1. pregnancy

2. PCOS

3. hyperprolactinemia

4. hypothalamic ammenorhea

5. hypothyroidism

6. premature ovarian insufficiency

7. eating disorder

8. medication s/e

FURTHER QUESTIONING

1. HOPI

   • common symptoms of pregnancy

   • thyroid symptoms

   • visual disturbance

   • galactorrhea

   • congenital abnormalities (MRKH syndrome, Turner's syndrome)

   • secondary sexual characteristics

2. PMH

   • previous chronic illness

   • birth control

   • any drug uses

   • any surgery

3. Social history

   • smoking

   • alcohol

   • diet

   • exercise

   • menarche

   • menstrual history

   • pregnancy

   • occupation

4. Sexual history

   • sexual activity

   • type of sexual activity

   • number of sexual partners

   • partner's health

   • STI

   • sexual problem (pain during intercourse)

   • contraception use (type)

   • sexual abuse/trauma history

5. Family history

   • any inherited problem/disease

6. Gynaecological histoey

   • HPV vaccination

   • cervical screening

   • history of STD

   • obstetric history (pregnancy status, how many children, miscarriage, termination, mode of delivery, complication during pregnancy)

     
     

for the last year and a half without success

• TTC

• problems in herself -fibroid, polyps, others

2. and her husband had proven

paternity with a previous wife.

• prove the husbnd fertility

3. She noticed a significant weight gain (24kg) over the last few months or so

• rapid weight gain

• endocrinopathy -pcos, hypothyroidism

4. convinced she was pregnant

even though all tests came back negative.

• she had pregnancy like symptoms due to desire to pregnant

5. Past Medical History: She had acne from age 20, visited dermatologist. Started laser hair removal on face from the age 25. -excessive androgen due to insulin insensitivity, hormonal imbalance can also lead to acne

6. Menstrual history: She stated that her menses were irregular, occurring every 25 to 47 days, and sometimes she skipped menses altogether. They were sometimes heavy, other times light with just brown spotting. She noted that her menses had always been this way,ever since menarche at age 12. - normal 21-35 days, normal menarche 10-16, average 12, irregular mens- oligomenorrhea might be due hypothyroidism, pcos, stress and significant weight changes or medication, brown spotting can be cause by hormonal imbalance or iud

Family History: her mother had HTN, type 2 diabetes, and obesity.

• have family metabolic syndrome

Social History: married at the age 24, no children.

Sexually active

since 24 with no history STI’s.

• indicate primary infertility, never achieved pregnancy after trying to conceive for one year

She never smoked or consumed

alcohol.

• symptoms not due to smoking or alcohol

Medications. The patient was not on any type of contraception and did

not take any medications.

• can rule out medication side effects

1. pregnancy

2. PCOS

3. hyperprolactinemia

4. hypothalamic ammenorhea

5. hypothyroidism

6. premature ovarian insufficiency

7. eating disorder

8. medication s/e

9. cushing disease

FURTHER EXAMINATION

1. vital sign

2. bmi

3. general inspection

4. pelvic examination

5. speculum examination

6. pregnancy test

Temperature 36.8 -normal

Heart rate 78 beats per minute -normal

Respiratory rate 14 breaths per minute -normal

Blood pressure 140/90 mmHg -high, obesity assoc with insulin resistance, related to hyperinsulinemia, cause sodium retention in kidney, activates RAAS, cause vascular muscular hyperthrophy, raise bp

2. BMI 31 kg/m2 (normal range: 18.5 – 24.9 kg/m2)

   -insulin resistance or sensitivity, increase androgen

   -androgen will increase weight gain, accumulattion of fat at abdomen, apple shape

   - cushing, pcos, genetic inherintance

   
   

3. On examination there is excessive hair growth on the lower arms, legs and thighs and in the midline of the abdomen below the umbilicus. There is a small amount of growth on the upper lip too.

-hirsutism,in pcos and cushing

-signs of pcos, ovarian dysfunction, androgen excess

4. The skin of her neck was darkish and looks velvety.

-term acanthosis nigricans, due to hyperinsulinemia, stimulate skin epidermal keratinocytes to proliferate, appears darken skin

4. The abdomen was

soft, and no masses were palpable.

-hyperandrogenism not from adrenal gland, no enlargemet in adrenal glands

-normal git system

6. Her pelvic examination was

limited by her obesity but normal.

-speculum examination, external examnination difficult to detect important landmarks

-examination is not suitable for the patient

7. On speculum examination. The vagina was normal pink, soft, rugosed and no lesions were found.

-normal pink- vagina mucosa healthy, good blood supply

-soft- no masses

-rugosed- normal

-no lesion - normal

1. pregnancy

2. PCOS

3. hyperprolactinemia

4. hypothalamic ammenorhea

5. hypothyroidism

6. premature ovarian insufficiency

7. eating disorder

8. medication s/e

9. cushing disease

10. 
    

    
    

    FURTHER INVESTIGATIONS

    • FBC

    • Blood test

      (serum hCG, cortisol, TSH, LH, FSH, prolactin, testosterone, DHEAS)

    • TFT (T4+T3)

    • Transvaginal US

Blood test

Follicle-stimulating hormone(FSH) 7 IU/L - normal

Luteinizing hormone (LH) 12 IU/L - normal

Prolactin 780 mu/L - high

• low GnRH, FSH, LH > anovulation, amenorrhea

• stress, lactation

  
  

Testosterone 3.2 nmol/L - high

DHEAS 3.92 to 10.66 - high

• hyperandrogen

  
  

Thyroid-stimulating hormone 4.9 mu/L - normal

Free thyroxine 14.7 pmol/L - normal

• exclude hypothyroidism

  
  

The pregnancy test - Negative

Transvaginal ultrasound revealed enlarged both ovaries (right 11.5 ml and left 12.3 ml) with more than 15 small follicles in each ovary arranged in a periphery

with central echogenic stroma.

• PCOS - string of pearls

The diagnosis of polycystic ovarian syndrome was made.

• 3 criteria (2/3) rottterdam

Management: The patient was started traement with letrozole and metformin combination for ovulation induction.

• Letrozole - indication breast cancer

  • MOA - inhibit androgen conversion to estrogen

  • Metformin - insulin resistance indication

She also advised exercise and calorie-restricted diet.

• + ovarian drilling

Complication

• CVD

• DM

• Obstructive sleeep apnea