and Leventhal Stein and Leventhal, On the other hand, there is currently a debate on the legitimacy of the relationship between PCOS and infertility.

Psychological features of PCOS There are very few studies to date that have explored the psychological aspect of PCOS, since most research has focused primarily on the biological and physiological features of the syndrome. However, these psychological features do, in fact, compromise quality of life and adversely impact on mood and psychological well-being. Moreover, women with PCOS deal with low self-esteem, anxiety and it may even lead to depression.

The other challenge for patients is dealing with psychosocial impact of mood disturbance and reduced psychological well-being on motivation and the ability to implement and sustain successful lifestyle changes that are critical in this condition. Recent literature has found that greater adiposity was described in more severe reproductive phenotypes characterized by hyperandrogenism associated with chronic anovulation ,49 and lean women had polycystic ovary syndrome evidence based practice essay reproductive phenotype compared with those who were overweight;97 so obesity can exacerbate the PCOS reproductive phenotypes.

Insulin resistance Insulin is a hormone produced by the pancreas to control the amount of sugar in the blood. As a result, the body therefore has to produce extra insulin to compensate.

High levels of insulin stimulate the ovaries to produce too much testosterone, which interferes with the development of the follicles i. Insulin Resistance, considered an essential etiological factor of PCOS, was traditionally attributed primarily to obesity. Although the demonstration of insulin resistance is not required to make the diagnosis of PCOS, it is clear that hyperinsulinemic insulin resistance plays a prominent role in PCOS.

Although there are several definitions of what is required to be polycystic ovary syndrome evidence based practice essay with metabolic syndrome, most health care professionals use criteria from the National Heart, Lung, and Blood Institute NHLBI and the American Heart Association. Consistent with the increased prevalence of insulin resistance, metabolic syndrome is also more common in women with PCOS. The majority of these occur in the PCOS woman. It is estimated that the prevalence of each risk factor is approximately double for women with PCOS when compared with controls, while it is 1.

  • Male pattern hair loss androgenic alopecia is a genetically determined disorder characterized by the gradual conversion of terminal hairs into indeterminate, and finally into vellus hairs;
  • The potential mechanisms which could promote the onset of neoplastic diseases in these women, particularly endometrial cancer, include the chronic anovulatory state, resulting in an unopposed estrogen action, associated with hyperandrogenism;
  • As this follicular phase progresses, one follicle in one ovary becomes dominant and produces estrogen while continuing to mature suppressing all of the other follicles in the group.

The potential mechanisms which could promote the onset of neoplastic diseases in these women, particularly endometrial cancer, include the chronic anovulatory state, resulting in an unopposed estrogen action, associated with hyperandrogenism. In particular, the risk of endometrial cancer may be even higher in the premenopausal subgroup of women with PCOS, while overall the risk of ovarian and breast cancer was not significantly increased.

Obesity is a recognized risk factor for endometrial cancer and the authors of the most recent meta-analysis acknowledge that the increased risk of this cancer could be attributed, at least in part, to increased prevalence of obesity in PCOS women.

  1. If this essay isn't quite what you're looking for, why not order your own custom Health essay, dissertation or piece of coursework that answers your exact question? Myo-inositol seems to correct the mal-functioning insulin pathways and reduce the signs and symptoms of insulin resistance [42].
  2. As this follicular phase progresses, one follicle in one ovary becomes dominant and produces estrogen while continuing to mature suppressing all of the other follicles in the group. Myo-inositol is a vitamin B-like substance that can function as the basis of a number of signalling and secondary messenger molecules in insulin signalling pathways.
  3. Lastly, metformin is beneficial in adolescent girls with PCOS with regard to ovulation, the normalization of the menstrual cycle and even loss of weight [38,39]. The majority of these occur in the PCOS woman.

The same issue applies to T2DM, another possible confounding factor that is most representative in PCOS women and associated with an higher risk of endometrial cancer, possibly secondary to hyperinsulinemia, hyperglycemia, and inflammation.

There is also insufficient evidence to evaluate any association of PCOS with vaginal, vulvar, and cervical cancer. Diagnosis Diagnostic criteria outlined in Table 1 have been modified on four occasions since the National Institute of Health first defined the syndrome in 2highlighting the complex nature of the disorder.

Today, the Rotterdamcriteria are the most widely utilized guideline requiring any two of the following three features: Despite frequent amendments to diagnostic criteria, the features first described by Stein and Leventhal continue to be recognized in the various classification systems. In particular, ovarian dysfunction manifesting as either oligomenorrhoea amenorrhoea and hyperandrogenism can be considered polycystic ovary syndrome evidence based practice essay hallmarks of the syndrome 6having been consistently recognized throughout the literature.

Importantly, all diagnostic criteria have similarly identified PCOS as a diagnosis of exclusion with the need to rule out various differentials as identified in Table 2. It was then decided that only two of the three criteria had to be polycystic ovary syndrome evidence based practice essay for a diagnosis of PCOS.

The expert panel concluded that each criterion has its own strengths and weaknesses; however, the use of multiple criteria was considered confusing, impeding progress in understanding PCOS. Blood is drawn to assess hormone, glucose, and lipid levels, and a pelvic ultrasound is performed to scan for ovarian cysts.

Most protocols in puberty also aim to reduce the androgen excess. However, most importantly, a healthy diet combined with exercise should be proposed as the number one priority, especially in overweight adolescent women. In fact, weight loss resulted in the restoration of spontaneous ovulation and higher fertility rate. Similarly, the use of cosmetics as well as hair removal, used in conjunction with androgen suppression therapy, could be effective in the treatment of hirsutism.

However, lifestyle modification programs are related to a low compliance and a high dropout rate. To overcome this problem, the feasibility and the efficacy of a structured exercise training program was evaluated in obese anovulatory PCOS patients. Successively, lifestyle modifications resulted more efficacious than clomiphene cictrate CC and metformin in terms of pregnancy rate, resulting in Specifically, CC was effective in increasing pregnancy rate compared to placebo OR 5.

Extended CC regimen resulted in higher ovulation and pregnancy rates in comparison with gonadotropins ovulation induction, suggesting that in CC-resistant PCOS patients a further period of CC administration might be preferable. Aromatase inhibitors Aromatase inhibitors AIssuch as estrogen modulators, were approved by the Food and Drug Administration as first-line adjuvant therapies for estrogen-receptor—positive breast cancer.

Letrozole was usually administered at a dose of 2. Metformin Metformin belongs to insulin-sensitizing drugs commonly used in treating T2DM. Because IR is a common condition in PCOS women, metformin was introduced in clinical practice in the treatment of these patients. Oral contraceptives are the basis of hormone therapy, as they contribute to the reduction of hyperandrogenemia, hirsutism and acne []. A combination of 35mg ethinyl estradiol and 2 mg cyproterone acetate is usually administered.

  • Moreover, women with PCOS deal with low self-esteem, anxiety and it may even lead to depression;
  • Recent literature has found that greater adiposity was described in more severe reproductive phenotypes characterized by hyperandrogenism associated with chronic anovulation ,49 and lean women had milder reproductive phenotype compared with those who were overweight;97 so obesity can exacerbate the PCOS reproductive phenotypes;
  • In consideration of the increasing prevalence of obesity, particularly abdominal, and the important bearing on the phenotype of PCOS, it is recommended that BMI and waist circumference be determined at every visit,167 considering the presence of abdominal obesity in European women with a waist circumference of at least 80 cm;
  • The other challenge for patients is dealing with psychosocial impact of mood disturbance and reduced psychological well-being on motivation and the ability to implement and sustain successful lifestyle changes that are critical in this condition;
  • Generally, PCOS is a chronic condition that usually begins in adolescence then transitions to include infertility and increase metabolic complications over time;
  • In line with these considerations, the main scientific societies dealing with PCOS,13,15,16,49 have recently proposed guidelines and consensus statements, suggesting a correct diagnostic approach to PCOS patients and an effort to properly identify the phenotype of each patient, with the aim to target specific treatments and to prevent these severe long-term risks.

However, it seems to have a negative effect on the lipid profile, causing a significant increase of triglyceride levels [37]. Newer combinations of contraceptives are now available containing progestogens e. Finally, a combination of 30mg ethinyl estradiol and drospirenone is also advisable. Its main advantage is that it does not cause weight gain due to its mild diuretic effects. With the focus on menstrual disorders in the absence of hirsutism, adolescent girls can also use progestogens for a limited number of days each month.

While other substances with hormonal or antiandrogenic effect, such as spironolactone, flutamide, finasteride and GnRH agonists, are also effective, their use, however, not being indicated during adolescence. Metformin, aimed to manage insulin resistance, is widely used in the treatment of PCOS, in daily doses ranging from mg to mg.

It has been shown to reduce hyperandrogenemia by increasing the levels of SHBG.