PCOS: uncovering polycystic ovary syndrome (in an 11-year old girl!)

PCOS: uncovering polycystic ovary syndrome
by Rebecca Murray

May, 2004

WHEN she was 11, Bethany * won a soda-drinking contest–26 cans of regular soda in 15 minutes.

Over the next week, Bethany felt sick and achy. She didn’t feel like eating, so she just drank soda. She kept getting weaker. Her mother took her to the emergency room.

Bethany was lethargic and dehydrated. Her blood glucose level was found to be an extremely high 994 mg/dl. She was admitted to the hospital to start treatment for what was thought to be type 1 diabetes. She was discharged on a split-mix insulin plan.

Bethany failed to reach healthy blood glucose levels with the doses originally prescribed, so the doses were increased at her next two appointments with her primary care doctor.

A Lot Of Insulin

At age 12, Bethany came to us for a school physical. We were surprised when she told us how much insulin she was taking. In the morning, she took 60 units lente plus 40 units rapid-acting insulin; at lunch, 45 units rapid-acting insulin; and at dinner, 70 units lente plus 30 units rapid-acting insulin.

Bethany was taking a total of 245 units of insulin a day, or 2.6 units per kilogram of body weight per day. We would expect a girl with type 1 diabetes of Bethany’s age to be taking 0.7 to 1.2 units/kg/day. For a girl of Bethany’s weight, that would be a total of 66 to 113 units per day.

Seven weeks before we saw her, Bethany’s A1C was 9 percent. This was more than her goal of less than 7 percent, so she had been told to increase her insulin doses. She hadn’t done so, because that would have put her over 100 units at breakfast and dinner, which would mean she’d have to take two shots. So she kept taking the same insulin doses, which allowed her to fill a single 1-cc syringe.

Bethany was taking a lot of insulin, and even that was not enough to keep her blood glucose levels in the healthy range. This indicated insulin resistance. Insulin resistance means that muscle and fat cells require high levels of insulin before they will take in glucose. Insulin resistance is characteristic of type 2 diabetes.

Bethany was five feet, four inches and weighed 208 pounds. Overweight is associated with insulin resistance and with type 2 diabetes.

We got a copy of Bethany’s medical records. At her emergency room visit, Bethany did not have ketoacidosis, a condition more commonly seen in children with type 1 diabetes than type 2. We ordered a blood test for the immune markers often seen in type 1 diabetes; the result was negative.

It seemed that Bethany had type 2 diabetes, not type 1. But that was only part of her story. She also had signs of another health problem, which was related to her insulin resistance.

Too Much Testosterone

Bethany reported that her periods didn’t come every month. She’d had fewer than nine periods in the past year.

She had severe acne on her face and back.

Her waist (45.5 inches) was bigger than her hips (43 inches). This “apple shape,” also known as male-pattern fat storage, is associated with certain health problems. (Storing fat in the thighs, giving the body a pear shape, is female-pattern fat storage.)

These were signs that Bethany had too much testosterone in her system.

Both men and women make testosterone. Healthy women produce a protein that binds almost all of this testosterone. If a woman produces extra testosterone or too little of the binding protein, she’ll have too much free testosterone (the active form) in her system and may show signs of this excess.

We ordered more blood tests. They showed that Bethany had both high levels of testosterone and low levels of the binding protein, leaving her with a very high, free (active) testosterone level.

We concluded that Bethany had polycystic ovary syndrome (PCOS).

PCOS

It may seem that if you have your period, you must be ovulating. But that’s not necessarily true. In the normal menstrual cycle, female hormones cause the uterus to prepare for a pregnancy, and also cause an egg to mature and be released. When the egg is released (ovulation), the balance of female hormones changes; if the egg is not fertilized, the uterus sheds its lining (your period).

Insulin resistance can lead to an imbalance of female hormones. The uterine lining may build up in the first half of the cycle, but if the balance of female hormones isn’t right for the release of the egg, ovulation won’t occur, and the uterine lining will continue to build up. Your period may be late, with heavy flow, clots, and lots of cramps. Of you may have what’s called dysfunctional uterine bleeding: You have short “periods” more than once a month, for example bleeding for just two days every two weeks or so.

Insulin resistance messes with more than the female hormones. It can lead to the production of excess testosterone, or too little of the binding protein.

No ovulation and too much testosterone indicate the polycystic ovary syndrome.

Sensitivity

We needed to lower Bethany’s insulin resistance.

Metformin is an oral medication that suppresses the liver’s production of glucose and increases insulin sensitivity (reduces insulin resistance). It’s often used to treat type 2 diabetes. We prescribed 500 mg extended-release metformin at night.

Bethany had been using lente insulin. Because lente has an unpredictable action curve, we prescribed the long-acting insulin analog glargine (Lantus), 100 units at night. She continued to take rapid-acting insulin before meals.

She switched to a combo meter that checks blood glucose levels and dispenses insulin. She was intrigued by this new meter, and it motivated her to check her blood glucose levels more often.

Bethany’s fasting blood glucose level, which had ranged from 200 to 300 mg/dl, went down to 88 mg/dl. We reduced her insulin glargine dose and increased her metformin dose every week until she was taking 2,000 mg of metformin a day.

Bethany met with her nurse practitioner, who was also a certified diabetes educator. Bethany learned one reason she and her brother had gained a lot of weight in the past year: From the time they got home from school until they went to bed, they ate snacks and drank soda. Bethany learned healthier eating habits. She also learned that by getting more exercise, she could reduce her insulin resistance even further.

In four months, Bethany lost 40 pounds. She was reaching her blood glucose goals, by taking 2,000 mg metformin, 35 units of glargine at night, and 20 units of rapid-acting insulin per day. So her daily insulin dose was now 0.7 U/kg/day, instead of 2.6 U/kg/day. Her acne was clearing up, and her periods had started again. Lab tests confirmed that her free testosterone levels were in the normal range (see “Bethany’s Lab Results” above).

* This case is real. The patient’s name has been changed.

signs and symptoms of PCOS in teens or adult women

* Abnormal menstrual cycles

* No periods

* Irregular periods

* Heavy or prolonged bleeding

* Painful periods

* Can’t get pregnant

* Acne

* Facial hair (more hair than is normal for your ethnic group)

* Waist measurement greater than 35 inches, or waist bigger than hips (apple shape)

* Male-pattern hair loss

* Acanthosis nigricans: darker patches of skin in neck folds, armpits, folds in waistline, or groin.

are you insulin resistant?

Any “yes” answer means you are at higher risk for insulin resistance:

Yes No

1. Do you have a family history of type 2 diabetes?

2. Do you belong to a race or ethnic group that has a genetic
predisposition to insulin resistance: American Indian, African
American, Latino, Asian/South Pacific Islander? (But being
Caucasian doesn’t exempt you: The patient in this case study
was Caucasian.)

3. Have you given birth to a baby weighing more than nine
pounds, or did you yourself weigh more than nine pounds at
birth?
Your daily insulin dose also gives you a clue about your insulin sensitivity.

Add up all the insulin units you take in a day: long-, intermediate-, short-, and rapid-acting insulins. Divide that total by your weight in kilograms (your weight in pounds divided by 2.2).The answer is your units per kilogram per day.

Below are expected daily insulin doses for people who have type 1 diabetes (that is, all their insulin needs are met with injected insulin) and normal insulin sensitivity. If you use more than this, it’s a sign that you have some degree of insulin resistance.

To Reduce Insulin Resistance

* Lose some excess weight. Just five to 10 pounds will make a difference.

* Be more physically active.

* Ask your health care provider about medications.

expected insulin doses

Dose
Who, What, When (U/kg/day)

Motivated exerciser, woman in first half of menstrual
cycle (the two weeks after bleeding starts) 0.6

Woman in last week of menstrual cycle (the week before
bleeding starts) or in 1st trimester of pregnancy, adult
mildly ill with a virus child starting puberty 0.7

Woman in 2nd trimester of pregnancy, child in mid-puberty,
adult with severe or localized viral infection 0.8

Woman in 3rd trimester of pregnancy, child in mid-puberty,
adult ill with bacterial infection 0.9

Woman with a full-term pregnancy, adult with a severe
bacterial infection or illness, child at peak of puberty 1.0

Child at peak of puberty who is ill 1.5-2.0

Bethany’s lab results

Average levels Bethany’s Bethany’s
in girls of results when results four
Bethany’s age first tested months later

Testosterone (ng/dl) 22 (normal 64.0 23.1
range: 13-32)

Sex hormone- 72 (normal 14.0 16.7
binding globulin range: 15-123)
(testosterone
binder) (nmol/L)

Free androgen (a 5 or less 15.5 5.0
calculated ratio of
testosterone and
the binder)
Rebecca Murray, APRN, MSN, FNP, CDE, is an assistant clinical professor of nursing on the adjunct faculty at Yale University School of Nursing in New Haven, Conn., and the nurse practitioner at the West Side School-Based Health Center in Groton, Conn. She is a nationally recognized speaker on the topic of insulin resistance and type 2 diabetes in children and adolescents.

COPYRIGHT 2004 American Diabetes Association
COPYRIGHT 2004 Gale Group
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