Soap Note: Polycystic Ovarian Syndrome Assignment

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Soap Note: Polycystic Ovarian Syndrome Assignment

Common Health Conditions with Implications for Women

Select a patient that you examined during the last four weeks as a Nurse Practitioner. Select a female patient with common endocrine or musculoskeletal conditions, Evaluate differential diagnoses for common endocrine or musculoskeletal conditions you chose .With this patient in mind, address the following in a SOAP Note:

Subjective: What details did the patient provide regarding or her personal and medical history?

Objective: What observations did you make during the physical assessment?Soap Note: Polycystic Ovarian Syndrome Assignment

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

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Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up appointment with the provider, as well as a rationale for this treatment and management plan.

Reflection notes: What would you do differently in a similar patient evaluation? And how can you relate this to your class and clinical readings. Soap Note: Polycystic Ovarian Syndrome Assignment

 

References

 

Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic health (2nd ed.). Burlington, MA: Jones and Bartlett Publishers.

Chapter 22, “Urinary Tract Infection in Women” (pp. 535–546)

 

Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.

 

Review: Chapter 8, “Primary Care in Women’s Health” (pp. 431–560)

 

Centers for Disease Control and Prevention. (2012b). Women’s health. Retrieved from http://www.cdc.gov/women/

 

National Institutes of Health. (2012). Office of Research on Women’s Health (ORWH). Retrieved from http://orwh.od.nih.gov/

Soap Note: Polycystic Ovarian Syndrome Assignment

U.S. Department of Health and Human Services. (2012a). Womenshealth.gov. Retrieved from http://www.womenshealth.gov/

Week 11 Soap Note: Polycystic Ovarian Syndrome

Bethel U. Godwins

Walden University

NURS 6551, Section 8, Primary Care of Women

Patient Initials: FJ Age: 23 Gender: Female

SUBJECTIVE DATA:

Chief Complaint: “I have increased coarse body hair, irregular periods, and pelvic pain for the past one year”. Comment by Erica Gifford: Great CC

History of Present Illness: FJ is a 23-year-old G0P0 African American obese female who presented to the clinic with complaint of increased coarse body hair; irregular periods, and pelvic pain for the past one year. FJ reported that she noticed weight gain, especially around her waist; increased hair growth on her chest, chin, lips, stomach, back, thumbs, and toes; and oil skin, acne, and dandruff. Patient also reported that she used to have quite regular period, but for the past one year, she skips periods two to four months before her next menstrual cycle. Patient reported that she wants to get pregnant, but she has never been pregnant. Patient reported breast pain and lower abdominal/pelvic pain. She also reported that she got married last years, and she started monitoring her ovulation with an over the counter ovulation kit. She noticed that she does not ovulated for the past one year since she started checking. Patient reported that she has skin tags, such as excess skin on her armpits and neck area. She is sad because of the reported symptoms and not being able to conceive. She decided to see an obstetrics and gynecologist for an evaluation and treatment. Patient denied fever, chills, nausea, vomiting, diarrhea, or constipation.

Location: Pelvic, lower abdominal, uterus, skin, and breast.Soap Note: Polycystic Ovarian Syndrome Assignment

Duration: One year

Quality: Pelvic/lower abdominal pain; breast pain; increased skin growth.

Radiation: None

Severity: 7/10 on pain scale

Timing/Onset: One year ago.

Alleviating Factors: Pain medication and heating pad.

Aggravating Factors: None

Relieving Factors: Ibuprofen pain medication and heating pad.

Treatments/Therapies: Over the counter ibuprofen pain medication, and heating pad.

Medications: Motrin 200-400 mg orally every 6 to 8 hours as needed for pain.

Allergy: No known drug or food allergy.Soap Note: Polycystic Ovarian Syndrome Assignment

Past Medical History: None

Past Surgical History: None

GYN History: LMP 07/15/2016; last Pap smear 2/20/2015: negative; menarche 12; cycle: 5 days, but irregular; age of first intercourse 18 year; sexual active and heterosexual with only one sex partner; no birth control measures.

OB History: Gravida: 0 Para: 0

Personal/Social History: Married; college graduate; employed; lives at home with the husband; denied alcohol abuse, tobacco abuse or illicit drug abuse.Soap Note: Polycystic Ovarian Syndrome Assignment

Immunizations: Flu vaccine 11/24/16; no pneumococcal shot.

Family History: Father: Diabetes, hyperlipidemia, BPH, hypertension; Mother: hypertension, diabetes. Siblings alive and well.

Review of Systems:

General: Positive weight gain; no fever, no night sweats, no chills, no fatigue, or no weakness.

Head: Admitted dandruff, denied dizziness, migraine or headache.

Eyes: Denied visual problem

Chest: no chest pain, cough, SOB

Heart: No palpitation, no irregular heartbeat

Breast: Admitted breast pain; no erythema, inflammation or nipple discharge.

Gastrointestinal: Reported lower abdominal pain; central obesity; increased waist fat; denied nausea/vomiting, constipation, or diarrhea.

Urinary: denied urinary tract infection or problems; no dysuria or urinary frequency.

GYN: Reports pelvic pain, irregular periods, difficult getting pregnant, no ovulation, skipped periods 2 to 4 months before her next menstrual cycle; no menorrhagia, no vaginal bleeding or discharge.

Musculoskeletal: denied pain radiation, muscle or joint pain.Soap Note: Polycystic Ovarian Syndrome Assignment

Skin: reports acne, oily skin, increased coarse hair growth on chest, stomach, back, thumbs, and toes. Patient reported skin tags like excess skin on armpit and neck.

Psychiatry: No mental health problems; mood changes, depression or anxiety.

Neurological: denied dizziness, weakness, or seizures.

Endocrine: No thyroid problem, no diabetes, no hot/cold intolerance.

Immunologic: No recurrent infections or immune deficiencies.

Hematologic: No cancer, anemia, blood transfusion or bleeding disorder.

OBJECTIVE DATA

Physical Exam:

General: Patient is obese, pleasant, alert/oriented, and answers questions appropriately. No acute distress.

Vital signs: T 37.0, B/P 125/76, P 68; RR 16; SPO2 100% RA. Weight 182 pounds, BMI 30.3, Height 5ft 5in. Weight reflected 15 pounds increase from what the patient reported was the last weight last 4 months.

HEAD: Atraumatic, normocephalic; scalp: + dandruff.Soap Note: Polycystic Ovarian Syndrome Assignment

Neck: supple, excess skin fold, no lymphadenopathy, no thyromegaly.

Chest/Lungs: Increased coarse chest hair noted; non-labored breathing; clear to auscultation.

Heart: Regular rate and rhythm.

Abdomen/pelvic: lower abdomen/pelvic tenderness, enlarged multiple ovaries noted, obese, waist circumference >35; waist-to-hip ratio > 0.85; upper/lower abdominal hair.

Back: increased upper back hair noted, Normal curvature.

Skin: Increased coarse hair noted on the chin, lips, chest, upper/lower abdomen, upper back, thumbs, toes. Oily skin, acne, skin tags like excess skin on armpit/neck, and acanthosis nigricans noted on neck and armpits.

Breast: + pain/tenderness; no redness, swelling or discharge.

Genitals: External genital normal, except clitoris that is enlarged, vagina pink, and cervix closed; no rash, redness or discharge. Comment by Erica Gifford: What about uterus size any tenderness? Bimanual exam?Soap Note: Polycystic Ovarian Syndrome Assignment

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ASSESSMENT:

Lab Test and Results:

Pregnancy urine tests for human chorionic gonadotropin (hCG): negative, blood tests like testosterone/androgen test: high/abnormal; Prolactin test: level high/abnormal, + infertility; cholesterol/triglycerides blood test: abnormal; TSH test: normal rule out under/over active thyroid; hydroxyprogesterone: normal ruled out adrenal problem. Glucose tolerance/insulin levels: + insulin resistance. Luteinizing hormone concentration/follicle–stimulating level test: Elevated.

Vaginal ultrasound (sonogram): + multiple cysts in the ovaries; thicker endometrium lining.

Soap Note: Polycystic Ovarian Syndrome Assignment

Differential Diagnosis:

1. Polycystic Ovarian Syndrome

2. Cushing Syndrome

3. Premature Ovarian Failure

Polycystic Ovarian Syndrome (PCOS): Women’s Health (WH, 2014) described polycystic ovarian syndrome as an imbalance of woman’s sex hormones estrogen and progesterone, which causes development of ovarian cysts and irregular or absent menstrual cycle in women. Also, the hormonal imbalance leads to fertility, cardiac function, blood vessels, hormones, and appearance problems. According to WH (2014), Women with PCOS usually have elevated levels of male hormones (androgens); missed or irregular periods; multiple little ovarian cysts; hirsutism like increased hair growth on the face, chest, stomach, back, thumbs, or toes; acne, oily skin, or dandruff; weight gain or obesity, usually with extra weight around the waist; pelvic pain; anxiety or depression; and sleep apnea. Diagnosis of PCOS according to WH Soap Note: Polycystic Ovarian Syndrome Assignment(2014) is based on acne and/or hirsutism; infertility due to anovulation; abdominal obesity; endocrine abnormalities based on laboratory tests; elevated androgen/testosterone level; positive insulin resistance; elevated luteinizing hormone concentration; follicle–stimulating level; multiple cysts in the ovaries; thicker endometrium

Polycystic ovarian syndrome is selected as the primary diagnosis because the patient’s clinical presentations; laboratory tests; and sonographic evaluations as aforementioned confirmed the diagnosis of polycystic ovarian syndrome. In fact, the results of the laboratory tests, radiologic evaluation; physical examination; and clinical presentation as aforementioned are all synonymous with the recommended clinical guideline for diagnosis of the PCOS. Comment by Erica Gifford: Excellent primary diagnosis

Cushing Syndrome (CS): The Pituitary Society (PS, 2015) described Cushing syndrome as the condition that occur due to excess cortisol hormone in the body. Cushing’s syndrome is fairly rare, but mostly found in women than men between ages 20 to 40Soap Note: Polycystic Ovarian Syndrome Assignment. Signs and symptoms as described by PS (2015) are weight gain, hypertension, irritability, round face, fatigue, menstrual irregularity, poor concentration, poor short term memory, excess hair growth in women, red, ruddy face, and extra fat around the neck. Cushing’s syndrome is also usually associated with moon facies, central fat deposition, bruising easily, decreased libido, stretch marks, sleep disturbance, hypertension, muscle wasting, abdominal striae, buff alo hump, and osteoporosis. Cushing syndrome is ruled out as the primary diagnosis for the patient because the signs and symptoms of CS that are specific to CS alone, such as buff alo hump, stretch marks, easily bruise, decreased libido, moon face, and sleeping disturbance were not synonymous with the patient’s clinical presentation. Moreover, diagnosis of CS cannot be made based on symptoms alone; but with the use of laboratory tests that measures the amount of cortisol in the patient saliva or urine and the clinical presentation according to PS (2015).Soap Note: Polycystic Ovarian Syndrome Assignment

Premature Ovarian Failure (POF): According to American Society for Reproductive Medicine (ASRM, 2015), POF is cessation of ovarian functioning before age 40 due to autoimmune disorder affecting the thyroid and adrenal glands; family history of POF; and medical treatments, such as chemotherapy and radiation therapy. Symptoms of POF according to ASRM (2015) are similar with menopause, such as irregular menstrual periods, hot flashes, night sweats, irritability, vaginal dryness, and trouble sleeping. Premature ovarian failure is ruled out as the primary diagnosis because the symptoms associate with the condition are not synonymous with most of the symptoms presented by the patient.Soap Note: Polycystic Ovarian Syndrome Assignment

 

PLAN:

Laboratory /Diagnostic Tests and Results:

The initial laboratory test that was completed was urine human chorionic gonadotropin level test to rule out pregnancy: Result- negative. Other laboratory/diagnostic tests include:

Blood tests like testosterone/androgen test: high/abnormal confirming high male sex hormones and the physical presentations; Prolactin test: level high/abnormal, + infertility; luteinizing /follicle-stimulating hormone blood level test are high and abnormal in this patient while the patient is not pregnant; cholesterol/triglycerides blood test: abnormal; TSH test: normal ruled out under/over active thyroid; hydroxyprogesterone: normal ruled out adrenal problem. Glucose tolerance/insulin levels: + insulin resistance.

Vaginal ultrasound (sonogram): + multiple cysts in the ovaries; thicker endometrium lining.Soap Note: Polycystic Ovarian Syndrome Assignment

Treatment / Management Plan and Follow up Care

Polycystic ovarian syndrome is selected as the primary diagnosis after physical, laboratory, and diagnostic tests ruled out other possible differential diagnosis, and treatment/management plan for the condition will depend on the patient‘s needs or goals because there is no cure for the condition according to WH (2015). Treatment/management therapy typically focus on either fertility improvement or treating the symptoms of hyperandrogenism (hirsutism) explained by WH (2015); however, long term measures should be taken to restore regular menses and prevent endometrial hyperplasia. The patient desire is to become pregnant. Therefore, the first line of treatment, and the safest measure to restore ovulation is weight loss since patient is obese. Patient will be placed on calorie restricted diets, such as limiting carbohydrates and fats; eat more proteins, fruits/vegetables, and regular exercise (Tharpe, Farley & Jordan, 2013).Soap Note: Polycystic Ovarian Syndrome Assignment

 

Medications:

Patient was advised to continue Motrin 200-400 mg orally every 6 to 8 hours as needed for pain.

Metformin 500 mg orally three time a day will be added with the aim of lowering growth of abnormal hair; help return of ovulation; lower body mass, enhance insulin resistance, and improve cholesterol levels (Tharpe et al., 2013).Soap Note: Polycystic Ovarian Syndrome Assignment

Clomid 50 mg orally for 5 days is prescribed to treat the patient’s ovulatory dysfunction; the aim is to stimulate ovulation and treat infertility. Clomid therapy may be increased to100mg orally for 5 days if the initial therapy did not result in pregnancy when patient follow up in 6 months for reassessment (Tharpe et al., 2013).

Patient will be advised to follow up every 3 to 6 months for reassessment of the treatment and management therapy, such as insulin resistance reassessment, weight management, and reevaluation of clomid and metformin treatment/management therapy to determine the effectiveness of the therapy. Then, make therapy adjustments if needed accordingly (Tharpe et al., 2013).Soap Note: Polycystic Ovarian Syndrome Assignment

Alternative Therapy

According to American Botanical Council (ABC, 2013), Chaste tree berry, licorice, and traditional Chinese medicine herb dong quai (Angelica sinensis) help to balance hormones in a patient with PCOS, they work well in restoring normal menstrual periods. Based on the confirmed effectiveness of chaste tree berry, licorice, and dong quai (angelica sinensis), they can be used as an alternative therapy to treat the patient PCOS. Furthermore, other herbs that can help with the patient’s menstrual and hormonal balance according to ABC (2013) are ginger, red raspberry, red clover, rosemary, soy, flax seed, partridge berry, and feverfew. In addition, legumes, chromium, cinnamon, tea (camellia sinensis), and/or coffee due to caffeine’s ability to improve insulin sensitivity; have been found to improve insulin resistance and would be recommended to the patient alternatively according to ABC (2013). Moreover, herbs like ginseng, licorice, ashwagandha, rhodiola, schisandra, and rhaponticum can be recommended for stress management explained by ABC (2013).Soap Note: Polycystic Ovarian Syndrome Assignment

Nonpharmacological Treatment

Patient was advised to continue using heating pad as needed for pain. Sirmans and Pate (2014) described the nonpharmacological treatment of PCOS to include acupuncture, massage, homeopathy, reflexology, herbalism as aforementioned. According to Sirmans and Pate (2014), acupuncture is the most common used nonpharmacological treatment because women with PCOS use acupuncture to regulate and manage their periods. Women with PCOs also use acupuncture to help in weight reduction, headache reduction, and improvement in moods/outlook. Moreover diet and exercise will help in weight reduction, improve sensitivity to insulin and improve ovulation abnormalities associated with PCOS according to Sirmans and Pate (2014).Soap Note: Polycystic Ovarian Syndrome Assignment

Health Promotion

Patient will be provided with age-appropriate educational materials on PICO causes, risk factors, diagnosis, and management therapy. Patient will also be reminded about the benefits of healthy lifestyle changes; nutrition & exercise; positive ways to cope with stress. Patient will be advised to incorporate regular exercise as part of her daily routine by exercising for a minimum of 20 to 30 minutes a day 4 to 5 times a week as well as eating fruits and vegetables; cut down on high fat/high cholesterol diet as well as include legumes in the patient’s diet (Tharpe et al., 2013)Soap Note: Polycystic Ovarian Syndrome Assignment. On-going support will also be made available for the patient. At every follow-up visit, patient’s concerns will be listened to and addressed. Clarification will be made about PCOS myths, ovarian cysts, infertility, and excess hair. Patient will be educated that there is no magic bullet about treating/managing the condition rather there are many ways to manage the presenting symptoms as well as lowering the risk for diabetes (Tharpe et al., 2013). Patient will be educated on the risk for other health problems associated with PCOS, such as risk of diabetes, risk of heart attack, greater risk of hypertension, high risk of having high cholesterol, and risk of developing sleep apnea. Also, patient will be educated about the risk of developing anxiety and depression due to the condition, but emphasis will be made on the importance of reaching out for help for mental health problem (Tharpe et al., 2013). Resources will be provided to the patient for help with weight loss and maintaining a healthy lifestyle. At this point, no referral was made because there was no identifiable need for referral.Soap Note: Polycystic Ovarian Syndrome Assignment

Reflection Note Comment by Erica Gifford: Thorough reflection

I learned a lot from the experience. I learned that PCOS could be the primary cause of most infertility, and the cause is usually women sex hormonal imbalance. I equally learned that the increase in male hormone androgens could result in most of the physical changes associated with the condition. I also learned that maintaining a healthy weight is very crucial in managing the condition. I am thrilled to learn about alternative and nonpharmacological herbs that can help control insulin resistance in the body because the knowledge is personal to me and my family members.Soap Note: Polycystic Ovarian Syndrome Assignment

I would not have done anything differently because I believed that I did an exhaustive patient assessment in collaboration with my preceptor based on the patient’s clinical presentation, and I followed the appropriate clinical guideline in collaboration with my preceptor to arrive at an appropriate primary/differential diagnosis, and management plan for the patient based on the patient wish to become pregnant. I selected the treatment plan as deemed appropriate and in consideration of the patient’s desires to have a baby.Soap Note: Polycystic Ovarian Syndrome Assignment

I would have loved to gather additional data about the patient’s maternal grandmother or grate grandmother’s health history to determine if there is anybody in the patient’s family history that have PCOS. The information could explain the reason why the patient have the condition because PCOS is known to run in the family. But, the patient denied that her mother or siblings have the condition. Although, the patient informed the author and the author’s preceptor that she had limited knowledge of her maternal history because her mother was adopted. I would not have done additional elements of exam because the physical exam, laboratory, and diagnostic tests were very exhaustive based on the required clinical practice guidelines for the diagnosis of the condition.Soap Note: Polycystic Ovarian Syndrome Assignment

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I totally agreed with my preceptor’s clinical judgement and decisions based on the evidence, patient clinical presentation, physical examination, laboratory, and diagnostic tests. Also based on the evidence-based practice and clinical practice guidelines for PCOS.

Soap Note: Polycystic Ovarian Syndrome Assignment

References

American Botanical Council. (2013). Treating PCOS Naturally. HerbalEGram, 10(3), 1-4.

American Society for Reproductive Medicine. (2015). What is premature ovarian insufficiency

known as premature ovarian failure? Retrieved from http://www.socrei.org/uploadedFiles /ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/POF-final_1-5-12.pdf

Pituitary Society. (2015)Soap Note: Polycystic Ovarian Syndrome Assignment. Cushing’s syndrome & disease diagnosis. Retrieved from

https://pituitarysociety.org/patient-education/pituitary-disorders/cushings/diagnosis-of-cushings-disease-and-cushings-syndrome

Sirmans, S. M., & Pate, K. A. (2014). Epidemiology, diagnosis, and management of polycystic

Ovary syndrome. Clinical Epidemiology, 6, 1-13. doi: 10.2147/CLEP.S37559

Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for

midwifery & women’s health (4th ed.). Burlington, MA: Jones & Bartlett

Publishers

Women’s Health. (2014). Polycystic ovary syndrome fact sheet. Retrieved from

http://womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.html#a

SOAP note rubric

Soap Note: Polycystic Ovarian Syndrome Assignment

Subjective (15 points)
· CC 1 1
· Pertinent positives (OLDCARTS) 5 5
· Pertinent negatives (from ROS) 5 5
· Pertinent PMH, SH, and FH 3 3
· Medications and drug/food allergies are not included 1 1
Objective (15 points)
· VS including BMI, / FHT if indicated 2 2
· Heart and lungs and thyroid 1 1
· Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included. -5 5
· Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted. -5 45
· Diagnostic test results 2 2
Assessment – 10 points for each priority diagnosis (total 30 points) 30 30
Plan (15 points)
· Medications discontinued (“d/c lisinopril 10 mg daily”) 1 1
· Medications started (“start Avapro 150 mg daily”)Soap Note: Polycystic Ovarian Syndrome Assignment 2 2
· Alternative therapies if appropriate (1 point) 1 1
· Health Promotion strategies – patient/family education 3 3
· Disease Prevention strategies with timeframe if appropriate 3 3
· Diagnostic tests ordered with timeframe (now, in 2 weeks, prior to f/u visit in 3 months) 3 3
· Referrals or consultations if appropriate 1 1
· Follow-up interval 1 1
Reflection notes (25 points)
· What did you learn from this experience? Any ah-ha’s? (5 points) 5 5
· What would you do differently?Soap Note: Polycystic Ovarian Syndrome Assignment 5 5
· What additional data would you have gathered? 5 5
· What additional elements of the exam would you have done? 5 5
· Do you agree with your preceptor based on the evidence? 5 5
Total points 100 99100

Soap Note: Polycystic Ovarian Syndrome Assignment

Excellent SOAP note

Definition/Description

Polycystic Ovarian Syndrome (PCOS), formerly known as Stien-Leventhal Syndrome, is a disorder affecting the hormones of women of childbearing age.  Ovaries are enlarged secondary to multiple cyst formations within the ovaries.Soap Note: Polycystic Ovarian Syndrome Assignment

PCOS has also been associated with features of metabolic syndrome which include insulin resistance and diabetes mellitus as well as cardiovascular factors such as dyslipidemia. Causative factors seem to be unknown but there are certain predispositions that are strongly correlated with the incidence of PCOS. Insulin resistance and compensatory hyperinsulinemia are said to be significant causes of hyperandrogenism in women with PCOS. Furthermore, obesity worsens these hormonal imbalances thus making the clinical features evident – it has been observed that women with PCOS who are obese have a higher incidence of menstrual irregularities and hirsutism compared to non-obese women with PCOS[1].Soap Note: Polycystic Ovarian Syndrome Assignment

Prevalence

Polycystic Ovarian Syndrome PCOS affects 4-12% of childbearing aged women[2] It is currently recognized as the leading cause of anovulatory infertility and the most prevalent endocrine disorder amongst women of reproductive age. [3]

  • 50% of these women have amenorrhea[4]
  • 30% of these women have abnormal menstrual bleeding[4]
  • 60% of these women are obese[5]
  • 40% of women with PCOS have associated insulin resistance and type 2 diabetes mellitus[4]

Pathophysiology

Polycystic Ovarian Syndrome PCOS is believed to be a genetically inherited metabolic and gynecological disorder.  A repetitive vicious cycle occurs with hormones resulting in the progression of PCOS. To begin with, failure of an ovary to release oocyte results in increased levels of androgen production/release from the ovaries as well as the adrenal cortex. Excess androgens have a twofold effect. First, androgens are stored in adipose tissue where they are then converted into estrogen. Excess androgens then result in an increased production of Sex Hormone Binding Globulin (SHGB). This increased SHGB then has the consequence of an even greater fabrication of androgens and estrogens. Thus the cycle begins. The cause of the excess androgen production has been correlated to surplus Luteinizing hormone (LH) stimulation resulting in the presence of cystic changes in the ovaries.[6]Soap Note: Polycystic Ovarian Syndrome Assignment

Characteristics/Clinical Presentation

Signs and symptoms of PCOS include the following:

  • Enlarged polycystic ovaries[6]
  • Obesity and central fat distribution[6]
  • Hirsutism – male pattern of hair growth primarily on the face, back, chest, lower abdomen, and inner thighs [6]
  • Virilization – development of male features including balding of the frontal portion of the scalp, voice deepening, atrophy of breast tissue, increased muscle mass, and clitoromegaly[6]
  • Anovulation – failure of the ovaries to release an oocyte[6]Soap Note: Polycystic Ovarian Syndrome Assignment
  • Amenorrhea – the absence of a menstrual period in women of childbearing age[6]
  • Oligomenorrhea – the presence of menstrual cycles greater than 35 days apart[6]
  • Dysfunctional uterine bleeding[7]
  • Acne related to hyperandrogenism[8]
  • Infertility; recurrent first trimester miscarriages[2]
  • Obstructive Sleep Apnea

Associated Co-morbidities

  • Type 2 Diabetes Mellitus[5]
  • Obesity[5]
  • Cardiovascular disease[5]
  • Hypertension[5]
  • Ovarian cancer[5]
  • Breast cancer[5]
  • Endometrial cancer[5]Soap Note: Polycystic Ovarian Syndrome Assignment

Diagnosis

There is no single specific test that can be used to accurately diagnose Polycystic Ovarian Syndrome. Rather a comprehensive examination needs to be carried out by a clinician which involves a detailed history, physical examination and investigative procedures. Clinicians should focus on taking a detailed menstrual history for any irregularities, any significant change in the patient’s weight and physical appearance (acne, alopecia, terminal hair, acanthuses nigricans, skin tags)[9]. Investigations that could help arrive at a definite diagnosis include:Soap Note: Polycystic Ovarian Syndrome Assignment

  • Ultrasound – An ultrasonic test allows visualization of any cysts which may be present on the ovaries or if there is any enlargement of one or both ovaries. A transvaginal ultrasound which involves inserting the probe into the vagina is usually done for women who have been sexually active. For women who are not sexually active, an abdominal ultrasound is opted for where the ovaries are viewed from outside the abdominal wall however, a clearer picture is obtained transvaginally compared to a transabdominal ultrasound[10].
  • Hormonal Blood Tests[10]Soap Note: Polycystic Ovarian Syndrome Assignment
    1. Hyperandrogenism – Testing for androgen levels and free androgen index (FAI) is best for diagnosis hyperandrogenism which is a key finding in women with PCOS.
    2. Tests to detect female hormonal levels – Estradiol, Follicle Stimulating Hormone, Luteinizing Hormone levels.
    3. Tests to exclude other conditions which could present as Polycystic Ovarian Syndrome PCOS – Thyroid Stimulating Hormone, Prolactin, Adrenal hormones.

Criteria for Diagnosis

A conclusive diagnosis for PCOS can be made if at least 2 out of 3 of the following is found criteria are met[10]:

  1. Polycystic ovaries – 12 or more follicles are seen on one ovary or the size of one or both ovaries have enlarged.
  2. Hyperandrogenism – high levels of androgenous hormones or male pattern of hair growth.
  3. Menstrual Abnormalities – lack of menses or menstrual cycle irregularities or anovulation.Soap Note: Polycystic Ovarian Syndrome Assignment

Medical Management

Medical management is completed through medications or surgical removal of the ovarian cysts/hysterectomy. Medications can be used to shrink ovarian cysts through control of the menstrual cycle and subsiding release of excess luteinizing hormone thus preventing the overproduction of testosterone.[2]

Medications

Treatment for infertility may include the following for inducing ovulation:

  • Clomiphene citrate[6]
  • Corticosteroids[6]
  • Metformin increases spontaneous ovulation for women with insulin resistance/increased insulin production[6]

Treatment for those not interested in conceiving a child may include:

  • Depo-Provera injections to decrease endometrial hyperplasia[6]
  • Oral progestin[8]
  • Oral combination contraceptive containing estrogen and progestin[8]Soap Note: Polycystic Ovarian Syndrome Assignment

Cystectomy

Physical Therapy Management

Exercise training has shown great improvement in 50% of the women diagnosed with Polycystic Ovarian Syndrome PCOS, by targeting menstrual irregularities and promoting ovulation. Weight reduction is an important component of the physical therapy program since weight reduction improves glucose intolerance which in turn could resolve the reproductive and metabolic derangements often associated with PCOS. Weight loss may also reduce the pulse amplitude of luteinizing hormone thus reducing androgen production[1].

Physical therapists should also be aware of the clinical presentation of Polycystic Ovarian Syndrome PCOS.  Women with PCOS may experience low back pain, sacral pain, and lower quadrant abdominal pain.  However, a thorough patient history can provide information about a gynecologic/metabolic connection.  The concern of the possible presence of Polycystic Ovarian Syndrome PCOS requires immediate referral to a physician.[4]

In treating patients with a past medical history of Polycystic Ovarian Syndrome PCOS for a non-related condition, be aware of related medical concerns that may affect the patient’s ability to participate in activities including glucose intolerance and insulin resistance.[4]Soap Note: Polycystic Ovarian Syndrome Assignment

Side effects of medications need to also be taken into account.  For example, the side effects of clomiphene citrate, an ovulation inducer, include insomnia, nausea/vomiting, blurry vision, and frequent urination.[4]

Lifestyle Changes

Recommendations:

  • Weight loss – Cornerstone in controlling all derangements seen in PCOS[8]
  • Regular exercise (30min/day) lowering insulin levels – walking/jogging[8]
  • Dietary Modifications – Reduction of carbohydrates consumed to reduce insulin levels[8]Soap Note: Polycystic Ovarian Syndrome Assignment

Differential Diagnosis

  • Pregnancy[2]
  • Hypothyroidism[2]
  • Hyperprolactinemia[2]
  • Late-onset Congenital Adrenal Hyperplasia[2]
  • Ovarian Tumor[2]
  • Hyperthecosis[2]
  • Adrenal tumor[2]
  • Cushing’s Syndrome [2]Soap Note: Polycystic Ovarian Syndrome Assignment

Resources

Case Report: Polycystic Ovarian Syndrome: Diagnosis and Management

Case Review: Long term health consequences of polycystic ovarian syndrome

Quality of Life, Psychosocial Well-Being, and Sexual Satisfaction in Women with Polycystic Ovary Syndrome

Health related Quality of Life in PCOS

Commentary: Promising clinical practices of metformin in women with PCOS and early-stage endometrial cancer

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References

  • Shetty D, Chandrasekaran B, Singh AW, Oliverraj J. Exercise in polycystic ovarian syndrome: An evidence-based review. Saudi Journal of Sports Medicine. 2017 Sep 1;17(3):123.
  • Sheehan MT. Polycystic ovarian syndrome: diagnosis & management. Clinical Medicine & Research 2004;2:13-27.
  • Harrison CL, Lombard CB, Moran LJ, Teede HJ. Exercise therapy in polycystic ovary syndrome: a systematic review. Human Reproduction Update. 2010 Sep 10;17(2):171-83.

Goodman CC, Fuller KS, editors. Pathology: implications for the physical therapist. 3rd ed. St Louis: Saunders Elsevier, 2009. Soap Note: Polycystic Ovarian Syndrome Assignment