Pcos Report Den Edited

7/31/2019 Pcos Report Den Edited

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Age: 26

G1P1 (1001)

Date of 1st Consultation Nov. 22, 2011


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Missed menses for 4months,

Decreased amount and duration

of menses for 2 months


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LMP : May 2011 PMP: April 2011

Jan2011

Feb Mar April May June July August

Sept Oct Nov

III IIII IIII IIII

DMPA DMPAPregnancy test (-)

Pregnancy test (-)2nd week

Pregnancy test (-)Nov. 22,2011


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1 month and 22 days prior to last consultation

Patient had irregular menses for 6 months

now (Nov. 19, 2011)

(-) dysuria

(-)fever

(-) hypogastric pain

(-)Pregnancy test Nov. 22, 2011


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Had mumps, measles, chickenpox during

childhood

No hypertension, no diabetes, no bronchial

asthma

No previous hospitalization, no blood

transfusion, no allergy to food and drugs


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Family History

Father and mother are apparently well.

No other known heredofamilial diseases such

as hypertension, diabetes and bronchial

asthma


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Menarche: 14 years old Subsequent menses

Duration:5 days

Amount:3-4 pads/day

Symptoms:

(-)dysmenorrhea

Interval-irregular

(60-120 days)

Duration:5 days

Amount:3-4 pads/day

Symptoms:

(-)dysmenorrhea


9/60

Total Pregnancies: G1 P1 (1001)

Last Pap smear(Dec. 2011)

Gravid Date Where How Pregnancy

1 Dec. 26,

2002

Home Normal

Spontaneous

Delivery

No

complications


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Oral Contraceptive pills (April 2010-January

2011)

Depot Medroxy progesterone acetate (DMPA)

(January 2011)

*last DMPA (May 2011)


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CNS: No headache, no blurring of vision CVS: No palpitation

Respiratory: No difficulty of breathing, no cough,

HEENT: no blurring of vision, no hearing loss, no tinnitus GIT: no nausea, no vomiting

GUT: no dysuria, no frequency, no urgency, no

retention, no hematuria

NMS: no arthralgia, no myalgia, no numbness, no

paresthesia


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General Survey: conscious, coherent, not in

cardiorespiratory distress

Vital signs: BP: 110/ 70 mmHg PR: 84 bpm

RR: 19 cpm Temp: 37.0C

Weight: 82 kg/mHeight: 157.2 cm

BMI: 33.6 kg/m2


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HEENT: Pink palpebral conjunctivae, white sclerae,

no tonsillopharyngeal congestion, no nasoauraldischarge, neck is supple, (+) upper lip hair, (+)acne

Neck: Neck is supple, no palpable lymph nodes Chest/lungs: Symmetrical chest expansion, no

retraction, no lagging, clear breath sounds, no

wheezes, no crackles

Heart: Adynamic precordium, normal rate, regularrhythm, no murmur

Abdomen: Flabby, soft, no mass, no tenderness,

normoactive bowel sounds


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Genitalia:

speculum exam: clean looking cervix with minimal

whitish discharge Internal Examination: Normal looking external

genitalia, parous introitus, vagina admits 2 fingerwith ease ,firm cervix, uterus and adnexae cannot

be assessed due to thick abdomen

Extremities : No gross deformities, full equal pulses

Skin: no active dermatoses


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Gravida 1 Para 1 (1001)

Abnormal Uterine bleeding probably secondary

to chronic anovulation

To Consider Polycystic Ovarian Syndrome


16/60

Well balanced diet

Increase fluid intakeStart Medroxyprogesterone 10mg/tab, 1

tablet OD x 5 days

For Transvaginal Sonogram c/o OBsonologist on Day 3-5 of menses

Advised daily perineal hygiene

Advised to come back on Day 1 of menses

or after 2 weeks if with no menstrualbleeding


17/60

1 month and 9 days prior to lastconsult

Subjective complaints:no dysuria, no fever, no hypogastric pain

BMI: 34.32 kg/m2 (34.4 previous BMI)

Still for Transvaginal sonogram on Day 3-5 of menses


18/60

1 month and 2 days prior to last consult

has completed Medroxyprogesterone 1 tab once a dayfor 5 days

still without menses

PE: BMI: 34.02 kg/m2 (34.32 previous BMI )

PLAN:

Still for Transvaginal sonogram on Day 3-5 of menses


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TransvaginalUltrasound

1 month and 2 days prior to last consultDec. 12, 2011(still without menses)

uterus 4.46x 2,.12x2.21

Anteverted, w/ homogenous matl

echopattern

Endometrium 0.65cm Thick, hyperechoic

Cervix 1.80x 2.47cmUnremarkable

Right ovary 2.12 x 2.21x 1.67cm

w/ multiple immature follicles arranged

subcapsularly 2/ dens central stroma

Left ovary 2.54x 2.29x1.54cmw/ multiple immature follicles arranged

subcapsularly 2/ dens central stroma

Impression anterverted unenlarged uterus, secretoryendometerium, unremarkable cervix,

polycystic bilateral ovaries


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Cont1 month and 2 days prior to lastconsult

PE:

Weight: 84.4 kg Height: 156.7 cm BMI:34.02 kg/m2 (previous BMI 34.32)

Refer to Reproductive Endocrinology and

Infertility


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1 month prior to last consult

BMI: 34 kg/m2 (previous BMI 34.02)

Refer to Reproductive Endocrinology and Infertility


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1 month prior to last consult(Reproductive Endocrinology Infertility notes)

regularly menstruating until had Depot Medroxy Progesterone Acetatelast May 2011

did not have menses upto now

1 day prior to consult had spotting-brownish

PE:HEENT: with facial hair, with acneABDOMEN: Abdominal circumference= 42 inches, flabby, soft, nopalpable mass nor tenderness

Speculum examination: clean looking cervix, minimal brownish

discharge per os

Internal examination: cervix firm, closed, corpus antevertedunenlarged, no adnexal mass nor tenderness

BMI:34 kg/m2 (34.02)


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Cont.

G1 P1 (1001), Secondary Amenorrhea 2 to DMPA,PCOS, T/C Metabolic Syndrome

Advised weight loss and lifestyle modification

For TSH, FSH,Prolactin

For 75 gm OGTTFor lipid profile

To come back with results, if normal results, start

Oral Contraceptive pills

Start Provera on day 16-25 of cycle while awaitinglipid profile results


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1 hour: less than 200 mg/dL

2 hours: less than 140 mg/dL. Between 140-

200 mg/dL indicates impaired glucose

tolerance (prediabetes). If test results are inthis range, a patient is at an increased risk

for developing diabetes. Greater than 200

mg/dL indicates diabetes

test result referencerange

interpretation

Thyroid Function

TSH:

2.6 UIU/ml 0.4-5.5 UIU/ml

Prolactin: 27.9 ng/ml 4-30 ng/ml

FSH: 16.7 MIU/ml 5-20

FBS: 5.80 mmol/L 3.9-6.1

mmol/L

1hr PPBS 8.1 mmol/L/ 145.8

mg/dl


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Cholesterol: 5.6 3.5-5.2mmol/L

Triglyceride: 1.68 0.3-1.9

mmol/L

N

HDL: 1.27 0.7-2.1mmol/L

N

LDL: 3.49 0-3.9 mmol/L N

VLDL: 0.84 0-1.02mmol/L N


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21 days prior to last consult

*Reproductive Endocrinology Infertility notes

advise diet modification

Start Metformin 500mg/tab once a day for 7 days;

then twice a day then 3 times a day

Continue Provera 10mg/tab for 3 more days


27/60

52 daysprior tolastconsult

39 daysPTC

32 daysPTC

30 daysPTC

21 daysPTC

4 daysPTC

Lastconsult

34.4 34.32 34.02 34.0 34.65 34.07 33.6

BMI Considered

Below 18.5 Underweight

18.5 to 24.9 Healthy weight

25.0 to 29.9 Overweight

30 or higher Obese


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26 years old

Chief complaint:Amenorrhea for 4 months,oligomenorrhea for 2 months

Acne

Facial hair (upper lip)

BMI=34 (obese) Pregnancy test (-)

Contraceptive method:

April 2010-Jan. 2011 (OCP)

Jan. 2011, May 2011( Injectable DMPA )

OB history: G1P1(1001)

o LMP: May 2011 PMP: April 2011


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Pregnancy

Polycystic ovarian syndrome


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Rule in Rule out

Amenorrhea for 4

months

Oligomenorrhea for 2

months

Pregnancy test negative(August, October, November2011)

Transvaginal ultrasound Dec.12, 2011: uterus unenlarged withhomogenous myometrial echopattern

Internal Examination:Normal looking externalgenitalia, parous introitus,vagina admits 2 finger wi thease ,firm cervix, uterus and

adnexae cannot be assesseddue to thick abdomen


31/60

Rule in Rule out

Amenorrhea for 4months

Oligomenorrhea for 2months

Transvaginalultrasound: bilateralpolycystic ovaries

Signs ofhyperandrogenism(increased facial hair,acne)

Cannot totally rule

out


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Probably the most common endocrine

disorder in women

Classically char. by findings of irregular(anovulatory) cycles symptoms or signs of

androgen excess and polycystic ovaries on

ultrasound


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Revised 2003 consensus on diagnostic criteria and long-term health risks related to PCOS

concluded that PCOS is a syndrome of ovarian dysfunction

along with the cardinal features hyperandrogenism and

polycystic ovary (PCO) morphology.

remains a syndrome, and as such no single diagnosticcriterion (such as hyperandrogenism or PCO) is sufficientfor clinical diagnosis.


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Most common endocrinopathy among women

of reproductive age

Menstrual irregularity and insulin resistancein 70%

Prevalent markers ofpremature

cardiovascular disease


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PCOS: Diagnostic criteria

1990 NIH: requires both

criteria12003 ESHRE/ASRM:

requires 2 of 3 criteria

Chronic anovulation Oligo- and/or anovulation

Clinical and/or biochemicalsigns of hyperandrogenism

Clinical and/or biochemicalsigns of hyperandrogenism (HA)

Polycystic ovaries

*With exclusion of other etiologies

In both NIH and ESHRE/ASRM definitions, the diagnosis


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In both NIH and ESHRE/ASRM definitions, the diagnosis

assumes exclusion of other diagnoses that may havesimilar clinical presentation as PCOS4such as:

non-classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency,

Cushings syndrome and

androgen-secreting tumours

exclusion of other related disorders:

High-dose exogenous androgens

Hyperprolactinemia

Thyroid dysfunction


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CLINICAL S/S LABORATORY

Ovarian

Tumor

Pelvic mass on bimanual

examination

Testosterone > 2ng/ml

DHEA-S normal

Confirm by UTZ, CT scan

and MRI

Androgen

Producing

AdrenalTumor

Rapidly progressive signs of

virilization.

DHEA-S > 8ug/ml

Cushing

syndrome

hirsutism or virilization is

prolonged and gradual

dexamethasone test/ Liddle

test

PCOS Hirsutism or virilization isprolonged and gradual

Menstrual irregularity

elevated LH levelsmild increase in

testosterone and DHEA-S

levels

UTZ findings


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Presence of

>=12 follicles in

each ovary

measuring: 2-9 mm in diameter

increased ovarian

volume (>10ml).


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HirsutismAcne

male pattern balding, and/or

male distribution of body hair

Lobo RA, et al.Ann Intern Med. 2000;132:989-993.

Hirsutism Acne


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A summary score of greater than 8 is considered

indicative of hirsutismexcessive hairgrowth

What is the


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What is the

pathophysiology of the

PCOS?


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Insulin

acts synergistically with LH to enhance androgen production

inhibits hepatic synthesis of SHBG

Diagnosis of PCOS: Workup for


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Clinical Biochemical

Hirsutism-primaryindicator

Free testosterone

Acne Free androgen index

Diagnosis of PCOS: Workup forhyperandrogenism


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Book description Patient

SIGNS >Hyperandrogenism(Hirsutism,

elevated blood

level of androgen-

testosterone,DHEA-S)

>enlarged

polycystic ovaries

(ultrasound)

HyperandrogenismFacial hair

Acne

transvaginal

ultrasound):

Polycystic bilateralovaries

SYMPTOMS amenorrhea 4 months

amenorrhea


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may also include:

Obesity

Insulin resistance and elevated serum LH

levelsalso common features

Assoc. w/ an increased risk of type 2 diabetes and

cardiovascular events.


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Menstrual Irregularity& hyperandrogenemia

may manifest at puberty w/ a delayed menarche ff. by onset ofirregular periods

or as the breakdown of a previously regular cycle w/in a few

years & often associated w/ weight gain(50% obese)

Anovulation>usually chronic & presents as oligomenorrhea / amenorrhea

>usually assoc.w/ varying degrees of infertilityFreq. cause of

anovulatory infertility(75%)


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LH

LH/FSH ratio

androgen levels*

sex hormone binding globulinmay increase free testosterone levels

Duncan S. Epilepsia. 2001;42(suppl 3):60-65.


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LDL cholesterol

triglycerides

HDL cholesterol -most common

Impaired fibrinolytic activity*

plasminogen activator inhibitor levels*=predict occurrence of MI

Strongly

linked to CVD


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Hyperinsulinemia and insulinresistance

*Women with PCOS tend to be hyperinsulinemic,regardless ofwhether they are lean or obese

a greater frequency &degree of both hyperinsulinemia +

insulin-resistance vs. weight-matched controls

Insulin resistance may be independent of the effect of

obesity both lean and obese womendecreased sensitivity to insulin in peripheral tissues but

not hepatic resistance, (unlike in type 2 DM)

i h l i li i i i


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peripheral insulin sensitivity & consequent

hyperinsulinemia

may play an impt. role in the pathogenesis of

PCOS

Insulin inhibit the prodn of SHBG in the liver SHBG free testosterone

Therefore, insulin resistance :

secretion of ovarian androgen

promotes free (biologically active) hormone


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COMPLAINT TREATMENT OPTIONS Patients medications

Infertility Metformin;Clomipene;Letrozole;

gonadotropins;ovarian

cauteryMetformin-1st line

Txweight./metabolic

concerns

Diet/lifestyle

management/

Metformin*

Skin manifestations Oral

contraceptive+antian

drogen(spironolactone

, flutamide,

finestride);gnrhagonist Cyproterone

Acetate+Ethinyl

estradiol(Althea)Dysfunctional

bleeding

Cyclic progestogen;

ocps


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Insulin resistance & elevated serum LH levels

Assoc. w/ increased risk oftype 2 diabetes &cardiovascular events.

importance of diagnosing PCOSwarrant lifelong surveillance

long-term consequences:

Endometrial cancer

ovarian cancer

DM

hypertension


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syndrome X

Constellation of dyslipidemia, elevated

bp,IGT, and central obesity

1 of the major health problems assoc. w/

obesity not only in Western and European

countries but also in Asia Pacific region

Insulin resistance and hyperinsulineamia

-implicated in etiology of glucose intolerance,

dyslipidemia and obesity


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Glucose intolerance/ insulin resistance

Raised arterial pressure

Raised plasma triglycerides

Central obesityMicroalbuminuria

PATHOLOGY: fundamental defect in pts. w/

Metab syndromeinsulin resistance in both

adipose and muscle tissue


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Central obesity defined as waistcircumference: >= 90 cm (35.4 inches) for Asian men

>= 80 cm (31.5 inches) for asian women (pts= 42 inches)

w/ ethnicity specific values for other groups + any 2 of

the ff. factors:

Raised TG level: >= 150 mg/dl (1.7 mmol/L)

or specific treatment for this abnormality

Pts 149 mg/dl(1.68 mmol/L )

Low HDL cholesterol (high-density


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lipoprotein cholesterol), or being on medicine

to treat low HDL.

< 50 mg/dL for women and


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Ovaries-being exposed to consistenetly

highlevels of insulinincreases testosterone

secretion

Major factor in the devt of pcos


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THANK YOU!

Pcos Report Den Edited

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