Jenny was a 28-year-old woman with PCOS. She had irregular periods (cycle length 45-90 days), excessive hair growth on her face and abdomen, and a family history revealed diabetes in both her mother and paternal grandparents.

Jenny was in the very unhealthy weight range. She was overweight at a young age and, as with most young Australian women, she had continued to gain weight at about 800g a year since puberty. She worked part time and studied. She was self-conscious about her weight, had low self-esteem, avoided exercise in public and was very sedentary.

Jenny had always struggled with her weight and had no confidence she could achieve meaningful, sustainable weight loss. She claimed to have tried “every diet available” and now attended wanting medical therapy to address her PCOS, which she had read on the Internet was the primary cause of her weight gain.

On examination Jenny was Caucasian and obese, with a BMI of 34kg/m². Abdominal waist circumference was increased at 95cm. She had hirsutism (Ferriman-Gallwey score of 9 (>8 indicates hirsutism or excessive hair growth), but had no acne and was not otherwise virilised.

Investigations revealed normal TSH, prolactin and 17 hydroxyprogesterone levels. A vaginal ultrasound revealed normal endometrial thickness and PCO (figure 3). Testosterone was 2.7nmol/L and the free androgen index was elevated at 10 per cent. An OGTT revealed a fasting glucose level of 5.6mmol/L and two-hour glucose level of 8.9mmol/L, demonstrating IGT.

The diagnosis of PCOS was confirmed, with the presence of hirsutism, hyperandrogenism and irregular cycles as well as PCO on ultrasound. Other causes were excluded clinically and biochemically.

When Jenny’s internet resources were reviewed it was apparent that she had been misinformed about her condition. She was directed to more appropriate evidence-based resources (see Resources).

It was also recognised that her psychosocial features were likely to impact negatively on her quality of life and on her ability to self-manage this chronic disease as well as her ability to set and achieve lifestyle goals. This was addressed as a priority.

A health coaching approach based on simple education, patient engagement, support and goal setting was discussed (with simple achievable goals agreed to by the patient and her health professional).

The successes of even small weight losses were reinforced and it was emphasised that these improvements are observed even when people remain clinically overweight or obese (BMI >25kg/m²).

The target was to support Jenny until she was able to transition to a position where her readiness to change had improved, before setting lifestyle goals. Hence she was referred to a psychologist to assist with care.

After Jenny started to address some of these psychosocial issues and had progressed to a stage where she was able to consider small sustainable changes in her lifestyle with goal setting, she was advised on the critical role of lifestyle and was referred to a dietitian.

She was advised that lifestyle change improves menstrual regularity, increases fertility, reduces pregnancy complications, reduces the risk of type 2 diabetes in people with IGT, improves psychological health (self-esteem, anxiety and depression), improves other cardiovascular risk factors (dyslipidaemia, inflammatory markers and blood pressure) and has long-term potential to reduce risk for cardiovascular disease. The successes of even small weight losses were reinforced and it was emphasised that these improvements are observed even when people remain clinically overweight or obese (BMI >25kg/m²).

Comprehensive assessment of lifestyle, including incidental activity, exercise, dieting and weight history had revealed a sedentary lifestyle and inappropriate diet, including skipping breakfast and carbohydrate loading later in the day. Physical activity tips were provided, including a focus on inexpensive options such as increasing incidental exercise (daily activities, e.g. climbing stairs) and making these changes a routine. Simple enjoyable activity such as walking on a daily basis was recommended.

Jenny was referred to a dietitian (Medicare eligible, as PCOS is recognised as a condition with obesity-related comorbidities). Eating breakfast was the first goal agreed on and slowly over the next 12 months Jenny made considerable step-by-step changes to her lifestyle, resulting in a 6 per cent weight loss and considerable improvement in healthrelated behaviours, mental wellbeing and energy levels. It was repeatedly emphasised that this degree of weight loss was significant from a health perspective and that reaching this goal was a significant health achievement.

Jenny’s high risk of type 2 diabetes (particularly with current IGT and family history of type 2 diabetes) was discussed. A lipid profile showed mild dyslipidaemia and ongoing monitoring was emphasised. Jenny’s family was screened and her father was found to have type 2 diabetes, giving Jenny a more than 70 per cent lifetime risk of developing diabetes and increasing her motivation to adhere to her new lifestyle program.

As medical treatment is no substitute for lifestyle change, in Jenny’s case it was deferred to focus on lifestyle therapy initially. Jenny had an increase in frequency of her menstrual cycles to an average of 35 days, and no medical therapy was instituted, although the role of therapy in the future was discussed (see Treatment).

This article first appeared in Australian Doctor - How to treat on 29 August 2008 and has been reproduced here with permission.

 Australian Doctor - How to treat: Polycystic ovary syndrome 437.44 Kb

Content updated 7 September 2011