NR 508 Week 1 TD and Quiz
PART 1:
Emily, a relatively healthy 5’5”, 32-year-old young woman weighing 190 pounds, presents to your clinic with hirsutism, anovulation, oligomenorrhea, and at times amenorrhea. Biochemical blood tests reveal elevated luteinizing hormone (LH, without a mid-cycle...
PART 1:
Emily, a relatively healthy 5’5”, 32-year-old young woman weighing 190
pounds, presents to your clinic with hirsutism, anovulation,
oligomenorrhea, and at times amenorrhea. Biochemical blood tests
reveal elevated luteinizing hormone (LH, without a mid-cycle surge)
and androgen elevation.
She mentions that she also has a family history of irregular cycles, and
that her grandmother experienced early menopause. She also states that
she is sexually active, occasionally smokes (1 pack/month), and desires
to be prescribed one medication to mitigate her symptoms, as well as,
prevent her from becoming pregnant.
Please provide a list of differential diagnoses, as well as an indication of
your primary diagnosis.
Once this has been completed, please indicate and describe your chosen
pharmacological treatment with inclusion of dose and mechanism of
action of your chosen prescription.
“The diagnosis of PCOS is confirmed once other conditions with features similar to
PCOS have been excluded, such as NCCAH, thyroid disease, and hyperprolactinemia”
(Barbieri, R. & Ehrmann, D, 2017)
“OCs containing one of the original progestins, norethindrone or norethindrone acetate,
are also good options; while they are not as low in androgenicity, they have not been
associated with excess VTE risk.” (Barbieri, R. & Ehrmann, D, 2016)
Differentials: NCCAH, thyroid dz, hyperprolactinemia, IF SEVERE
hyperandrogenism and virillization, then consider androgen-secreting
ovarian and adrenal tumors and ovarian hyperthecosis.
Tx: Ortho Tri-Cyclen (norgestimate/ethinyl estradiol) 0.25 mg/35 mcg daily.
Encourage patient to stop smoking and make her aware of all the risks
involved with smoking and oral contraceptives. Or Yasmin
,“We typically start with an OC containing 20 mcg of ethinyl estradiol
combined with a progestin with minimal androgenicity (such as
norgestimate). Other progestins with minimal androgenicity or
antiandrogenic properties include desogestrel and drospirenone, but both
have been associated with a possible higher risk of venous
thromboembolism (VTE) (table 1). OCs containing one of the original
progestins, norethindrone or norethindrone acetate, are also good options;
while they are not as low in androgenicity, they have not been associated
with excess VTE risk.”
“Although transdermal or vaginal ring preparations are potential options,
they have not been well studied for the management of hirsutism and there
are concerns about an excess risk of VTE with both regimens.”
PRIMARY DIAGNOSIS:
Polycystic Ovary Syndrome (PCOS) is a very common metabolic/endocrine
disorder in women that causes an increased amount of androgen secretion,
irregular menstrual cycles, and is commonly the cause of infertility (Azziz,
2017). Most often, true PCOS cases will present clinically with menstrual
irregularity (oligomenorrhea, amenorrhea, or excessive bleeding),
hyperandrogenism (acne and hirsutism), polycystic ovarian features
(visualized via an ultrasound), and obesity (Solomon, McCartney, &
Marshall, 2016). Many patients will also present with an increased
luteinizing hormone and a normal or low follicle-stimulating hormone
(Barbieri & Ehrmann, 2017). Emily presents to the office with classic
features of PCOS.
PCOS has become regarded as an intricate and complicated genetic trait
because several genetic branches and environmental elements are combined,
which then facilitates one developing the disorder (Azziz, 2017). Multiple
studies have correlated an increase in PCOS cases with patients who have a
close relative, such as a mom or sister that also has PCOS. According to
Azziz (2017), 20 to 40 percent of women diagnosed with PCOS have a
mother or sister who have been diagnosed as well. Patients diagnosed with
PCOS have a higher risk of developing cardiovascular disease, metabolic
, syndrome, endometrial cancer, and type 2 diabetes (Barbieri & Ehrmann,
2017). Most patients are diagnosed during their adolescent years, however
some are not diagnosed until they are peri- or postmenopausal (Solomon,
McCartney, & Marshall, 2016).
The clinical manifestations of PCOS may mimic those of puberty,
menopause, or nonclassic congenital adrenal hyperplasia (NCCAH)
therefore a definite diagnosis must be made. In order to rule out NCCAH, a
17-hydroxyprogesterone-plasma level should be obtained and results need to
be less than 200ng/dL (Solomon, McCartney, & Marshall, 2016). One
marker that can also be used to help identify PCOS is the mean platelet
volume (MPV) (Lucidi, 2016). A patient newly diagnosed with PCOS will
typically have high MPV levels (Lucidi, 2016).
Treatment of PCOS includes a variety of options with the overall goals
being to alleviate symptoms associated with excess androgen, manage
metabolic issues including reducing the risks for cardiovascular disease and
type 2 diabetes, impede endometrial hyperplasia and endometrial cancer, and
restore ovulation for those who desire pregnancy (Barbieri & Ehrmann,
2016). For patients who are overweight, weight reduction via diet and
exercise should be strongly encouraged. Weight loss helps improve
hyperandrogenism and insulin resistance (Barbieri & Ehrmann, 2016). In
fact, even a 5 to 10% reduction in weight can decrease risks for
cardiovascular disease, reduce androgen levels, improve menstruation, and
can possibly improve fertility (Solomon, McCartney, & Marshall, 2016).
The mainstay pharmacologic treatment for PCOS is oral contraceptives
(OCs), specifically estrogen-progestin combinations or combination oral
contraceptives (COCs) (Solomon, McCartney, & Marshall, 2016). This
combination quells androgen and gonadotropin secretion, which helps
reduce hirsutism and acne (Solomon, McCartney, & Marshall, 2016). The
estrogen in the combination helps stimulate the liver to produce sex
hormone-binding globulin (SHBG), which helps decrease the amount of
androgen available in the body (Solomon, McCartney, & Marshall, 2016).
The use of an estrogen-progestin COC can help regulate bleeding, which can
assist in preventing endometrial hyperplasia (Solomon, McCartney, &
Marshall, 2016). The issue is that OCs/COCs increase the patient’s risk of
developing an embolus, especially if the patient smokes and/or is obese
(Solomon, McCartney, & Marshall, 2016). Metformin is can be ordered in
conjunction with COCs because it decreases hyperinsulinemia and reduces
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