A 36-year-old white female presents with the chief complain of infertility associated with a history of a menstrual period every 3-4 months since menarche at age 12. The physical examination is normal except for moderate obesity, acne, and coarse facial hair. A urine hCG is negative.
Further evaluation to confirm your diagnosis of polycystic ovary syndrome will most likely reveal:
Correct Answer A:
This patient presented with classic symptoms of polycystic ovary syndrome (PCOS) - oligomenorrhea, infertility, hirsutism, and acne-reflecting hyperandrogenic anovulation. The underlying pathophysiology of PCOS includes insulin resistance leading to increased ovarian androgen production. LH and FSH levels are often elevated in PCOS, with the LH:FSH ratio often being greater than 3:1. Prolactin is usually normal, although mild elevations are possible. Marked elevations should prompt investigation of other causes. Elevated 17-hydroxyprogesterone levels are seen in congenital adrenal hyperplasia, and high TSH values would point to hypothyroidism as a cause for this patient’s oligomenorrhea.
Most individuals with polycystic ovarian syndrome have:
Correct Answer E: Polycystic ovarian syndrome, one of the most common endocrine disorders, is associated with insulin resistance and a higher risk for development of glucose intolerance and type 2 diabetes mellitus.
Patients may have abnormal hormone levels, such as higher androgen and estrogen levels and lower levels of progesterone. FSH levels are within the reference range or low. LH levels are elevated for Tanner stage, sex, and age. The LH:FSH ratio is usually greater than 3. Thyroid function tests are within the reference range.
In evaluating a reproductive age woman who presents with secondary amenorrhea, which of the following conditions will result in a positive (withdrawal) progesterone challenge test?
Correct Answer E:
In pregnancy, progesterone is produced by the corpus luteum followed by the placenta. Exogenous progesterone will not lead to withdrawal bleeding. In ovarian failure as well as pituitary failure, no estrogen stimulation of the endometrium exists, and progesterone cannot cause withdrawal bleeding. With Mullerian agenesis, there is no endometrium.
Polycystic ovarian syndrome (choice E) has an abundance of circulating estrogen, so the endometrium will proliferate.
→ In pregnancy (choice A) progesterone withdrawal will not occur since the corpus luteum is producing progesterone. The placenta will take over, starting at 7 weeks, and will be the sole producer of progesterone by 12 weeks.
→ Diagnoses unique to primary amenorrhea include vaginal agenesis, androgen insensitivity syndrome, Turner syndrome (45,X) (choice B), and mosaicism.
→ Pituitary failure (choice C) is an incorrect answer because without gonadotropin stimulation, there will not be enough estrogen to stimulate the endometrial lining.
→ Mullerian agenesis (choice D) is an incorrect answer - there is no uterus, thus no bleeding.
A 22-year-old G0 female presents to the office complaining of irregular cycles. She rarely had regular cycles since her menarche (11). She is not sexually active. Her past medical history is non contributory. Her family history is significant for diabetes in both parents.
Her temperature is 37.0°C, BP is 140/87 mm Hg. She is 170 cm tall and weighs 80 kg. Black hair is noted on her chin and upper lip. Her physical exam including speculum and bimanual examination is normal, without any tenderness or palpable masses.
What is the most likely diagnosis of this patient?
Correct Answer B:
According to Rotterdam criteria, any two of the following diagnose polycystic ovarian syndrome (PCOS) (choice B):
Our patient meets the first two criteria for diagnosis; however ultrasound of the ovaries, hormonal assessment (LH/FSH ratio, androgens…) and metabolic evaluation (FBS, lipid profile…) would be warranted.
→ Hypothyroidism (choice A) usually presents with cold intolerance, fatigue, sleepiness, irregular heavy cycles, weight gain.
→ The usual presentation of prolactinoma (choice C) includes amenorrhea, galactorrhea, decreased libido and visual fields defects (Bitemporal hemianopia or Tube Vision).
→ Sheehan’s syndrome (choice D) is the postpartum pituitary necrosis caused by a severe postpartum hemorrhage.
→ Turner’s syndrome (choice E) presents with primary amenorrhea, short stature and other congenital abnormalities.
A 30-year-old female comes to your office because she is concerned about irregular menses (fewer than 9/year), acne, and hirsutism. Her BMI is 36.0 kg/m². She has no other medical problems and would like to have a baby. Her fasting blood glucose level is 7.8 mmol/L.
Which one of the following would be the most appropriate treatment for this patient’s condition and concerns?
Correct Answer C:
This patient has classic features of polycystic ovary syndrome (PCOS). The diagnosis is based on the presence of two of the following: oligomenorrhea or amenorrhea, clinical or biochemical hyperandrogenism, or polycystic ovaries visible on ultrasonography. Lifestyle modifications are necessary, but medications are also needed. First-line agents for the treatment of hirsutism in patients with PCOS include spironolactone, metformin, and eflornithine. First-line agents for ovulation induction and treatment of infertility in patients with PCOS include metformin and clomiphene, alone or in combination with rosiglitazone. Metformin can also improve menstrual irregularities in patients with PCOS, and is probably the first-line agent for obese patients to promote weight reduction. In addition, metformin improves insulin resistance (diagnosed by elevated fasting blood glucose) in patients with PCOS, as do rosiglitazone and pioglitazone.
→ Pioglitazone (choice B) would not be appropriate for this patient because it causes weight gain.
→ Oral contraceptives (choice D) would improve the patient’s menstrual irregularities and hirsutism, but she wishes to become pregnant.
→ Testosterone (choice E) would worsen the hyperandrogenism and would not treat the PCOS.
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