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LEARNING OBJECTIVES

  1. Describe criteria used for the diagnosis of polycystic ovary syndrome (PCOS).

  2. Evaluate clinical manifestations and long-term risks associated with PCOS.

  3. Explain the pathophysiologic abnormalities in PCOS involving gonadotropin secretion, excess androgen production, and insulin resistance with hyperinsulinemia.

  4. Compare and contrast medications used for the treatment of PCOS, including oral contraceptives, insulin sensitizers, antiandrogens, and ovulation induction medications.

  5. Formulate a comprehensive clinical plan including nonpharmacologic and pharmacologic therapy for a patient with PCOS.

INTRODUCTION

Polycystic ovary syndrome (PCOS) affects approximately 1 in 10 women of childbearing age, making it the most common endocrine abnormality and the leading cause of anovulatory infertility for this age group.1 The cause of PCOS is unclear, but it is theorized to be affected by both genetic and environmental factors.2 The clinical presentation will vary among individual women and can make management intriguing, complex, and challenging. The syndrome manifests with hyperandrogenism, ovulatory dysfunction, polycystic ovaries, and often insulin resistance.2,3 Women with PCOS can struggle with a poor self-image because of hirsutism, acne (which can cause scarring), and/or obesity despite rigorous diet and exercise plans. The syndrome can also have a major impact throughout a woman’s lifespan, including adverse consequences on reproductive, metabolic, and cardiovascular health.2 Women with PCOS have lower overall quality and satisfaction of life.4 Health care providers play an important role in PCOS by assessing symptoms and assisting in the decision-making process for appropriate treatment based on the patient’s therapeutic goals.

PCOS was first described in 1935 by Stein and Leventhal when they reported infertility and amenorrhea in seven women with enlarged cystic ovaries.5 Stein later added excessive male-patterned hair growth and obesity to the description.6 Although it has been called Stein-Leventhal syndrome, polycystic ovary, polycystic ovarian disease, hyperandrogenic chronic anovulatory syndrome, and functional ovarian hyperandrogenism, the name PCOS has been widely accepted to describe the heterogeneous nature of this disorder.

Patient Case (Part 1)

J.C. is a 21-year-old obese woman who presents to clinic and will be seen by her primary care provider and the clinical pharmacist.

Chief Concern: “I have hair growth above my upper lip, mild acne, and irregular menstrual periods. My irregular and unpredictable periods cause me anxiety since I am sexually active and I do not want to get pregnant.”

History of Present Illness: When she does have a period, she considers them to be normal, without pain or excessive bleeding. Her periods usually last 5 to 7 days. She states that the hair on her upper lip has always been bothersome, but she gets it waxed routinely. She struggles with her obesity because she has been unable to lose weight despite walking vigorously for 20 minutes 5 days/week over the past 6 months.

Medical History: Occasional headaches when stressed. Last Papanicolaou (PAP) smear normal 2 years ago.

Family History: Mother—type 2 diabetes, hypertension; father—type 2 ...

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