Polycystic ovary syndrome (PCOS), a common androgen-excess disorder that occurs in 6% to 15% of reproductive-aged women (Fauser et al., 2012; Futterweit, 2007), is often a missed diagnosis. Futterweit estimated that 50% to 75% of women with PCOS were undiagnosed. Further, many women visit several health care providers before they are diagnosed correctly (Futterweit, 2007). Women with PCOS need to be correctly diagnosed because they are at risk for many short- and long-term consequences of the disorder. With the onset of PCOS in late adolescence or early 20s, women can experience a variety of signs and symptoms including acne, hirsutism, androgenic alopecia, weight gain, menstrual dysfunction, and potential infertility, as well as increased anxiety and depressive symptoms (Fauser et al., 2012; Futterweit, 2007,). As women with PCOS age, they have an increased risk for developing impaired glucose tolerance, type 2 diabetes (T2DM), metabolic syndrome, and cardiovascular disease (Fauser et al., 2012; Futterweit, 2007). Early detection and management of PCOS can help control PCOS symptoms and reduce risk for long-term comorbidities (Fauser et al., 2012; Futterweit, 2007).
Rural nurse practitioners (NPs) play an essential role in the diagnosis and management of PCOS because they practice in settings where rural women may present initially with PCOS-related health problems. For example, women may not be aware that their acne or menstrual dysfunction might be a sign of an underlying problem, including PCOS. Therefore, rural NPs need to be able to diagnose and manage women with PCOS to identify and control short-term PCOS symptoms and help prevent long-term PCOS comorbidities.
Background on PCOS
The exact cause of PCOS is unknown, but research suggests that regulation of the hypothalamic-pituitary-ovarian axis is disrupted in women with PCOS, causing their ovaries to increase testosterone production, resulting in the aforementioned clinical signs and symptoms (Ehrmann, 2005). Insulin signaling defects in women with PCOS may contribute to an inherent insulin resistance in these women, placing them at greater risk for T2DM (Corbould et al., 2005) Further, women with PCOS are also at more risk for depression and anxiety, compared with similar women without PCOS (Dokras, Clifton, Futterweit, & Wild, 2011, 2012). The 3rd PCOS Consensus Workshop concluded that it was not known whether it was the syndrome itself or the clinical manifestations of PCOS that caused psychological stress (Fauser et al., 2012).
The Rotterdam criteria are commonly used for diagnosing PCOS (Rotterdam ESHRE/ASRM-sponsored PCOS Consensus Workshop Group, 2004). For diagnosis, a woman must meet two of three of the following criteria: (a) oligomenorrhea or anovulation usually expressed as irregular menstrual cycles, (b) clinical (hirsutism, acne, androgenic alopecia) or biochemical signs of elevated androgens (elevated testosterone levels), and (c) polycystic ovaries on an ultrasound. Polycystic ovaries alone are not sufficient for diagnosis. PCOS is a diagnosis of exclusion, and related conditions such as Cushing's syndrome, thyroid disease, prolactinemia, adrenal hyperplasias, or androgen tumors need to be excluded before making a diagnosis of PCOS.
Due to the high reported rate of undiagnosed PCOS cases in women, there was a concern that rural NPs might not be able to correctly assess, diagnose, and provide basic management for women with PCOS due to a lack of access to educational programs about PCOS and geographic distance from PCOS specialists. Continuing education (CE) programs should identify and address practice gaps (Lubejko, 2016), as well as focus on 100% mastery of content (Bleich & Jones-Schenk, 2016). Therefore, a CE program was developed to provide essential information about PCOS assessment, diagnosis, management, and prevention of consequences for NPs practicing mainly in rural areas. The study objective was to determine whether this CE program would improve NPs' PCOS knowledge. The study aims were to describe baseline NP knowledge regarding assessment, diagnosis, management, and prevention of consequences for women with PCOS, and to assess whether this CE program on PCOS is an effective tool for increasing NP knowledge.
A study was conducted using a pretest–posttest design at a 2015 annual pharmacotherapy conference in a mainly rural–frontier mountain western state sponsored by a statewide NP organization. The University of Wyoming Institutional Review Board approved the study protocol.
A PhD-prepared certified family nurse practitioner and a Doctor of Nursing Practice–prepared certified family nurse practitioner or certified nurse midwife, both of whom have PCOS expertise, developed and conducted a 45-minute CE program. The program covered the following essential information about PCOS:
- Introduction: The role of NPs in diagnosing PCOS.
- Epidemiology: Quick facts about the incidence of PCOS.
- Etiology: Overview of dysfunction of the female reproductive system in PCOS.
- Diagnostic criteria: Overview of Rotterdam diagnostic criteria.
- Assessment and diagnosis: Patient history, physical examination, and laboratory testing.
- Management of women with PCOS: Pharmacologic and nonpharmacologic treatment.
- Long-term management and outcomes.
- Summary and conclusion: Crucial role of NPs in health care for women with PCOS.
Participants and Procedures
All attendees (N = 78) at the CE session on PCOS were invited to participate in the study. Copies of the pretest and a cover letter explaining the study were distributed to attendees prior to the start of the session. At the session's end, posttest questionnaires were distributed to the attendees. Attendees were informed that completion of the pre- and posttests was voluntary. They also were instructed not to discuss the questions among themselves. The preand posttests were collected by conference officials (the study team did not collect surveys).
Development of Pre- and Posttest Questionnaires
The pre- and posttest questionnaires were designed to evaluate common knowledge domains about PCOS found in textbooks and journal articles: diagnostic criteria, laboratory testing, treatment options, and long-term consequences (Freshman, 2013; Futterweit, 2007) (Table 1). Four short-answer questions covered Rotterdam diagnostic criteria, laboratory testing, treatment options, and long-term consequences. Short-answer and multiple choice questions have similar reliability and validity (Bacon, 2003). The questionnaire content was similar to the content covered in a study by Cussons, Stuckey, Walsh, Burke, and Norman (2005), in which PCOS diagnostic and management strategies were compared between endocrinologists and gynecologists. Finally, the questionnaire had four demographic questions: license type, type of practice, years in practice, and where the participant learned about PCOS. Questionnaire content was reviewed and approved by a reproductive endocrinologist with PCOS expertise.
Pre- and Posttest Questionnaire
All statistical analyses were conducted with SPSS software, version 22.0; p < .05 were deemed statistically significant. Descriptive statistics (means and standard deviations) were calculated for participant characteristics and all pre- and posttest questionnaire items. Next, a two-step multivariate analysis of variance (MANOVA) was used. First, an overall MANOVA was conducted to compare the pretest–posttest questionnaire responses in four categories: (a) percent correct of Rotterdam criteria for assessment and diagnosis, (b) percent correct on the laboratory tests that need to be ordered to confirm a diagnosis of PCOS, (c) percent correct on treatments of PCOS, and (d) percent correct on long-term consequences. If the overall MANOVA was significant, follow-up univariate analysis of variance (ANOVA) tests then were used to explain differences by examining the four categories separately.
Forty-eight conference attendees completed the pretest questionnaire (61.5% return rate) and 43 completed the posttest questionnaire (55.1% return rate). Of the pretest participants, 91.7% were NPs, with an average of 8.2 years as an NP. The majority (59.6%) were employed in family practice. Other respondents were clinical nurse specialists and NP students. The clinical nurse specialists were retained because they practiced in an area (e.g., adult psychiatric) where they might encounter women with PCOS. NP students were retained in the analysis because they can encounter women with PCOS in a variety of clinical settings in NP programs. Respondents most commonly learned what they already knew about PCOS from school, work, or conferences. Of the posttest participants, 90% were NPs, with an average of 9.2 years as an NP. Again, the majority (60.5%) were employed in family practice. Table 2 summarizes participant demographics.
Study Aim 1: Describe Baseline NP Knowledge Regarding Assessment, Diagnosis, and Management of Women With PCOS
Pretest: Assessment and Diagnosis of PCOS.Table 3 presents the percent of pretest participants responding correctly to questionnaire items in the categories of Rotterdam criteria for diagnosis, laboratory testing, long-term consequences, and treatment. Approximately 56% of participants reported menstrual irregularity (i.e., amenorrhea, oligomenorrhea, dysmenorrhea, or menstrual irregularities) as a Rotterdam criterion. Next, 43.8% of participants identified hyperandrogenism (i.e., acne, hirsutism, androgenic alopecia, elevated testosterone or “androgen levels”) for the second Rotterdam criterion. For the third Rotterdam criterion, 18.8% identified polycystic ovaries as an assessment and diagnostic marker. Less than 17% of participants identified total or free testosterone or dehydroepiandrosterone sulfate (DHEA-S) as laboratory tests for assessment and diagnosis of PCOS.
Pre- and Posttest Responses for Laboratory Testing, Rotterdam Criteria, Long-Term Consequences, and Treatment
Pretest: Long-Term Consequences and Treatment of PCOS. For long-term consequences of PCOS, approximately 40% of the pretest participants reported T2DM. Less than 17% of participants reported cardiovascular disease, metabolic syndrome, psychosocial mental health, or endometrial cancer. Approximately 52% of pretest participants reported infertility. Table 3 summarizes these results.
For management of PCOS, 45.8% of the pretest participants reported contraceptives as an option. Other options included metformin (75%), spironolactone (29.2%), or clomiphene citrate (4.2%). Less than 15% recognized the importance of diet, exercise, and weight loss in managing PCOS.
Study Aim 2: Assess Whether a CE Program on PCOS Is an Effective Tool for Increasing NP Knowledge
Posttest: Assessment and Diagnosis of PCOS.Table 3 presents the percent of posttest participants responding correctly to questionnaire items in the categories of Rotterdam criteria for diagnosis, laboratory testing, long-term consequences, and treatments. Approximately 79% of participants reported menstrual irregularity (i.e., amenorrhea, oligomenorrhea, dysmenorrhea, or menstrual irregularities) as a Rotterdam criterion. Next, 93% of participants identified hyperandrogenism (i.e., acne, hirsutism, androgenic alopecia, elevated testosterone or other androgen levels) for the second Rotterdam criterion. For the third Rotterdam criterion, 65.1% identified polycystic ovaries as an assessment and diagnostic marker. For laboratory studies, 95.4% reported total testosterone, 74.4% reported free testosterone, and 62.8% reported DHEA-S as essential tests to assess and confirm a diagnosis of PCOS.
Posttest: Long-Term Consequences and Treatment of PCOS. Regarding long-term consequences of PCOS, 93% of posttest participants reported T2DM. Other long-term consequences of PCOS reported by posttest participants were cardiovascular disease (58.1%), psychosocial mental health (4.6%), metabolic syndrome (4.6%), and endometrial cancer (7%).
For management of PCOS, 95.3% of the posttest participants reported contraceptives as an effective option. Other options reported were metformin (62.8%), spironolactone (67.4%), or clomiphene citrate (16.3%). Lifestyle interventions reported were diet (14%), weight loss (7%), exercise (16.3%), and lifestyle (20.9%).
Differences in Knowledge: Pretest to Posttest
The overall MANOVA procedure was significant (Hotelling's T-Square = 48.16, p = .00) for differences in pretest–posttest mean scores for the categories of Rotterdam criteria, essential laboratory tests, treatment options, and long-term consequences of PCOS (Table 4). The follow-up ANOVA tests showed significant increases in mean scores from pretest to posttest in each of the four separate categories: Rotterdam diagnostic criteria from 39.6% to 77.5% (p = .000); essential laboratory tests from 11.8% to 76.8% (p = .000); appropriate treatment and management options from 57% to 95.4% (p = .000); and long-term consequences from 64.6% to 95.3% (p = .000).
Means, Standard Deviations, and Manova for Pretest–Posttest Scores on Rotterdam Criteria, Laboratory Tests, Treatments, and Long-Term Consequences for Polycystic Ovary Syndrome
This study may be the first to examine NP baseline knowledge about PCOS. In this study, many rural NPs did not have the baseline knowledge to diagnose and manage PCOS. This lack of knowledge represents a significant practice gap in the ability of NPs to recognize PCOS and supports the claim by Futterweit (2007) that many cases of PCOS are missed. The NP participants practiced in family practice, women's health, internal medicine, and adult mental health—all settings where women may present with a PCOS-related problems. PCOS affects 6% to 15% of women (Fauser et al., 2012), or approximately 1 of 10 women; therefore, NPs must be able to recognize presenting signs and symptoms. Only approximately 40% of pretest participants recognized T2DM as a long-term consequence of PCOS. PCOS is a major risk factor for T2DM, even among lean women with PCOS (American Diabetes Association, 2017; Wang et al., 2011). Given that the estimated economic burden for the initial evaluation of PCOS is 2.3% of the total economic PCOS burden, but treatment for T2DM is estimated to be 40.4% of the total burden (Azziz, Marin, Hoq, Badamgarav, & Song, 2005), early identification and treatment of women with PCOS is critical in decreasing the economic burden associated with PCOS.
This study also sheds new light on the value of a CE program on PCOS for NPs. Participants' PCOS knowledge scores for content areas including the Rotterdam diagnostic criteria, laboratory testing, management strategies, and recognizing long-term PCOS consequences significantly increased pretest to posttest. In addition, the program was successful in educating participants about the newest treatment guidelines for managing PCOS and broadening their perspectives on available treatment options. For example, on the pretest, 75% of the participants reported metformin as a management strategy for PCOS. Metformin is no longer a first-line treatment option for PCOS, except for impaired glucose tolerance, T2DM, and inability to tolerate hormonal contraceptives (Legro et al., 2013). Use of metformin as a management strategy decreased to 62.8% in our posttest, whereas other PCOS management recommendations, such as contraceptives, spironolactone, lifestyle, and exercise, increased in frequency.
Similarly, weight loss, reported as a primary management strategy, declined from 12.5% of pretest participants to 7% of posttest participants. The decline could be attributed to participants' recognition that a multipronged approach that included diet, exercise, and lifestyle changes, as well as weight loss, was a viable treatment option for women with PCOS. The findings demonstrate the need for ongoing updates on PCOS management options.
Further research is needed to examine whether these study findings are consistent in other rural areas of the country, as well as in urban areas. A 6-month and 12-month follow-up is needed to determine retention of knowledge and to identify time points where continuing education boosters would be helpful. Surveying NP faculty about PCOS content in their programs of study could help determine whether program content is adequate for graduating students.
Study limitations were a small sample size at one regional conference, thus limiting study generalizability. The authors did not use a code to link pre- and posttest questionnaires to protect anonymity. Therefore, we do not know whether the participants completing the pretest were the same participants completing the posttest. Further, not all pretest participants completed the posttest. In addition, the study had a short interval of 45 minutes between the pre- and posttest, which could have affected the results.
An evidence-based CE seminar was developed to increase rural NP knowledge about the assessment, diagnosis, and management of women with PCOS. The pretest–posttest design supported the effectiveness of the intervention to significantly increase NP knowledge about PCOS. This study was meaningful because it demonstrated that nurse educators need to include PCOS in CE program content.
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Pre- and Posttest Questionnaire
Please indicate your provider status.
What is your area of practice?
How long have you been practicing in your area?
Please list three criteria for the assessment and diagnosis of polycystic ovary syndrome (PCOS) per the Rotterdam criteria.
Please list three laboratory tests to help assess and confirm a diagnosis of PCOS.
Please list three treatment options for a woman with PCOS.
Please list two long-term consequences of PCOS.
Where did you learn about PCOS?
|License Typea||Pretest (n = 48)||%||Posttest (n = 43)||%|
|Licensed nurse practitioner||44||91.7||39||90.1|
|Nurse practitioner student||2||4.2||2||4.6|
| Doctor of Nursing Practice student||1||2.1||1||2.3|
| Family Nurse Practitioner student||1||2.1||1||2.3|
|Clinical nurse specialist||2||4.2||2||4.6|
|Practice Areaa||Pretest (n = 47)||%||Posttest (n = 43)||%|
|Ear, nose, and throat||1||2.1||1||2.3|
|Mean experience in practice (years)||8.23||–||9.18||–|
Pre- and Posttest Responses for Laboratory Testing, Rotterdam Criteria, Long-Term Consequences, and Treatment
|Category||Pretest % (n = 48)||Posttest % (n = 43)|
| Criteria I, menstrual irregularity (amenorrhea, oligomenorrhea, dysmenorrhea, menstrual irregularities)||56.2||79.1|
| Criteria II, polycystic ovaries||18.8||65.1|
| Criteria III, hyperandrogenism (acne, hirsutism, alopecia, elevated testosterone, androgen symptoms)||43.8||93|
| Free testosterone||0||74.4|
| Testosterone (total)||16.7||95.4|
| Dehydroepiandrosterone sulfate||14.6||62.8|
| Type 2 diabetes (altered glucose metabolism, glucose intolerance, insulin resistance, diabetes)||39.6||93|
| Cardiovascular disease||8.3||58.1|
| Psycho-social-mental health||4.2||4.6|
| Metabolic syndrome||16.7||4.6|
| Endometrial cancer||6.2||7|
| Contraceptives (oral pills, patch, intrauterine devices, progesterone, oral contraception, birth control)||45.8||95.3|
| Clomiphene citrate||4.2||16.3|
| Weight loss||12.5||7|
Means, Standard Deviations, and Manovaa for Pretest–Posttest Scores on Rotterdam Criteria, Laboratory Tests, Treatments, and Long-Term Consequences for Polycystic Ovary Syndrome
|Variable||Pretest (n = 48)||Posttest (n = 43)|
|Mean||SD||95% CI||Mean||SD||95% CI||F||p|
|Rotterdam||39.6||31.2||[31.30, 47.86]||77.52||25.94||[68.77, 86.27]||39.2||.000|
|Laboratory||11.8||18.8||[5.08, 18.53]||76.75||27.73||[69.64, 83.85]||173.9||.000|
|Treatments||57||35.7||[49.03, 64.86]||95.35||13.77||[86.98, 103.72]||43.9||.000|
|Consequences||64.6||39.9||[55.78, 73.79]||95.35||14.70||[86.05, 104.65]||22.8||.000|