Obgyn · Year 3 · from Obgyn
Case 1: Polycystic Ovary Syndrome with Oligomenorrhea
Patient Demographics
- Age: 24 years
- Sex: Female
- Occupation: Graduate student
Chief Complaint
"I haven't had my period in 4 months and I'm gaining weight."
History of Present Illness
The patient presents with a 4-month history of amenorrhea. Her periods have been irregular since menarche, occurring every 35-60 days. Over the past year, her cycles have become even more irregular, and she has now gone 4 months without a period. She has gained 25 pounds over the past 2 years despite no major dietary changes. She also notes increasing facial hair requiring daily shaving and persistent acne that has not responded to topical treatments.
Gynecologic History
- Menarche: Age 14
- Cycles: Always irregular (35-60+ days)
- Last menstrual period: 4 months ago
- Sexually active: No current partner
- Prior pregnancies: None
Past Medical History
- No chronic medical conditions
- No prior surgeries
Family History
- Mother: Type 2 diabetes, diagnosed age 45
- Sister: Irregular periods, told she has "cysts on ovaries"
Physical Examination
- Height: 5'5" (165 cm)
- Weight: 185 lbs (84 kg)
- BMI: 30.8 kg/m2 (Obese Class I)
- Vital Signs: BP 128/82 mmHg, HR 76 bpm
- Skin: Moderate inflammatory acne on face and back; hirsutism on chin, upper lip, and sideburns (Ferriman-Gallwey score: 12)
- Neck: Acanthosis nigricans present
- Abdomen: Soft, obese, non-tender
- Pelvic: Normal external genitalia, cervix normal, uterus normal size, no adnexal masses
Diagnostic Workup
First Step - Pregnancy Test: Negative
Laboratory Evaluation:
| Test | Result | Reference |
|---|---|---|
| FSH | 6.2 mIU/mL | Normal |
| LH | 18 mIU/mL | Elevated (LH:FSH ratio 2.9) |
| Total Testosterone | 82 ng/dL | Elevated (normal <50) |
| Free Testosterone | 12 pg/mL | Elevated |
| DHEA-S | 320 mcg/dL | Normal |
| TSH | 2.1 mIU/L | Normal |
| Prolactin | 18 ng/mL | Normal |
| 17-OH Progesterone | 120 ng/dL | Normal (rules out CAH) |
| Fasting Glucose | 108 mg/dL | Impaired fasting glucose |
| HbA1c | 5.9% | Prediabetes |
| Lipid Panel | LDL 142, HDL 38, TG 185 | Dyslipidemia |
Pelvic Ultrasound:
- Right ovary: 12 mL volume, 15 antral follicles (2-9 mm)
- Left ovary: 14 mL volume, 18 antral follicles (2-9 mm)
- Endometrial thickness: 8 mm
Diagnosis: Polycystic Ovary Syndrome
Rotterdam Criteria (2 of 3 required):
- Oligo/anovulation: YES (oligomenorrhea/amenorrhea)
- Clinical or biochemical hyperandrogenism: YES (hirsutism, elevated testosterone)
- Polycystic ovarian morphology: YES (>12 follicles per ovary)
Associated Findings:
- Insulin resistance (acanthosis nigricans, prediabetes)
- Metabolic syndrome (central obesity, dyslipidemia, impaired glucose)
- LH:FSH ratio >2
Exclusion of other causes:
- TSH normal (excludes thyroid disease)
- Prolactin normal (excludes hyperprolactinemia)
- 17-OH progesterone normal (excludes late-onset CAH)
- DHEA-S normal (makes androgen-secreting tumor unlikely)
Management Plan
1. Menstrual Regulation and Endometrial Protection:
- Combined oral contraceptive pill (OCP with anti-androgenic progestin - drospirenone)
- Alternatively: Cyclic progestin (MPA 10 mg x 10-14 days monthly)
- Goal: Prevent endometrial hyperplasia from unopposed estrogen
2. Hirsutism and Acne Treatment:
- OCP (addresses both menstrual and androgen symptoms)
- Add spironolactone 100 mg daily after 3 months if hirsutism persists
- Must use reliable contraception with spironolactone (teratogenic)
3. Metabolic Management:
- Lifestyle modification: Structured diet and exercise program
- Goal: 5-10% weight loss (can restore ovulation and improve metabolic parameters)
- Metformin 500 mg twice daily (for prediabetes and insulin resistance)
- Repeat glucose testing in 3 months
4. Long-term Screening:
- Annual fasting glucose or HbA1c
- Lipid panel annually
- Blood pressure monitoring
- Screening for obstructive sleep apnea if symptomatic
Patient Counseling
- PCOS is a lifelong condition requiring ongoing management
- Weight loss of even 5-10% can restore ovulatory cycles
- Increased risk of endometrial cancer if untreated (unopposed estrogen)
- If she desires pregnancy in future: Letrozole is first-line for ovulation induction
- Type 2 diabetes risk: 30-40% by age 40 in women with PCOS
Follow-up (3 months)
- Weight: 178 lbs (lost 7 lbs)
- Menses: Regular withdrawal bleeds on OCP
- Acne: Significantly improved
- Fasting glucose: 98 mg/dL (improved)
- Will add spironolactone for persistent hirsutism
Clinical Image
Image Description: Transvaginal ultrasound image demonstrating a polycystic ovary with multiple small follicles (>12) arranged in a peripheral "string of pearls" pattern around an echogenic stroma. The ovarian volume exceeds 10 mL.
Attribution: Image from Radiopaedia. Case courtesy of Dr. Matt Skalski. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/polycystic-ovary-syndrome