A woman with oligoamenorrhoea

Question 1

Hx taking for oligoamenorrhoea

Answer 1

• Chief complaint
• Menstrual history (regularity, duration, frequency, menarche [irregular since menarche?], flow, dysmenorrhea, IMB, LMP, PMP)
• Previous consultation
• Reason for attendance
• Sexual history, contraception, pregnancy test
• Associated symptoms
• Hyperandrogenic symptoms (arm, legs, chest, back, pubic area, face)
• Thyroid symptoms (cold, heat intolerance, tremor, palpitation)
• Symptoms of hyperprolactinemia / pituitary tumour (abnormal nipple discharge, headache, blurring of vision)
• Weight change
• RF for functional hypothalamic amenorrhoea (work stress, exercise)
• PMH
• Past gynaecological history
• Cervical smear
• Past obstetric history
• Fertility wish
• Social history (NSND)
• Drug allergy & drug history
• Surgical history
• Family history (O&G problems)

Question 2

After taking Hx, what will be the next step?
- What will you note during physical examination
- What Ix will you perform?
- How will you explain these to patient?

Answer 2

• Blood pressure
• Body weight, height, BMI
• General examination
  — Some acne, no hirsutism
  — No goitre
  — No Cushingoid features
• Abdominal and pelvic exam
  — Unremarkable
  — No clitoromegaly

Ix:
- Urine PT
- Cervical smear

Question 3

What is used to describe /assess severity of hirsutism?

Answer 3

Each of the 9 body areas which are most sensitive to androgen are assigned a score from 0 (from no hair) - 4 (lot of hair)

Focal hirsutism: 1-7 (common normal variant)
Generalised hirsutism: 8+ (abnormal in general UK population)

Lower in Asian population, higher in Mediterraneans

Question 4

Plan of investigation for oligoamenorrhoea

Answer 4

1. Blood test
   - Hormone levels, FSH, LH, oestradiol, TSH, prolactin, testosterone, etc.
2. Ultrasound
   - Look at ovaries (PCOS?)
3. Progestogen challenge test
   - 1 week
   - When stopped, see if there is withdrawal bleeding
4. Arrange follow-up

Question 5

Comment

Answer 5

Slightly raised LH
- Not uncommon in patients with PCOS

Question 6

What are transvaginal USG signs of PCOS?

Answer 6

‘String of pearl’ sign = multiple peripherally located small follicles in ovaries that is typically in PCOS

Question 7

What is the diagnostic criteria for PCOS (2018)?

Answer 7

Question 8

Long-term health sequelae of PCOS

Answer 8

• Endometrial hyperplasia / cancer
• Infertility
• Metabolic syndrome: HT, DM, hyperlipidaemia, CVD

Question 9

How would you explain diagnosis and plan of management to patient with suspected PCOS who has had positive response to Progestogen withdrawal test?

Answer 9

• How’s menstruation?
• Explaining test results?
• Ultrasound for uterus is normal
• Many small cysts were seen in ovaries
• Explain diagnosis of PCOS
• Advise weight reduction
• Do exercise (~30 minutes)
• Increased risk of endometrial hyperplasia and cancer

Treatment
- Endometrial protection: OCP or periodic Progestogen = regulates menstrual flow and prevent unopposed estrogen
- Contraception still needed if no plan for pregnancy
- Metabolic risks (HT, DM, HC, CVD)
- Do BP and OGTT and measure cholesterol
- Exercise, eat healthy
- Fertility issue = ovulation induction
- Summary of plan
- Arrange follow-up

Question 10

• Management of PCOS
• Monitoring of PCOS

Answer 10

• Weight reduction = diet control + regular exercise
• COC pills or periodic Progestogen
  — protects endometrium
  — What are the pros and cons of each?
• Monitor:
  — BMI, blood pressure
  — OGTT and lipid profile

Question 11

What is fertility treatment for PCOS?

Answer 11

Fertility treatment
- Weight reduction
- Ovulation induction
— 1st line: Letrozole (off-label use) or clomiphene citrate)
— 2nd line: Gonadotrophins or laparoscopic ovarian drilling (if resistant to 1st line medications)
— 3rd line: in-vitro fertilisations