Polycystic Ovary Syndrome (PCOS) in the Adolescent Patient: Management Strategies
Introduction
Pathogenesis of PCOS
The Diagnostic Work-Up
Management Strategies
Conclusion
References
Management Strategies
Patients, depending upon where they fall on the lifespan trajectory, have different issues or concerns related to management of PCOS. Because of the long-term consequences associated with insulin resistance and impaired glucose tolerance related to the development of type 2 diabetes and subsequently cardiovascular disease, it is important to diagnose and treat young girls with this disorder. In addition, because of the body image issues that plague adolescents and their need to be similar to members of their peer group, the hirsutism, acne, weight, and irregularity issues can be disturbing to young women with this disease. Therefore, management strategies for the adolescent patient should focus on resolving irregularity issues regarding the menstrual cycle, controlling hirsutism, managing acne, managing weight, controlling insulin resistance and hyperinsulinemia, and reducing cardiovascular risk factors. The cornerstones of this approach involve both the use of medications and lifestyle modification. In addition, nurses who care for adolescents with the disease must also address hair removal and the psychosocial issues that can be associated with PCOS.
Use of Medications in the Management of PCOS
Currently, there are no FDA approved medications indicated for the treatment of PCOS. Any drug that is used in clinical practice is used off-label (Meisler, 2002). Medications commonly prescribed to treat the many troubling signs and symptoms associated with PCOS include oral contraceptive pills, progestin, metformin, AldactoneAE, and Vaniqa99. See Table 2 for a summary of commonly used medications in the treatment of PCOS along with information regarding their use.
For many years, oral contraceptive pills have been the mainstay of therapy for women with PCOS not desiring pregnancy. The best choices are the combined oral contraceptives (COCs). This hormonal therapy can be used to regulate grossly irregular cycles, as well as decrease testosterone, thus decreasing the occurrence of acne and hirsutism. A newer COC, YasminAE, is being marketed as a good choice for PCOS patients because its progestin component (drospirenone) is an analog of spironolactone, a known antiandrogenic agent. An observational study on Yasmin in the management of PCOS symptoms revealed that this COC was effective in improving acne, showed little effect on improving hirsutism, and had a negative influence on fasting insulin concentrations and triglycerides (Palep-Singh, Mook, Barth, & Balen, 2004).
If girls cannot tolerate a COC, another pharmacological method available for regulating cycles is the use of a progestin such as medroxyprogesterone acetate (Provera). The patient is instructed to take 10 mg by mouth daily for 10 days. Once stopped, the patient should have bleeding mimicking a menstrual period. This type of cycle control can be used every 2-3 months to prevent the build up of the endometrial lining of the uterus that may lead to endometrial hyperplasia and subsequent endometrial carcinoma.
Another pharmacological treatment modality that has been used with success, although still being tested through additional clinical trials, is metformin. Metformin HCl (Glucophage) is a biguanide used in the management of patients with type 2 diabetes to control blood glucose levels by improving glucose uptake by peripheral tissues. Most recently, this drug has been used with very good success in women with PCOS to regulate periods, improve ovulation, enhance the effectiveness of fertility drugs, and decrease BMI (Sheehan, 2004). Only recently has the use of metformin with adolescents been studied. Recent clinical trials show good results with altering hyperinsulinemic insulin resistance (Ibanez et al., 2004). In clinical trials of less than 6 months with adolescents, metformin has also been shown to restore normal menstrual cycles (Kent & Legro, 2002). Metformin is prescribed in doses of 1,500 to 2,000 mg daily in treating patients with PCOS. Common gastrointestinal side effects (nausea, vomiting, diarrhea, and flatulence) can be avoided if the medication is started at lower doses and titrated upwards slowly.
Aldactone is another medication used in patients with PCOS. Aldactone (Spironolactone) is actually a diuretic that is commonly used to treat patients with hypertension and heart failure. Aldactone acts as an antiandrogen and actually decreases the amount of free, circulating testosterone, thus impacting most significantly on hirsutism (Richardson, 2003). Up to 200 mg can be taken daily as tolerated. Common side effects include nausea, menstrual irregularities, and increased breast size. The drug needs to be used for at least 6-9 months before any noticeable results may be seen (Attaran, 2005). Once the drug is stopped, hair growth will resume (Tweedy, 2000).
COCs can be used alone or along with antiandrogens and insulin sensitizing agents to improve control of unwanted body hair. In fact, because of the teratogenic effects of aldactone and because metformin can induce ovulatory cycles, if these medications are used, all sexually active females should be encouraged to take a COC concurrently.
Another medication that has shown moderate results in controlling hirsutism is Eflornithine HCl (Vaniqa). This topical agent (cream) acts to slow terminal hair growth resulting in a mild improvement in the presence of unwanted facial hair. Vaniqa is applied to the face, mainly the upper lip, chin, and side-burn area twice daily to achieve the best results.
Lifestyle Modification as a Treatment Modality
Although the use of medications has shown promise in the treatment of various symptoms associated with PCOS, the role of lifestyle modification can not be underestimated. Lifestyle modification revolves around weight loss through dietary modification and exercise.
Research indicates that even a moderate decrease in weight, as little as 5% from baseline, can improve rates of ovulation and conception by lowering androgen levels, as well as improve the insulin resistance associated with the disorder (Hill, 2003). Adolescents who are overweight or obese at the time of diagnosis should be encouraged to engage in a diet and exercise plan that will aid them in attaining and subsequently maintaining a healthy body weight, not just for overall health but for controlling many issues related to having PCOS.
Although there is not one particular type of diet reported as being the best diet for women with PCOS, simple dietary modifications that girls with PCOS may want to consider as a way to improve signs and symptoms associated with the disease could be considered. Dietary measures that have shown promise in this population include those that limit simple carbohydrates in lieu of complex carbohydrates. Small, frequent meals that combine healthy proteins, fats, and complex carbohydrates should be encouraged because small frequent meals consumed throughout the day help to lower elevated insulin levels (Tufts University, 2001). This type of eating plan helps to modulate the release of insulin when compared with larger meals filled with simple sugars that cause insulin surges.
The consumption of foods high in polyunsaturated fatty acids (PUFAs) has also been shown to be beneficial in patients with PCOS. PUFAs have been shown to modulate blood glucose as well as to control levels of sex hormones (Kasim-Karakas, 2004). PUFAs can be found in oily fish, nuts, nut butters, olive oil, and canola oil.
Moderate physical activity, 30-60 minutes per day, should be the goal of all patients with PCOS. Aerobic exercise through walking, jogging, swimming, or biking should be encouraged.
Dealing With Unwanted Body Hair
The presence of unwanted body hair must also be addressed. Women with PCOS find this one of the most troubling aspects of the disease and the one that can impact their feelings as a woman the most severely (Kitzinger & Willmott, 2002).
Electrolysis and laser ablation therapy are the only two methods that claim to be permanent hair removal techniques. Electrolysis and laser therapy can be expensive and painful procedures. It is also important to refer patients to reputable technicians who perform these procedures to reduce the incidence of complications that are often associated with these methods of hair removal (scarring with electrolysis and hypopigmentation with laser ablation therapy). Plucking and waxing are inexpensive methods that can be performed in the privacy of one's home or through salon services. These are much less expensive, as compared with electrolysis and laser therapies, but are by no means a permanent solution to hirsutism. Shaving is yet another option, but many women find this very undesirable.
Psychosocial Support
Offering psychosocial support can be one of the most important aspects of managing this disease. This begins by building positive, supportive relationships with adolescents diagnosed with PCOS. These relationships will allow the adolescent to express her feelings and concerns regarding having a chronic disease whose signs and symptoms can greatly impact one's body image and self-esteem.
Education is another important component of psychosocial support. Through education, the adolescent can become knowledgeable about the disease and available treatment options. The adolescent will then feel empowered to make informed health care decisions on her own behalf. Education can occur through verbal exchanges, the distribution of written materials, and/or access to Internet-based information contained on Web sites. See Table 3 for a list of Internet resources.
The ability to interact and build relationships with other adolescents who have PCOS can also be a source of psychosocial support. The use of face-to-face or web-based support groups could certainly accomplish this management goal.
Also giving her foaming clothes to wash with and two foams (one for morning and one for evening). 
I think I want to make sure she gets her bloodwork done before she starts this medication. I'd hate to find out later there was an indication, but the medication covered it up. 
), as well as asking about her losing/or thinning hair. Sounds like he covered a lot of what you've mentioned. Hopefully no upset stomach, she deals with that enough during "that time", and occasionally deals with lightheadedness. 
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