LESSON PLAN ON

POLYCYSTIC OVARY SYNDROME

( PCOS)
S. TIME SPECIFIC CONTENT TEACHING LEARNING AV EVALUATION
NO OBJECTIVES ACTIVITY ACTIVITY AIDS
1 3min Students will Anatomy and physiology Lecture Answering Mode .
l
be able to The ovary is an organ found in the female reproductive cum
review the system that produces an ovum. The ovaries also Discussio
anatomy and secrete hormones that play a role in the menstrual n and
physiology of cycle and fertility. The ovary progresses through many stages questionin
Ovary beginning in the prenatal period through menopause. It is also an g
endocrine gland because of the various hormones that it secretes.

Structure
 The ovaries are considered the female gonads. Each ovary is
whitish in color and located alongside the lateral wall of
the uterus in a region called the ovarian fossa.

 This area is about 4 cm x 3 cm x 2 cm in size. The ovaries are

surrounded by a capsule, and have an outer cortex and an inner
medulla.
Microanatomy

The surface of the ovaries is covered with membrane consisting

of a lining of simple cuboidal-to-columnar shaped mesothelium.

The outermost layer is called the germinal epithelium.

 The outer layer is the ovarian cortex, consisting of ovarian

follicles and stroma in between them.

 Included in the follicles are the cumulus

oophorus, membrana granulosa, corona radiata, zona
pellucida, and primary oocyte.

 Theca of follicle, antrum and liquor folliculi are also

contained in the follicle.

 Also in the cortex is the corpus luteum derived from the

follicles. The innermost layer is the ovarian medulla.

 It can be hard to distinguish between the cortex and

medulla, but follicles are usually not found in the medulla.

Follicular cells flat epithelial cells that originate

from surface epithelium covering the ovary, are surrounded
by Granulosa cells - that have changed from flat to cuboidal and
proliferated to produce a stratified epithelium

Ligaments
 The ovaries lie within the pelvic cavity, on either side of the
uterus, to which they are attached via a fibrous cord called
the ovarian ligament.

 The ovaries are uncovered in the peritoneal cavity but are

tethered to the body wall via the suspensory ligament of the
ovary which is a posterior extension of the broad ligament of
the uterus.

 The part of the broad ligament of the uterus that covers the
ovary is known as the mesovarium.

 The ovarian pedicle is made up part of the fallopian

tube, mesovarium, ovarian ligament, and ovarian blood
vessels.

Functions
1. Gamete production: oocytes (eggs) are produced, protected
and released from ovaries.
 2. Hormone secretion: it produces female reproductive
hormones called estrogen and progesterone,very small
amounts of androgens and some lesser hormones called
relaxin and inhibin.
Estrogen used by the body to help develop adult female
characteristics, such as breasts and larger hips, and to aid in the
reproduction cycle.
Progesterone is also key to reproduction.
Relaxin loosens the pelvic ligaments so they can stretch during
labor.
Inhibin prevents the pituitary gland from producing hormones.

Define PCOS?
 Taking Roll
2 2min Students will notes er
be able to boar
define PCOS d

Listening
& taking
Hypothalamic pituitary and gonadal Axis notes

PCOS
DEFINITION
Polycystic ovary syndrome is a type of hormonal imbalance or
cystic disorder that affects the ovaries.
-Brunner & Suddart’s
Polycystic ovary syndrome is a chronic disorder in which many
benign cysts form on the ovaries
-Lewis

Polycystic ovary syndrome defined by multiple cysts growing on

the outer edge of the ovaries due to a lack of hormones that allow
an egg to be released from the follicle.
- Wikipedia
Polycystic ovary syndrome (PCOS) is a condition in
women characterized by irregular or no menstrual periods, acne,
obesity and excess hair growth. - Umland EM
 List out
etiology and
Listening Han risk factors of
&Taking d PCOD?
3 3min Students will notes outs
be able to list
out etiology
of PCOD INCIDENCE:
It is the most common disorder occur in women under 30 years of
age group.
Approximately 5 to 10 percent of women of childbearing age
In united states 4-12% of reproductive age women.
In European countries 6.5-8% are affecting with PCOS.
In India 2.2-26% are reported with PCOS

ETIOLOGICAL FACTORS
 The exact cause of PCOS isn't known.

Factors that might play a role include:

 Heredity. Research suggests that certain genes might be

linked to PCOS. Mutation of the insulin receptor gene in the
peripheral target tissue
  Excess insulin. Insulin is the hormone produced in the
pancreas that allows cells to use sugar, body's primary
energy supply. If cells become resistant to the action of Narrate the
insulin, then blood sugar levels can rise and body might Listening Patho-
4 3min Students will produce more insulin. Excess insulin might increase & OHP physiology of
be able to androgen production, causing difficulty with ovulation. Asking PCOD?
narrate the  Low-grade inflammation. Research has shown that women doubts
Patho- with PCOS have a type of low-grade inflammation that
physiology of stimulates polycystic ovaries to produce androgens, which
PCOD can lead to heart and blood vessel problems.
 Excess androgen. The ovaries produce abnormally high
levels of androgen, resulting in hirsutism and acne.

PATHOPHYSIOLLOGY

Answerin
g
 Enlist the
clinical
Leaf manifestations
Listening lets of PCOD?
Students will and taking
5 3min be able to notes
enlist the
clinical
manifestations
of PCOD

Enumerate the
Excess androgen(hyperandrogenism)
diagnostic
 findings of
Taking Blac PCOD?
Reduced Lipid Abdomi Sympto
Students will Insulin notes k
sex abnormal nal ms of
be able to insensiti boar
hormone ities obesity androg
6 4min enumerate the vity d
binding en
diagnostic
globulin excess
findings of
PCOD (SHBG)
CLINICAL MANIFESTATIONS
Signs and symptoms of PCOS often develop around the time of the
first menstrual period during puberty.
Menarche: Menstrual irregularities (Oligomenorrhea (70-75%)
amenorrhea (20%) most common sign of PCOS.
Acne and hirsutism
Reproductive: Infertility (30-70%) Miscarriages, Pregnancy
complications
Menopause: Endometrial hyperplasia
Excess androgen. Excess facial and body hair (hirsutism), and
occasionally severe acne and male-pattern baldness
Acanthosis nigricans: brown to black, poorly defined, velvety
hyperpigmentation of the skin.
Obesity
Insulin resistance
DIAGNOSTIC EVALUATIONS:

 History collection- this including menstrual periods and

weight changes.

 A physical exam- this will include checking for signs of

 excess hair growth, insulin resistance and acne.

 Modified ferriman gallwey score for assessing hirsutism

9 areas of hormonally sensitive body parts. upper lip, jaw& neck,

chin, upper back, lower back, upper arms, thighs sideburn area.
Score 1-4. 0- absence of terminal hair,4-extensive terminal hair
growth.
Score of > 8 -hirsutism
 A pelvic exam. The doctor visually and manually inspects
reproductive organs for masses, growths or other
abnormalities.

 Blood tests. Elevated total testosterone

Most values in PCOS <150 ng/dl( if >200 ng/dl consider

ovarian or adrenal tumor)

Free androgen index > 4.5 (FAI= Total testosterone x

100/SHBG) Considered a better indicator.

Normal SHBG =80-144 nmol/L

 LH/FSH Ratio >2 has little diagnostic sensitivity

 Hyperinsulinemia: FBS -110-125 mg/dl

 75grams Oral glucose tolerance test is more sensitive

Normal: 2 hour glucose <140 mg/dL

Mention the
Impaired glucose tolerance: 2 hour glucose 140–199 mg/Dl medical
 Diabetes: 2 hour glucose ≥200 mg/dL Answerin Slide management of
7 4min Students will g s PCOD?
be able to  An ultrasound: Increases ovarian area(>5.5cm2) or
mention the volume(11ml/presence of >12 follicles measuring 2-9 mm in
medical [Link] sclerotic cortex
management  Periodic checks of blood pressure, glucose tolerance, and
of PCOD cholesterol and triglyceride levels

Screening for depression and anxiety

 Screening for obstructive sleep apnea
MANAGEMENT:

GENERAL MEASURES:

Life style modification: PCOS who are obese. endocrine metabolic

parameters markedly improve after 4-12 weeks of dietary
restrictions

Diet &exercise:

Daily 500-1000 calorie deficit with 150 mts of exercise per week
can causes ovulation

MEDICAL MANAGEMENT

FIRST LINE AGENTS:

Clomiphen (clomid):
Mechanism of action: it helpful for the induction of ovulation.
This oral anti-estrogen medication is taken during the first part of
menstrual cycle.
Dose: 50 to 100 mg per day

Adverse affects: Multiple pregnancy/ovarian hyperstimulation,

thromboembolism, visual disturbances

Edlornithine(Vaniqa): Mechanism of action: it Inhibits hair

growth

Dose: 13.9% cream applied to face twice per day

Adverse affects: Mild skin irritation

Metformin therapy: ( Glucophage, Fortamet, ). This oral

medication for type 2 diabetes improves insulin resistance and
lowers insulin levels. If women don't become pregnant using
clomiphene, doctor might recommend adding metformin. If
women have prediabetes, metformin can also slow the progression
to type 2 diabetes and help with weight loss.

It can improve menstrual irregularities (e.g., oligomenorrhea).

Starting dose is 500 mg given orally twice a day
Target dose: 1500-1800 mg/day

Adverseeffects:
Dairrhoea,Nausea,Vomiting,Flatulence,Indigestion,Abdominal
Discomfort.
Hormone therapy

To regulate your menstrual cycle, doctor might recommend:

Oral contraceptive pills( Desogestrel/ethinyl estradiol)

Mechanism of action: oral contraceptive

Dose: 0.15 mg desogestrel plus 30 mcg ethinyl estradiol per day.

Adverse effects: Increased total cholesterol and low-density

lipoprotein cholesterol; thromboembolism, stroke, MI

Combined contraceptive pills ( Aviane, Azurette, Balcoltra,

Beyaz)
Mechanism of action: It inhibits ovulation by inhibiting
gonadotrophin secretion via an effect on both pituitary and
hypothalamic centres. The progestational agents suppress LH and
estrogens suppress FSH.
Adverse effects: Nausea, vomiting, mastalgia, Breakthrough
bleeding ,Migraine headache ,Wt. gain , Acne and Hirsutism (19-
nortestosterone derivatives), Chloasma (skin pigmentation),
Thromboembolism, Ischemic heart disease ,Hypertension, Increase
TAG , Cholecystitis and gall stones. , Hepatotoxicity
Progestin therapy. Taking progestin for 10 to 14 days every one
to two months can regulate periods and protect against endometrial
cancer. Progestin therapy doesn't improve androgen levels and
won't prevent pregnancy. The progestin-only minipill or progestin-
containing intrauterine device is a better choice
Gonadotropins.( follicle-stimulating hormone [FSH] injections) .
 Mechanism of action: It triggers ovulation.
Dose: 150 IU daily.
Adverse effects: Headache, nausea, vomiting, mild
stomach/abdominal pain, bloating, redness/pain
Spironolactone (Aldactone).
Mechanism of action: Antiandrogenic (blocks the effects of
androgen on the skin). It isn't recommended if women pregnant or
planning to become pregnant.
Dose: 50 Mg Per Day To 100 to 200 Mg Per Day
Adverse effects: Hyperkalemia, nausea, breast tenderness
SECOND LINE DRUGS:
Acarbose (Precose): It is using to treat the hirsutism and
menstrual irregularities
Mechanism of action: Insulin-sensitizing agent increases insulin
sensitivity. Discuss the
Dose: 150 mg per day (for menses regulation) nursing
Adverse effects: GI upset Listening Blac process of
8 5min Students will Letrozole (Femara): k PCOD?
be able to Mechanism of action: Nonsteroidal competitive inhibitor of boar
discuss the aromatase; inhibits conversion of adrenal androgen d
nursing Dose: 2.5 mg per day
process of Adverse effects: Osteoporosis, thromboembolism, MI, hot flashes,
PCOD arthralgia
Sibutramine (Meridia)
Mechanism of action: Centrally acting appetite [Link] will
reduces the hirsutism.
Dose: 10 mg /day
Adverse effects: Tachycardia, hypertension, headache, dry mouth
Electrolysis. A tiny needle is inserted into each hair follicle. The
needle emits a pulse of electric current to damage and eventually
destroy the follicle.
SURGICAL MANAGEMENT:
Should be used only as a method of induction of ovulation not for
treatment of PCOS symptoms
Laparoscopic ovarian drilling using electrocautery or laser therapy:
to destroy parts of the ovary. By destroying areas of the ovary,
ovulation can be triggered.
NURSING MANAGEMENT:
Nursing assessment:
Subjective data:
Assessment of the patient for pelvic conditions involves assessing
for risk factors presenting symptoms medical and gynaecological Answerin
history. g
Objective data: hypertension, changes in blood hormone levels,
changes in serum cholesterol and blood glucose levels, sites of
excessive hair growth.
NURSING DIAGNOSIS:
1. Anxiety related to outcome of health status/effect of health
condition/insufficient knowledge of disease as evidenced by
expressed concerns due to change of life events /fearful/over
excited.
2. Disturbed body image related to changes in physical appearance
(obesity, acne) as evidenced by refusal to verify actual change/loss
by impersonal.
[Link] knowledge related to cognitive limitation as evidenced
by verbalization of the problem/inappropriate behaviours
[Link] individual coping related to cause of infertility as
evidenced by
5. Fear related to procedures and treatment as evidenced by
excitement/looking panic.
NURSING PROCESS
Nursing diagnosis: Anxiety related to outcome of health
status/effect of health condition as evidenced by expressed
concerns due to change of life events /fearful/over excited
Goal: The client will relate less anxiety after teaching
Verbalizes reduction of anxiety within one week.
Interventions Rationale

Assess the client level of It helps to know the

anxiety and physical reactions anxiety levels of the individual.
to anxiety(tachycardia ect)
Determine the level of It helps to better
understanding and reinforce understanding of the
physician’s explanation health status

Explain all activities, It lessens the anxiety levels

procedures to the patient. and helpful for better coping

Provide backrub/massage Massage decrease anxiety

or perception of tension

Use therapeutic touch and It transfer of healing energy

healing touch from the environment through
the healer to the patient
 Provide psychological It helps to decrease the
&emotional support to the emotional feelings
patient.
Encourage to express their It helps to improve the
feelings &expression. coping capabilities.

Expected outcome: client will identify and verbalizes symptoms

of anxiety
Verbalizes absence or decrease in level of anxiety
Demonstrate some ability to reassure self
2. Nursing diagnosis: Disturbed body image related to changes in
physical appearance (obesity, acne) as evidenced by refusal to
verify actual change/verbalization of feelings.
What are the
Goal: The client will verbalize acceptance of changed physical
complications
appearance
Flas of PCOD?
Interventions Rationale
9 2min Students will h
be able to card
Assess and identify the clients It helps to provide baseline
what are the s
concerns about changes of information for further activities
complications
body image
of PCOD
Discuss possible changes in It helps to reduce the fear
weight and hair loss and anxiety.
Observe client’s usual coping It helps to assist the client to
mechanisms during times of cope with change
stress and reinforce their use
in current situation
 Encourage the client to make It helps to adjust to the changes
own decision and participate in body image List the
in plan of care lifestyle
10 2min Students will Encourage the client to write Client need assistance and encouragement in adjusting to Blac modifications
be able to list their concerns related to alterations in body image and k for PCOD?
the lifestyle change helps to coping toward change in boar
modifications body image. d
for PCOD Expected outcome: client demonstrate acceptance of change in
body image
Client return to previous social involvement and activities
COMPLICATIONS
Complications of PCOS can include:
 Infertility
 Gestational diabetes or pregnancy-induced high blood
pressure
 Miscarriage or premature birth
 Nonalcoholic steatohepatitis — a severe liver inflammation
caused by fat accumulation in the liver
 Metabolic syndrome — a cluster of conditions including high
blood pressure, high blood sugar, and abnormal cholesterol
or triglyceride levels that significantly increase your risk of
11 cardiovascular disease
 Type 2 diabetes or prediabetes
 Sleep apnea
 Depression, anxiety and eating disorders
 Abnormal uterine bleeding
 Cancer of the uterine lining (endometrial cancer)
 LIFESTYLE AND HOME REMEDIES
To help decrease the effects of PCOS, try to:
 Maintain a healthy weight. Weight loss can reduce insulin
and androgen levels and may restore ovulation and meet
regularly with a dietitian for help in reaching weight-loss
goals.
 Limit carbohydrates and sugars
 Include diet contain Low-fat, low-carbohydrate and low in
sugar Choose complex carbohydrates, which raise your
blood sugar levels more slowly
 Ideal diet consists of a variety of foods from various food
groups—healthy carbohydrates, such as vegetables and
fruits; lean meats, such as poultry; fish; and high fiber
grains. Take ∼1400 kcal/day
 Be active. Exercise helps lower blood sugar levels.
Increasing daily activity and participating in a regular
12 exercise program may treat or even prevent insulin resistance
and help to keep weight under control and avoid developing
diabetes.
13

SUMMARY
 So far we have discussed definition, aetiology, risk factors, Pathophysiology, clinical manifestations, diagnostic evaluations,
medical management, nursing interventions, complications and life style modifications of PCOS. So that the student can improve the knowledge
on PCOD.

CONCLUSION

 The students now know the PCOS

 Students should be able to provide nursing care to the patients suffering with PCOS in the hospital & community care settings
Hope that students understood the topic

BIBLIOGRAPHY
Book References:
1. Textbook of Medical Surgical Nursing, Brunner & Suddarth, 12thedition, wolters kluwer pvt. Ltd New Delhi, Page no. 1075 -1077
2. Manual of Nursing Practice, Lippincott Williams &Wilkins, wolters kluwer health publishers, 10thedition, page no. 685 – 686
3. Medical Surgical Nursing clinical management for positive outcome, Joyce. M. Black, Jane Hokanson Hawks, ELSVIER publishers,
7thedition, volume – 1, page no. 812 – 814
4. Phillips “Medical Surgical Nursing” 8thedition, 2007 by Mosby Elesvier publishers, page no. 807 - 810

Journal References
1. World Journal of emergency Surgery, April 2014, volume24, page no. 83
2. Journal of medical emergency, July 2003, volume 67, page no. 114
3. Karger journal of Reproduction, october 5th 2016, vol- 31, page no. 43
4. US International Journal of Medicine, June 11th 2017, vol- 56, page no. 114-117
5. American Journal of Surgery, November 2nd 2015, vol- 17, page no. 216-218

Net References
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