#167 MUNDO, Jxyp Alfe I.

1. What are the salient features of the case?

 A 25-year old woman
 G1P0 (0-0-1-0)
 No menses for 8 months (amenorrhea)
 History of miscarriage
 Underwent curettage
 BMI of 35 which considered to be an obese
 Facial acne and hirsutism
 Unremarkable pelvic exam

2. What additional information, if any, would you like to ask from the patient to obtain a
good impression?
 Ask the patient’s family history like possible genetic anomalies or any of the
family members who are obese.
 Ask if she is diabetic or have family history of diabetes.
 Ask if she is hypertensive or other cardiovascular diseases.
 Ask if she experience abdominal pain, visual changes, headaches, hot flushes,
vaginal dryness or cold and clammy skin.
 Ask the age of menarche, thelarche as well as age of pubarche.
 Was the menarche induced or spontaneous?
 Ask if she experience some systemic illness or autoimmune disease like SLE and
thyroid diseases.
 Ask if she use contraceptives.
 Ask about her social history if she experience stress physically, psychologically,
emotionally or nutrition related.
 Ask if she loss or gain weight.
 Ask when was her curettage and if she experienced severe bleeding.

3. Describe the Pubertal Rating according to Tanner stage.

Breast development and stages of pubic hair in girls are rated from 1 which is
prepubertal to 5 which is an adult type. The breast budding occurs during Stage 2 of breast
growth and marks the onset of gonadarche whereas stage 2 of pubic hair growth marks the
onset of adrenarche. Stage 3 of breast growth is the enlargement of breasts with glandular
tissue, without separation of breast contours. Stage 3 of pubic hair growth is when the labial
hair spreads over the mons pubis. The secondary mound formed by areola occurs at stage 4
of breast development while the lateral spread of pubic hair occurs during stage 4 of pubic
hair growth.

4. Differentiate Primary amenorrhea from Secondary amenorrhea.

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According to ASRM, they defined primary amenorrhea as the absence of menses in a

woman who has never menstruated by the age of 15 years. Others defined as girls who have
not menstruated within 5 years of breast development. It is usually the result of a genetic or
anatomic abnormality. On the other hand, secondary amenorrhea is defined as the absence of
menses in a woman for 3 months period with previously normal cycles and/or absence of
menses in a woman for 6 months period with previously abnormal cycles.

5. What are the differential diagnoses?

Differential Diagnosis Rule in Rule out

Pregnancy  Amenorrheic for 8  Confirmation throught

months Pregnancy Test, TVS,
 Reproductive age, Abdominal ultrasound
25years old

Non-classical Congenital  Amenorheic for 8  Cannot be completely

Adrenal Hyperplasia (CAH) months ruled out need further
 Presence of facial history
acne and
hirsutism

Premature ovarian insufficiency  Amenorrhiec for 8  Histologic examination,

months immunofluorescence
techniques

Intrauterine Adhesions  Amenorrheic for 8  Confirmation through

months hysterosalpingogram

PCOS  Amenorrhea for 8  Thyroid function test

months
 Obese, 2nd degree
 Facial acne
 Hirsutism
 History of
miscarriage
 Serum prolactin
 Free androgen index
 Serum FSH and LH
 OGTT
 Transvaginal
Ultrasonography
 Transrectal US

6. What is the most likely impression?

G1P0 (0010), Secondary Amenorrhea probably secondary to Polycystic Ovarian
Syndrome
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7. What diagnostic examinations will be requested? Explain the rationale for requesting the
diagnostic examination?
 Pregnancy test- this would help you to take a thorough history and a complete
physical examination to rule out pregnancy as a cause of amenorrhea.
 TSH assay- it should be perform to rule out the rare asymptomatic thyroid
disorders that produce secondary amenorrhea.
 Progesterone challenge test- should be done as an indirect means of determining
whether estrogen is sufficient enough to produce endometrial growth that will
slough after the progesterone levels fall.
 E2 Assay- to be able to determine the true estrogen status
 Patients with PCOS, moderate stress, weight loss or hypothalamic-
pituitary dysfunction will usually have E2 levels of at least 30pg/mL
 Those with pituitary tumors, ovarian failure, severe dietary weight loss or
anorexia nervosa, severe stress or hypothalamic lesion will usually have
very low E2 levels, typically in the postmenopausal range
 MRI/CT Scan of the hypothalamic-pituitary region- to rule-out any lesion
 If with pituitary destruction is seen- ACTH reserve should be tested by
performing insulin tolerance test (hypoglycemia is induced and should
normally cause a cortisol increase of 7 ug/100mL within 120 minutes)
 If no lesion identified- it is termed hypothalamic-pituitary failure and
normal ovarian function will resume without treatment

8. What is Polycystic Ovarian Syndrome? Its pathophysiology? Signs and symptoms? Its
consequences?
PCOS is a diverse disorder that may present with prolonged periods of
amenorrhea with a typical menstrual pattern of either irregular or oligomenorrhea. Patient
with this disease is inclined to be obese or overweight, or have signs and symptoms of
hypergonadism. The pathophysiology of PCOS occurs when luteinizing hormones (LH)
secretes in increased number together with the enhanced responsiveness of theca cell and
lead to production of excess ovarian androgen. The increased number of androgen will
inhibit the steroid negative feedback effects on hypothalamic gonadotropin-releasing
hormone (GnRH) pulse generation to account for rapid LH pulse frequency. Furthermore,
increased numbers of androgen levels are associated with obesity, visceral fat deposition,
and dyslipidemia, which may contribute to insulin resistance. On the other hand, obesity,
hyperandrogenemia, and hyperinsulinemia may decrease sex hormone-binding globulin,
thus increasing testosterone. Lastly, increased number of androgen may have direct
effects on the ovary that leads to increase number of follicles and its size and possibly
will enhance the granulosa cell responsiveness to follicle-stimulating hormone (FSH).
PCOS patient experience these signs and symptoms: hair loss from scalp, hair growth in
unexpected places (hirsutism), oily skin, acne problems, weight gain, infertility or
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repeated miscarriages, menstrual problems and depression or mood swings. PCOS

complications include: Gestational diabetes or high blood pressure, infertility,
miscarriage or premature birth, Type 2 DM, sleep apnea, depression, anxiety, eating
disorders, endometrial cancer, obesity, metabolic syndrome, cardiovascular risk, non-
alcoholic steatohepatitis, and abnormal uterine bleeding.

9. What are the Criteria for the Diagnosis of Polycystic Ovarian Syndrome according to
National Institute of Health and Human Development (1990), ESPHRE-ASRM 2003 and
AEPCOS 2012?
1990 NIH: requires both criteria
1. Chronic anovulation
2. Clinical and/or biochemical signs of
hyperandrogenism
2003 ESHRE-ASRM: requires 2 out of 3 criteria
1. Oligo- and/or anovulation
2. Clinical and/ or biochemical signs of
hyperandrogenism
3. Polycystic ovaries
2006 AEPCOS: requires all 3 criteria
1. Ovarian dysfunction (oligo-ovulation and/or
polycystic ovaries)
2. Hyperandrogenism (hirsutism and/or
hyperandrogenemia)
3. Exclusion of other androgen excess disorders

10. How will you manage this case?

There are three categories to consider when managing the patient with PCOS, theis
include: androgen excess and symptoms of hyperandrogenism, irregular bleeding and
endometrial disease, and lastly, fertility concerns. Specific treatment for androgen excess
symptoms usually involves the use of OC with or without an anti-androgen. Treatment of
irregular bleeding should be directed at supplying the missing progesterone in anovulatory
women. OCs are the most logical and effective treatment, particularly because it is known
that they reduce the risk of endometrial cancer. If women with PCOS desire conception,
administration of clomiphene citrate or letrozole is successful in inducing ovulation. If
conception is not desired, periodic progesterone administration (medroxyprogesterone
acetate, 10mg/day, for 10-20days) to reduce the high risk of endometrial cancer and it is
sufficient to administer every 3 months. Treatment of subfertility in PCOS is predominantly
due to anovulation. Ovulation induction may be accomplished by a variety of agents,
including metformin, clomiphene, letrozole, gonadotropins, and pulsatile GnRH.