Polycystic Ovary Syndrome Patient Cases (Written by Dr. Kassandra Bartelme, Concordia University Wisconsin School of Pharmacy and Dr. Laura Borgelt, University of Colorado - Denver School of Pharmacy) PATIENT PN PN is a 31 year old female who was referred to you by her OB/GYN for education and therapeutic recommendations. She was diagnosed with PCOS when she was 24 years old. Labs at that time showed she had an intact HPO axis (normal FSH and estrogen production). She was put on a combined hormonal pill. That worked well to regulate her cycle and reduce her acne. She denies any problems while on the pill. She went off the pill in October 2013 when she got married. Her husband and she have been trying to get pregnant for about a year without success. Initially, she was tracking her body basal temperature without much success as she found it difficult to check her temperature before moving in the morning and therefore the temperatures were all over the place. She has recently tried tracking whether or not she’s been ovulating using an ovulation prediction kit. She has not had a positive OPK in the past three months that she’s been tracking it. She came to her OB/GYN to talk about her options. She is wondering how having PCOS affects her ability to get pregnant and wonders what she can do about it. SH: No tobacco, no alcohol, drinks 1 can of diet Coke daily, no illicit drug use, no intentional exercise PMH: PCOS, diagnosed in 2010 Medications: Pre-natal vitamins 1 tablet PO once daily for supplementation Vitamin D 2000 units 1 capsule PO once daily for supplementation Allergies : NKDA Height: 5’7” ADRs: None Weight: 185 lbs BP: 119/62 P: 79 Urine hCG: negative FBG: 105 mg/dL TSH: 2.3 milli-international units/ml (0.5 – 5 milli-international units/ml) 1. How would you explain to PN how PCOS affects her ability to get pregnant? 2. What do you recommend to PN to assist her in getting pregnant? 1 3. What education points to share with PN? LONGITUDINAL PATIENT KB Encounter #1: KB is a 25 yr old female in clinic today for a co-consult with the medical resident and clinical pharmacists because she does not have normal periods. She has not had a normal period since she was 13 years old. She has now been trying to become pregnant for more than 15 months. She states the hair growth on her upper lip has been growing thicker the past few years, but she gets it waxed routinely. She has struggled with being obese and finds it hard to lose weight. She has walked 5 days/week for 20 minutes for the past 6 months and lost 2 pounds. She is interested in finding out what is “wrong with her” so she can become pregnant. Allergies: none Meds: none Family history: father with diabetes Social history: no tobacco, occasional alcohol Objective: Vitals WNL Height: 5’7” Weight: 205 pounds Assessment: possible PCOS as evidenced by patient history and clinical characteristics Plan: draw pertinent laboratory values, have patient follow-up in 1 week. Continue exercise. Encounter #2: KB presents to clinic today for follow-up of lab values and evaluation of probably PCOS. No changes from previous visit. O: Significant lab findings: LH:FSH ratio 3.5 (high) TSH 3.5 IU/ml (normal) free testosterone 70 ng/dl (high normal) FPG 116 mg/dl A: PCOS as evidence by menstrual dysfunction and hirsutism. Lab values support diagnosis. Impaired glucose tolerance based on FPG (100-125 mg/dl). P: Continue non-pharmacologic regimen, with more aggressive diet and exercise. Options for hair removal discussed and referred to clinical pharmacy for pharmacotherapy recommendations. Question #1: Would you consider an antiandrogen in KB for hirsutism? 2 Encounter #3: KB has been referred to the clinical pharmacist for a therapy recommendation. She has been compliant with her diet and exercise regimens, but unable to lose weight. She desires to become pregnant in the near future. O: BP 134/88 HR 74 Temp 98.7F Ht: 5’7” Wt: 204# A: PCOS. Desire to meet patient and treatment goals. Options include ovulation-induction agents and insulin sensitizing agents. Question #2: What would you recommend? 3