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Integrated Nursing Practice

Introduction to Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS) is the most common hormonal disorder among females during their reproductive age and is the leading cause of female infertility (Havelock, 2018). Females that have PCOS usually show either irregular or prolonged menstruation and often reported to show excess androgen levels. The ovaries in the case of PCOS develops abundant follicles and fails to release the eggs regularly (Hayek et al. 2016). In the given case study, a caucasian female of 26 years of age named Sharon Munroe has a history of Polycystic Ovarian Syndrome for the past 6 years. Her medical history enlists that her menses have been terminated several years ago and she has gained 20 kg weight in the past 5 years, along with this mounting hirsutism, acne, and two prior miscarriages has also been mentioned.

Pathophysiology of Polycystic Ovarian Syndrome

Researchers consider that stress along with environmental factors such as diet, pollution, and exercise play a vital role in the expansion of polycystic ovarian syndrome. Other potential causes encompass the extreme prenatal exposure towards androgen and way too much production of the insulin (McCartney & Marshall, 2016). The pathophysiology of the polycystic ovarian syndrome starts with hypersecretion of androgens i.e., male hormones by the help of stromal theca cells of the polycystic ovaries. This results in the cardinal clinical expression of the disease pattern and hyperandrogenism along with one of the processes whereby follicular development gets subdued with the consequential surplus of the immature follicles. Hyperandrogenism includes hirsutism, acne, and androgenic alopecia.

Later on, the hypersecretion of the luteinizing hormone from the pituitary gland occurs which is the resultant of both of the anarchic ovarian-pituitary response along with the overstated pulses of Gonadotropin-releasing hormone modulator from the hypothalamus. This helps in stimulating the secretion of testosterone by the ovary. In addition to this, Insulin intensifies the impacts of luteinizing hormone because insulin serves as a persuasive stimulus in the secretion of androgen by the ovary. However, by the means of a dissimilar receptor for insulin that does not exhibits any insulin resistance amplifies the degree of hyperandrogenism. This occurs by the suppression of liver production of the major carrier protein i.e., sex hormone-binding globulin, and this uplifts the ‘free androgen index’. It is considered to be the combination of various genetic abnormalities that are combined with the environmental attributes. These attributes could be body weight and nutrition, which gradually starts affecting the expression of the syndrome (Rosenfield & Ehrmann, 2016).

Diagnostic Assessment of PCOS

PCOS is confirmed if someone is diagnosed with at least two of the symptoms among irregular periods, higher levels of androgen diagnosed from the blood test results, indications such as male-pattern balding, acne, or extra hair growth on chin, face, or body, or through the presence of cysts in the ovaries as depicted in an ultrasound examination. However, the whole diagnostic assessment first starts with the physical assessment which is later on followed by some blood tests (Bani Mohammad & Majdi Seghinsara, 2017).

In physical assessment examination of blood pressure, body mass index, extra hair growth, acne, and waist size is done. After this, Pelvic examination is done by taking a look at the vagina, uterus, cervix, fallopian tubes, ovaries, and rectum to examine if there is anything unusual. This is followed by the ultrasound of the pelvic region and if it shows 1½ to 3 times larger ovaries in size than normal then the PCOS is confirmed. Detection of luteinizing hormone, follicle-stimulating hormone, estrogens, testosterone, androstenedione, sex hormone-binding globulin, anti-mullerian hormone, and human chorionic gonadotropin is also done from blood test variance in the level of these hormones also confirms the PCOS (Witchel, Oberfield & Pena, 2019).

Pharmacological Management of PCOS

Evidence-based management of PCOS is of three types non-pharmacological, pharmacological, and surgical. However, focusing on the pharmacological management of PCOS, In a study by Williams, Mortada & Porter, (2016) it has been stated that pharmacological management and treatment is target specific manifestations and depend as well as administered according to the personalized patient goals. While selecting a treatment routine for Sharon Munroe, there is a need to focus on the comorbidities along with the patient's desire for pregnancy as she has gone through 2 miscarriages. There are few drugs that have been approved for the management of polycystic ovary syndrome. Insulin-sensitizing drugs are designated to most of the women who have PCOS as they show positive effects on insulin resistance, hirsutism, anovulation, menstrual irregularities, and obesity.

Clomiphene citrate and Metformin are considered to be safe in PCOS management. Clomiphene citrate is considered as an anti-estrogenic and estrogenic drug and found to be a competitive binding ER. Reports have shown that clomiphene citrate shows the ovulation rates of approximately 60%–85% while 30%–50% is its pregnancy rates after six ovulatory cycles. It has also been reportedly verified that the rates of twin and triplet pregnancy are 5%-7% and 0.3%, respectively. However, if the ovulation or pregnancy is not achieved after sixth ovulatory cycles with the utilization of clomifene citrate, then the patient is considered to be clomifene citrate resistant. While, Metformin alone has shown better ovulation results along with clinical pregnancy rate but, not live- birth rate. However, Metformin in combination with clomifene citrate shows a comparatively higher ovulation rate, pregnancy rate, and live-birth rate in the case of PCOS.

Conclusion on Polycystic Ovarian Syndrome

In this assessment, it has been concluded that there is still not a single cause found for the PCOS, however, stress, environmental factors, extreme prenatal exposure towards androgen, extreme production of the insulin are considered to play a vital role in the expansion of polycystic ovarian syndrome. The pathophysiology of the polycystic ovarian syndrome starts with hypersecretion of androgens and proceeded to the uplifting of the free androgen index. Male-pattern balding, acne, or extra hair growth on chin, face, or body, or the presence of cysts are some of the symptoms shown by the females that have PCOS. The diagnosis assessment encompasses the diagnostic assessment of the physical assessment which is later on followed by a few blood tests that show the confirmatory results of PCOS. However, there are certain Pharmacological ways to manage the PCOS that consists of insulin-sensitizing drugs that shows positive effects on insulin resistance, hirsutism, anovulation, menstrual irregularities, and obesity. Along with this, drugs such as Clomiphene citrate and Metformin or the combination of both are tried and tested safe in the management of PCOS and they are helpful in increasing the ovulation rates and the chances of pregnancy.

References for Polycystic Ovarian Syndrome

Bani Mohammad, M., & Majdi Seghinsara, A. (2017). Polycystic Ovary Syndrome (PCOS), Diagnostic Criteria, and AMH. Asian Pacific journal of cancer prevention : APJCP, 18(1), 17–21. https://doi.org/10.22034/APJCP.2017.18.1.17

El Hayek, S., Bitar, L., Hamdar, L. H., Mirza, F. G., & Daoud, G. (2016). Poly Cystic Ovarian Syndrome: An Updated Overview. Frontiers in Physiology, 7, 124. https://doi.org/10.3389/fphys.2016.00124

Havelock, J. (2018). Polycystic ovarian syndrome. BC Medical Journal, 30(4), 210-216.

McCartney, C. R., & Marshall, J. C. (2016). CLINICAL PRACTICE. Polycystic Ovary Syndrome. The New England journal of medicine, 375(1), 54–64. https://doi.org/10.1056/NEJMcp1514916

Rosenfield, R. L., & Ehrmann, D. A. (2016). The pathogenesis of polycystic ovary syndrome (PCOS): The hypothesis of pcos as functional ovarian hyperandrogenism revisited. Endocrine Reviews, 37(5), 467–520. https://doi.org/10.1210/er.2015-1104

Williams, T., Mortada, R., & Porter, S. (2016). Diagnosis and Treatment of Polycystic Ovary Syndrome. American Family Physician, 94(2), 106-113.

Witchel, S. F., Oberfield, S. E., & Peña, A. S. (2019). Polycystic ovary syndrome: Pathophysiology, presentation, and treatment with emphasis on adolescent girls. Journal of the Endocrine Society, 3(8), 1545–1573. https://doi.org/10.1210/js.2019-00078

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