# Clinical Cases: Female Reproductive Disorders

## Case 1: Polycystic Ovary Syndrome (PCOS)

### Clinical Image
![PCOS Ultrasound](case_01_image.jpg)
*Source: [Wikipedia - Polycystic ovary syndrome](https://en.wikipedia.org/wiki/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

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## Case 2: Endometriosis

### Clinical Image
![Endometriosis Laparoscopy](case_02_image.jpg)
*Source: [Wikipedia - Endometriosis](https://en.wikipedia.org/wiki/Endometriosis) - CC BY-SA 4.0*

### Case Presentation
A 31-year-old nulligravid woman presents with a 6-year history of progressively worsening dysmenorrhea. Her menstrual pain begins 2 days before the onset of bleeding and continues for the first 3 days of her period, requiring her to miss work 1-2 days per month despite using maximum doses of NSAIDs. She also reports deep dyspareunia and dyschezia (painful bowel movements) that worsens perimenstrually. She and her husband have been attempting pregnancy for 2 years without success. Physical examination reveals a fixed, retroverted uterus and tender nodularity along the uterosacral ligaments palpable on rectovaginal exam. Transvaginal ultrasound shows a 4 cm left ovarian cyst with homogeneous low-level echoes (ground-glass appearance) consistent with an endometrioma. CA-125 is mildly elevated at 58 U/mL. Given her symptoms, examination findings, and infertility, diagnostic and therapeutic laparoscopy is performed. At surgery, stage III endometriosis is found with extensive adhesions, blue-black "powder burn" lesions on the peritoneum, and left ovarian endometrioma. Lesions are excised, adhesions are lysed, and the endometrioma is carefully removed with ovarian preservation. Postoperatively, she conceives naturally within 6 months.

### Key Learning Points
- Endometriosis is defined by endometrial glands and stroma outside the uterus; the classic triad is dysmenorrhea, dyspareunia, and infertility
- Physical exam findings suggestive of endometriosis include fixed retroverted uterus (from adhesions), tender uterosacral nodularity, and adnexal masses (endometriomas)
- Endometriomas appear as "chocolate cysts" with homogeneous low-level echoes (ground-glass) on ultrasound
- Laparoscopy remains the gold standard for diagnosis and allows concurrent surgical treatment; excision may improve fertility in moderate-severe disease

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## Case 3: Uterine Fibroids

### Clinical Image
![Uterine Fibroids](case_03_image.jpg)
*Source: [Wikipedia - Uterine fibroid](https://en.wikipedia.org/wiki/Uterine_fibroid) - CC BY-SA 3.0*

### Case Presentation
A 42-year-old G2P2 African American woman presents with a 3-year history of progressively heavy menstrual bleeding. She soaks through a super tampon and pad every 1-2 hours during the first 3 days of her period and passes large clots. Her periods last 8-9 days. She has developed fatigue and exertional dyspnea. She also reports pelvic pressure, urinary frequency, and a visibly enlarged lower abdomen. Physical examination reveals a firm, irregular, enlarged uterus palpable at the umbilicus (approximately 20-week size). Hemoglobin is 8.2 g/dL with microcytic indices consistent with iron deficiency anemia. Pelvic ultrasound demonstrates a 14 cm intramural fibroid distorting the uterine cavity, multiple smaller intramural fibroids, and a 3 cm submucosal fibroid. Endometrial biopsy shows secretory endometrium without hyperplasia. Given her completed childbearing, severe symptoms, anemia, and bulk symptoms, surgical options are discussed. She elects to proceed with hysterectomy. Pathology confirms multiple benign leiomyomas, with the largest measuring 15 cm. Post-operatively, her symptoms resolve and her hemoglobin normalizes with iron supplementation.

### Key Learning Points
- Uterine fibroids (leiomyomas) are the most common pelvic tumors in women; Black women have higher prevalence and more severe disease than other racial groups
- Fibroids are classified by location: submucosal fibroids disproportionately cause heavy bleeding and infertility; intramural and subserosal fibroids cause bulk symptoms
- Treatment options range from medical management (tranexamic acid, GnRH agonists, hormonal contraception) to procedures (uterine artery embolization, myomectomy) to hysterectomy
- Fibroids are estrogen-dependent and typically regress after menopause; GnRH agonists cause temporary regression but are limited by hypoestrogenic side effects