Polycystic Ovary Syndrome Awareness Month

What is polycystic ovary syndrome?

Polycystic ovary syndrome (PCOS) is an imbalance in female sex hormones in women, which may cause problems such as excess hair growth, irregular menstrual cycles, trouble getting pregnant, ovarian cysts, and obesity. The most widely accepted criteria for diagnosis includes having at least 2 of the following 3 conditions: irregular or no ovulation, high levels of androgen (a male hormone) determined by either a blood test or symptoms, or multiple cysts on the woman’s ovaries. Often times many other diseases need to be ruled out in order for PCOS to be diagnosed. Some of these diseases include androgen secreting tumors, enlargement of the adrenal gland, and high levels of prolactin.

How many women are affected by PCOS and why should I worry about it?

PCOS currently affects anywhere from 4% to 12% of reproductive-aged women, making it the most common hormonal disorder in this age range. Many women are unaware they have PCOS until they try to become pregnant; diagnosis typically happens when women are in their 20s and 30s. The following list shows some, but not all, health risks that are associated with PCOS:

•        Pregnancy complications
•        Infertility
•        Type 2 diabetes mellitus
•        Cardiovascular diseases
•        Endometrial cancer
•        Depression

What are some of the signs and symptoms of PCOS?

PCOS is associated with many vague signs and symptoms. Women with PCOS may experience some of the following:

•        Irregular or absence of menstrual cycles
•        Excess hair growth in unusual places
•        Struggling to get pregnant
•        Unexplained weight gain
•        Pelvic pain
•        Acne after pubescence that does not go away with usual treatments
•        Oily skin

What can I expect when I go to my doctor?

There are multiple tests your doctor may choose to run to help make a diagnosis of PCOS, and to rule out other possible causes of PCOS symptoms.

Menstrual Cycle History and Pelvic Exam: Your doctor may ask about your previous menstrual cycles to try and determine if irregular ovulation is occurring. Be prepared to provide a previous history of your menstrual cycle for a longer duration than normally asked. An ultrasound, or other imaging technique, may be done to determine if your ovaries have any cysts.

Physical Exam: Since weight gain is a common sign of PCOS, your doctor may measure your weight and compare it to your previous weight. Body Mass Index (BMI), waist circumference, and blood pressure may be measured as well.

Blood Tests: A battery of blood tests may be conducted not only to help diagnose PCOS but also to rule out other causes of high levels of androgen hormones. Some of the following hormone levels may be tested: testosterone, thyroid stimulating hormone, prolactin, luteinizing hormone, anti-mullerian hormone, and dehydroepiandrosterone sulfate (DHEA-S). Even though this is a long list, typically one blood draw is all that is needed to test all of these levels. Your doctor may also instruct you to not eat before your office visit in order to perform an oral glucose tolerance test. This is when the insulin response to glucose in an unfed state is tested; your doctor will provide further instructions.

What are the treatment options for PCOS?

Treatment for PCOS ranges widely depending on the individual patient goal. The first line treatment recommendation for all symptoms is lifestyle modifications including diet and exercise. This has been shown to decrease a woman’s risk for cardiovascular disease and restore ovulation. It is important to remember that treatment for excess hair growth may take 6 to 12 months to see an improvement. Oral medications are unable to affect the hair that has already grown, therefore it may take longer to see an effect. Guidelines for treatment recommendations come from the American College of Obstetricians and Gynecologists and the Endocrine Society.

Treatment for absent or irregular menstrual cycles (less than 8 menstrual cycles per year):

•       Combined (estrogen and progesterone) hormonal contraceptives

o   First choice for this symptom

o   Examples include oral contraceptives, the patch, and the vaginal ring

o   Helps regulate menstrual cycles, decrease acne, and improve excess hair growth

•       Metformin

o   Second choice for therapy for women who cannot take contraceptives

o   Helps regulate insulin levels and potentially affects menstrual cycles

•       Progesterone Withdrawal Bleeding

o   Causes menses for women who do not want to use hormonal contraceptives

o   Recommended every 1-3 months

Treatment for infertility:

•       Estrogen modulators (clomiphene, letrozole, etc.)

o   First choice for women who experience difficulty getting pregnant

o   Can be combined with metformin, although unclear if it affects the ability to get pregnant

•       Exogenous gonadotropins

o   Examples of exogenous gonadotropins include purified urinary follicle-stimulating hormone (u-FSH), human menopausal gonadotrophin (hMG), and gonadotrophin-releasing hormone analogues (GnRH-a)

o   Second choice for women who experience difficulty getting pregnant

•       Procedures

o   Laparoscopic ovarian drilling removes ovarian cysts for women who don’t respond to clomiphene  

o   Timed intercourse and intrauterine insemination for women on clomiphene

o   In vitro fertilization (IVF) is the last line therapy for women with PCOS who have difficulty getting pregnant

Treatment for glucose intolerance:

•       Metformin

o   An insulin sensitizer that helps decrease the circulating levels of insulin

o   Given to women with type 2 diabetes mellitus

Treatment for excess hair growth:

•       Combined hormonal contraceptives

o   First choice for this symptom

o   Can add metformin

•       Spironolactone

o   Given at higher doses it can help decrease hair growth

Treatment for acne:

•       Combined hormonal contraceptives
•       Spironolactone
•       Topical creams or gels

o   Topical retinoids

o   Topical benzoyl peroxide

•       Topical or oral antibiotics
•       Isotretinoin

What can I do to help prevent complications if I already have PCOS?

It is important for women with PCOS to treat all symptoms, not just one. For example, changes in insulin levels may not cause physical symptoms, but they can lead to diabetes and future health complications. Therefore, it is important to regularly test for diabetes. Another way to help prevent future complications is through lifestyle modifications, including diet and exercise. Even a 5% decrease in body weight has shown to improve many symptoms of PCOS and help prevent future complications such as cardiovascular disease and diabetes.

Where can I find more information about PCOS?

PCOS Foundation

http://www.pcosfoundation.org

PCOS Awareness Association

http://www.pcosaa.org

American College of Obstetricians and Gynecologists

http://www.acog.org/~/media/For%20Patients/faq121.pdf?dmc=1&ts=20131119T1102251715

U.S. Department of Health and Human Services, Office on Women’s Health

http://www.womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.pdf

Mayo Clinic

http://www.mayoclinic.org/diseases-conditions/pcos/basics/definition/CON-20028841?p=1

Kendall Elayne Buchmiller

UIC - College of Pharmacy

​​Drug Information Extern​

​Class of 2016 President

September is Atrial Fibrillation Month

What is atrial fibrillation?

You might be thinking to yourself, what is atrial fibrillation (AF) and why should I care about it? To start off, AF is the most common type of irregular heartbeat.¹ Why is this important? Atrial fibrillation can lead to more severe complications, such as stroke or heart failure! Data show that patients with untreated AF are at a greater risk for having a stroke. How AF can cause a stroke is due to how the heart operates in these patients. The heart beats irregularly, causing blood to settle in the heart and form clots. These clots can be transported to the brain and cause a stroke.

Who does atrial fibrillation affect?

Atrial fibrillation affects up to 6.1 million Americans, with an overall frequency of occurrence around 1%.² In people aged 40 years or older, the general life-time risk for AF is 1 in 4. It is also seen more commonly in men than women.¹ Children are rarely affected by AF, unless they are born with structural heart disease.³ Some people are at a higher risk for developing AF than others. Factors known to increase your chances of developing atrial fibrillation are listed:

·       Increasing age

·       Hypertension

·       Diabetes

·       Heart attack

·       Heart failure

·       Obesity

·       Smoking

·       Excessive alcohol use

·       Hyperthyroidism

·       Family history of atrial fibrillation

How does one know if they have AF?

Patients can have AF without even knowing it. Many patients do not experience any symptoms. If a patient does have symptoms, they might feel things like a rapid pulse, shortness of breath, lightheadedness/dizziness, or vision problems. These symptoms are not specific for AF, and are seen in other health problems; getting diagnosed properly is key for detection of AF.

How is AF diagnosed?

A physician should be the one to diagnose atrial fibrillation. The main diagnostic test used to identify if a patient has AF is called an electrocardiogram (ECG). An ECG measures the rate and frequency of heartbeats. When a patient is in AF, an ECG is used to document the presence of it. Once diagnosed, blood tests should be completed to rule out other problems associated with AF.

What are the different types of AF?

There are three main types of AF, and each type is defined based on the frequency, duration, and rate of abnormal heart rhythms. Table 1 gives a broad summary on how each AF differs.

Table 1. Types of Atrial Fibrillation⁴

Type	Definition
Paroxysmal AF	·       Lasts less than 7 days without treatment
Persistent AF	·       Lasts longer than 7 days and does not end by itself
Permanent AF	·       Lasts longer than 7 days, even after medical attempts to fix it

How does one manage/treat atrial fibrillation?

One possible way to manage atrial fibrillation is through “electrical cardioversion.” This is a procedure where the heart undergoes electrical shocks, causing the heart to go from its irregular beats back to normal, regular rhythm. Not all patients can undergo this procedure, and the cardiologist will decide which patients should use it. Candidates of cardioversion are recommended to take a blood thinner called an anticoagulant for at least 3 weeks prior to electrical cardioversion, and for at least 4 weeks afterwards to prevent development of a stroke.

There are two main groups of drugs to help control the heartbeats in AF patients: rate controlling medications or rhythm controlling medications. A cardiologist should be the one deciding what type of medication a patient should be on. Some common rhythm control medications are amiodarone, flecainide, sotalol, and dronedarone. Some common rate control medications used would be beta-blockers (such as metoprolol), calcium channel blockers (such as diltiazem or verapamil), and digoxin.

As stated earlier, risk of stroke is a concern for patients with AF. Some patients are at higher risk, and a physician or pharmacist can determine a patient’s risk. If there is an increased risk for developing a stroke, most patients would be on a blood thinner, such as aspirin and/or an anticoagulant. Choice of anticoagulant depends on what your physician feels best fits your needs. The anticoagulants available are warfarin, dabigatran, apixaban, and rivaroxaban.

Overall, people can live a long, normal life with AF; however, proper diagnosing, treatment, and management are the keys to preventing complications. For more information on AF, refer to the links below, or speak to your physician or pharmacist!

·       Atrial Fibrillation Association

o   http://www.atrialfibrillation-us.org/

·       American Heart Association on Atrial Fibrillation

o   http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Atrial-Fibrillation-AF-or-AFib_UCM_302027_Article.jsp

·       StopAFib

o   http://www.stopafib.org/resources.cfm

   

1. Atrial fibrillation. In DynaMed [database online]. EBSCO Information Services. http://web.a.ebscohost.com/dynamed/detail?vid=3&sid=fc02e003-71da-44d1-9c78-f3b1b619e210%40sessionmgr4002&hid=4201&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#db=dme&AN=115288. Updated July 28, 2014. Accessed August 14, 2014.

2. DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. Chapter 8. The Arrhythmias. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 9e. New York, NY: McGraw-Hill; 2014.http://accesspharmacy.mhmedical.com/content.aspx?bookid=689&Sectionid=48811457. Accessed August 12, 2014.

3. Marchlinski F. Chapter 233. The Tachyarrhythmias. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012. http://accesspharmacy.mhmedical.com/content.aspx?bookid=331&Sectionid=40727006. Accessed August 14, 2014.

4. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;

5. Strum M. Chapter 10. Anticoagulation Services. In: Ellis AW, Sherman JJ.eds. Community and Clinical Pharmacy Services: A Step-by-Step Approach.New York, NY: McGraw-Hill; 2013.http://accesspharmacy.mhmedical.com/content.aspx?bookid=684&Sectionid=45145845. Accessed August 14, 2014.

Written by: Daniel Ky UIC Rockford PharmD Candidate 2015.

Childhood Cancer

The late Robin Williams with a St. Jude Children’s Research Hospital (SJCRH) patient.¹ St. Jude specializes in the research and treatment of childhood cancer and other catastrophic childhood diseases.²

What is cancer?

Our bodies are made up of many, many cells.³ All of these cells contain and are supervised by a substance called DNA. When there is damage in the DNA, the cells may not grow and divide as they were intended to.  The DNA damage can occur as the cell is dividing, be inherited (transmitted between parent(s) and child), or be induced by something occurring around us.  Sometimes, when these cells with DNA damage grow out of control and grow into other tissues abnormally, they can be classified as cancer cells.  These cancer cells can form a tumor or grow in the bloodstream.

How is cancer different between adults and children?

In adults, the DNA damage which leads to cancer may be linked to being exposed to something toxic in the environment around them or poor lifestyle habits, such as cigarette smoking or physical inactivity.³ Because these risk factors take a long time to build up, they are rarely associated with cancer in children.  The DNA damage which causes childhood cancer usually happens early in the child’s life and may have even occurred before birth.  The types of cancer which occur more frequently in children are also very different than the ones which are more common in adults.  The types of childhood cancer will be discussed in more detail in the next section.

What kinds of cancers occur in children?

The cancers which may occur in children are different than those which occur in adults.³ Some of the cancers which occur in children are listed below.

●      Leukemias: cancers of the blood and bone marrow.  These are the most common childhood cancers

●      Brain and other central nervous system tumors: second most common cancer type in children

●      Neuroblastoma: forms in certain nerve cells

●      Wilms tumor: forms on 1 or both kidneys in rare cases

●      Lymphoma (Hodgkin and non-Hodgkin): begins in lymphocytes, a kind of cell found in the immune system

●      Rhabdomyosarcoma: begins in certain muscle cells which are used to move the body

●      Retinoblastoma: occurs in the eye

●      Bone cancer (osteosarcoma and Ewing sarcoma): these are more common in older children and teenagers, but can occur at any age

How common is childhood cancer?

Although childhood cancer is rare, making up less than 1% of all cancer diagnoses, it is still the second leading cause of death in children.³ The American Cancer Society estimates that 10,450 children younger than 15 will be diagnosed with cancer in 2014.  Recently, the mortality rate for many childhood cancers has been cut in half, and over 80% of children with cancer will survive at least 5 years; these positive strides have been due to the latest advancements in the treatment of cancer.  The exact mortality and survival statistics vary by the type of cancer, and additional resources for more information can be found at the websites listed in a later section.

Prevention/screening

Because childhood cancer usually isn’t associated with risks that build over time (like smoking), it is difficult to prevent cancer in young children.³ Only very few factors (such as radiation) have been linked to an increase in childhood cancer risk, but radiation may even be unavoidable for a child who needs it to treat an existing cancer.

Checking children for cancer who do not otherwise have symptoms is referred to as cancer screening.³ Regular screening for cancer in all children is generally not done because it is so rare.  In rare instances, some children may be more likely to get certain cancers; doctors may recommend more frequent check-ups and/or regularly scheduled special tests for these children to check for the early signs of cancer. 

Cancer that develops in children may be hard to detect because the cancer’s physical features might be similar to ones that happen frequently in otherwise healthy children.³ Often, kids run into objects and get a bruise or bump, catch colds, or get stomach aches - but these might hide the early warning signs of cancer.  Some symptoms to watch out for are:

●      Bruising easily

●      Sudden eye or vision changes

●      Weight loss that comes on suddenly and cannot be explained by other factors

●      Continuous pain in one body part

●      A swelling or lump that seems unusual

●      Limping

●      Unexplainable paleness and decrease in energy

●      Unexplainable sickness/fever which doesn’t go away

●      Frequent headaches which may come with vomiting

Depending on the type of cancer, other symptoms may be present.  It is important for parents and caretakers to be aware of unusual features that do not go away after a long period of time.

How do I deal with a diagnosis?

When a child is diagnosed with cancer, the lives of everyone involved in the child’s life and those who care about the child will change dramatically.⁴ They and the child who was just diagnosed may go through reactions such as shock, denial, fear, anxiety, guilt, depression, anger, and many other emotions.  These feelings are a normal part of the process, and there are ways to cope with the tough times.   Some important ways of coping with such a devastating diagnosis are: trusting the medical team treating the child and getting support from sources such as the community, place of worship and friends/extended family.  Family members should make sure to make time for themselves and express their emotions in healthy ways. 

For more information on coping, please see this website by the American Cancer Society:  http://www.cancer.org/acs/groups/cid/documents/webcontent/002592-pdf.pdf

How might your child’s cancer be treated?

There are a variety of ways to treat childhood cancer.³ The exact treatment will depend mostly on the type and severity of the cancer.  The severity of the cancer may also be referred to as the stage.  Frequently, a variety of treatment methods will be used to treat the cancer.  These methods include chemotherapy, surgery, radiation, and other treatments.  Mostly, treatments are effective against childhood cancers.  It is important for your child to receive care at a childhood cancer specialized center because these centers will have extensive experience treating such a rare condition.  There, the teams of professionals who will treat your child include professionals such as doctors, nurses, social workers, psychologists, chaplains, and pharmacists. 

There are both short-term and long-term consequences of the cancer and its treatment.³ A thorough discussion should occur between your family and the health-care team about these effects.  It is important to follow the directions of the health-care team and the follow-up schedule they suggest after finishing treatment.  As time goes on after the end of a successful treatment, the risk of the cancer happening again decreases, so the frequency of follow-up appointments may decrease. These appointments will still be highly important because some effects of treatment may not be seen until years after the end of treatment.  Some specific long-term effects which may occur are:

●      Problems with the heart or lungs

●      Slowed or delayed growth and development

●      Learning issues

●      Changes in sexual development and ability to have children

●      Increased risk of other cancers later in life

How can I help or find out more information?

●      http://www.cancer.org/treatment/childrenandcancer/index

●      http://www.nlm.nih.gov/medlineplus/cancerinchildren.html

●      http://www.cancer.gov/cancertopics/types/childhoodcancers

●      http://www.childrensoncologygroup.org/

●      http://www.stjude.org/

References:

1.     St. Jude mourns the loss of friend and supporter Robin Williams. St. Jude Children’s Research Hospital website. http://www.stjude.org/stjude/v/index.jsp?vgnextoid=b656abe3c96c7410VgnVCM100000290115acRCRD&vgnextchannel=fa1113c016118010VgnVCM1000000e2015acRCRD.  Accessed August 12, 2014.

2.     About St. Jude. St. Jude Children’s Research Hospital website. http://www.stjude.org/about.  Accessed August 12, 2014.

3.     Cancer in children. American Cancer Society website. http://www.cancer.org/acs/groups/cid/documents/webcontent/002287-pdf. Accessed August 6, 2014.

4.     Children diagnosed with cancer: dealing with the diagnosis. American Cancer Society website. http://www.cancer.org/acs/groups/cid/documents/webcontent/002592-pdf.pdf.  Accessed August 12, 2014.

Written by Ruixuan Jiang, UIC PharmD Candidates 2015