Medicine>>>>>Women’s Health
Question 9#

A 33-year-old woman presents to your office with complaints of inability to become pregnant. She and her husband have been having regular intercourse for 10 years without contraception. Her husband has normal sperm count and motility. Her menses are irregular, occurring every 28 to 60 days. She has noticed some facial and upper back acne, as well as increased amount of pubic hair. On examination, her waist circumference is 36 in and she has cystic acne on her neck, forehead, and upper back. She also has acanthosis nigricans in her groin and posterior neck.

Lab results:

• fasting blood glucose: 106 mg/dL
• Urine glucose: absent
• DHEA-S: 360 µg/dL (follicular 32.2-308 µg/dL) (luteal 29.5-269 µg/dL)
• Total testosterone: 1.1 ng/mL (0.1-0.6 ng/mL)
• Pelvic sonogram: normal

What is the best plan for the initial management of this patient? 

A. Weight loss through diet and exercise
B. Metformin
C. Isotretinoin
D. OTC appetite suppressants
E. Gastric bypass surgery

Correct Answer is A

Comment:

This woman has polycystic ovarian syndrome (PCOS), the most common cause of infertility in women. Although the precise definition of PCOS is controversial, most agree it may be diagnosed in women with some combination of oligomenorrhea, clinical, or biochemical evidence of hyperandrogenism (excluding other causes of hyperandrogenemia), and polycystic ovaries by ultrasound. (Polycystic ovaries on ultrasound are not required in the diagnosis of PCOS.) High levels of androgens, either from the ovaries or the adrenal glands, interfere with ovulation and result in ovarian cyst formation, excess facial and body hair, and acne. Most women with PCOS will have elevated serum DHEA-S and testosterone concentrations. Hyperinsulinemia and insulin resistance, seen clinically as acanthosis nigricans, are also common findings. Women with PCOS are at increased risk of metabolic syndrome, diabetes, and cardiovascular disease. Exercise and weight loss are firstline recommendations, and may restore normal ovulation without medications. Treatment for women not pursuing pregnancy includes oral contraceptives or metformin. Spironolactone has clinical efficacy but is not FDA approved for this use. Rapid weight loss through gastric bypass is not the best option for this patient due to her mild obesity and her desire to become pregnant immediately. Isotretinoin for acne treatment should not be used in women actively trying to conceive due to the extremely high risk of birth defect.