Reproductive · Year 2 · from Reproductive
Case 1: Polycystic Ovary Syndrome (PCOS)
Clinical Image
Source: Wikipedia - Polycystic ovary syndrome - CC BY-SA 3.0
Case Presentation
A 24-year-old woman presents with irregular menstrual periods since menarche at age 13. She has 4-6 periods per year and has never had regular monthly cycles. She also complains of progressive facial hair growth over the past 5 years, requiring daily plucking, and persistent acne that has not responded to topical treatments. Her BMI is 32. Physical examination reveals hirsutism with a Ferriman-Gallwey score of 14 (moderate), inflammatory acne on the face and back, and acanthosis nigricans on the posterior neck. Laboratory studies show total testosterone 72 ng/dL (elevated), free testosterone elevated, DHEA-S normal, 17-hydroxyprogesterone normal (ruling out congenital adrenal hyperplasia), TSH normal, and prolactin normal. Fasting glucose is 108 mg/dL and hemoglobin A1c is 5.9% (prediabetes range). Transvaginal ultrasound shows bilateral ovaries with >20 follicles each in a peripheral distribution and ovarian volumes of 14 mL and 16 mL. Using the Rotterdam criteria (oligomenorrhea + clinical hyperandrogenism + polycystic ovarian morphology), the diagnosis is PCOS. She is not currently seeking pregnancy. Treatment is initiated with combined oral contraceptives (containing a low-androgenic progestin) for cycle regulation and to suppress ovarian androgen production, plus spironolactone 100 mg daily for hirsutism. She is counseled about lifestyle modification for weight loss and metabolic risk reduction.
Key Learning Points
- PCOS is diagnosed using the Rotterdam criteria when 2 of 3 features are present: oligo-ovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology on ultrasound (after excluding other causes)
- The metabolic syndrome is common in PCOS; insulin resistance drives hyperandrogenism, and affected women require screening for diabetes and cardiovascular risk factors
- Treatment is tailored to patient goals: combined OCs for cycle regulation and hyperandrogenism; letrozole or clomiphene for ovulation induction if pregnancy desired
- Long-term unopposed estrogen exposure increases endometrial hyperplasia and cancer risk, making cycle regulation essential