Sample Case Study (8/02)

Case study: 
    HPI:  28 year old woman has been trying to get pregnant "for a long time".  She has been married over 2 years and has never used any form of contraception.  GYN History:  Menarche age 14, always has had irregular periods.  In the last few years, the patient has only had a period every 4-5 months.  Darkhair  began to grow on her upper lip and chin about 2 years ago. She has also had trouble with acne and has gained 30 pounds since completing high school.

Differential diagnoses: 

• Polycystic ovarian disease

• Cushing's syndrome

• Testosterone-producing ovarian tumor

• Testosterone-producing adrenal tumor

• Prolactin-producing pituitary tumor

• Hyperthecosis

• Adult-onset adrenal hyperplasia

• Hyperandrogenism

• Secondary medications such as anabolic steroids, testosterone, corticosteroids, danazol

• Eating disorder

• Hyper/hypothyroidism

• Idiopathic hirsutism

• Infertility r/t hormonal imbalance, structural defect

Chosen diagnosis:  Polycystic Ovarian Syndrome

ICD codes:  256.4 Polycystic ovaries;  628.0  Female infertility associated with anovulation

Expected historical data:

• Irregular menses since menarche or no period for a period of time

• increasing hair growth on chin, upper lip, around nipples

• acne

• no pattern of regular periods

• infertility

• weight gain/obesity

• Positive family history of infertility and PCOS

• no major medical problems

• denies contraceptive use.

• denies androgen like medications

• may complain of lower abdominal pain

• May notice decrease breast size

• may complain of skin discoloration in "armpit" area

• weight gain

• eating disorder

• androgen like drugs such as Danizol

Significant physical data:

• VS normal

• Weight.  30 pound gain noted in chart.  BMI over 26

• Central obesity

• Skin

  • Acne

  • Dark hair on upper lip, chin, few course hairs around nipples

  • Slight temporal baldness

  • possible streia

  • Possible acanthosis nigricans

• HEENT

  • possible deepening voice

  • possible moon face

  • otherwise normal exam

• Neck. 

  •  No increased thyroid size or nodules

• Chest.  Clear breath sounds

• Breasts.  Possible decrease in size, terminal hair.  No nipple discharge

• Musculo-skeletal. 

  • ROM of joints of upper and lower body complete. 

  • Possible increase size of muscles eg biceps, quadriceps

  • Possible increase strength

• Neuro

  • Oriented X 3; Cranial nerves 2-12 grossly intact; able to do rapid alternating movements of hands; walk on heels and toes; sensation grossly intact upper and lower extremities

• Abdomen

  • BS positive

  • Abdomen obese

  • No pain to percussion or palpation

  • Spleen and liver not enlarges

  • No masses noted

• Pelvic exam

  • Pubic hair pattern in male pattern

  • Possible increased clitoris size

  • Possible enlarged ovaries bilaterally

  • Cervix without lesions

  • Uterus small

Tests to order

• Pregnancy test

• Menses calendar might be helpful

• CBC, Chemistry profile

• LH/FSH (>=2.5 - 8.0/1)

• Prolactin level

• TSH

• Serum testosterone (total and free) (increased but below 200ng/dL)

• DHEA-S (increased but less than 800 ug/dL)

• Fasting plasma glucose

• Lipids

• 17-hydroxyprogesterone

• Pelvic Ultrasound, prefer vaginal

• Possible dexamethasone suppression test

Plan

• Weight loss counseling.  Weight loss decreases insulin resistance.  Of course this is so very hard for our patients-- and ourselves.

• Education and handouts about PCOS

• Oral contraceptive pills to increase sex hormone binding globulin for 6-12 months, avoid androgenic progestin's

• Hirsutism. Counsel re bleaching, electrolysis

• Refer to OB-GYN if fertility desired for ovulation induction

• Possible treatment with Metformin

Follow-up:

• 1 week or after test results are back.  This would include explanation of test results, what diagnosis is and what the treatment possibilities would be.  Patient would help decide treatment.  Does patient desire pregnancy?  Does patient desire regular periods and decrease androgen?

• 3-4 months after treatment begun to assess response.

• Refer to OB-GYN for ovulation induction if the patient desires pregnancy.

Medications:

• Any birth control pill.  Avoid the more androgenic progestin's.

• In consultation with physician, begin Metformin 500mg BID, increasing to 1000mg BID to decrease insulin resistance.  Must DC if pregnant.

• In consultation with physician, begin clomiphene citrate (Clomid) 50 mg day 5 through 9 of menstrual cycle.

•  Folic acid 1000 ug daily, probably in a PNV, for women trying to become pregnant.

• Provera 5-10 mg or Prometrium 200 mg daily last 2 weeks of the cycle or the month if patient not having periods to protect endometrium from unopposed estrogen.

• Anti-androgens. Spironolactone 25-100mg BID, flutamide (Eulexin) 259 BID,

•  cyproterone (Cypprostat) 25-50 mg q day 10 days a month.

Patient handout:

• www.aafp.org/afp/20000901/1090ph.html

References:
Beckmann, C.R. B., Ling, F. W., Laube, D. W., Smith, R. P., Barzansky, B, M. and Herbert, W. N. P. Hirsutism and virilization. Chapter 37. Obstetrics and gynecology, Fourth Edition. Philadelphia, Pa: Lippincott Williams & Wilkins; 2002; 472-481.
 

Hunter, M. H. and Sterrett, J.J. Polycystic ovary syndrome:  it's not just infertility. American Family Physician.  2000:  62:1079-1088.

   
Pennill, M. Polycystic ovary syndrome:  an overview.  Topics in Advanced Practice Nursing e.Journal.2(3), 2002. Available at http://www.medscape.com/viewarticle/438597

I need to find a research article.