PCOS — Practical Examination Case

CASE PRESENTATION

1. Irregular menstrual cycles for 3 years
2. Excessive facial and body hair for 2 years
3. Weight gain for 2 years
4. Multiple acne lesions on face and back

HISTORY OF PRESENT ILLNESS

EXAMINATION FINDINGS

General

• Obese female, BMI 32 kg/m²
• Acanthosis nigricans at the nape of neck and axillae (marker of insulin resistance)

Vitals

• BP: 128/82 mmHg | PR: 82/min | RR: 16/min | Temp: 37°C

Dermatological (Androgen Excess Signs)

• Ferriman-Gallwey hirsutism score: 14 (≥8 = clinically significant hirsutism)
• Comedonal and inflammatory acne on face and upper back
• Moderate androgenic alopecia (bitemporal thinning)
• Acanthosis nigricans in skin folds

Abdominal

• Central obesity; waist circumference 92 cm
• No palpable abdominal/pelvic mass

Gynaecological

• Uterus normal sized; bilateral ovaries slightly enlarged (palpable per abdominally)

INVESTIGATIONS

Pelvic Ultrasound (Transvaginal)

• Both ovaries enlarged: Right ovary 12 cm³, Left ovary 13 cm³ (normal <10 cm³)
• ≥12 follicles (2–9 mm diameter) per ovary arranged in a "string of pearls" periphery
• Increased stromal echogenicity and volume
• Uterine endometrium: 8 mm (proliferative)

DIAGNOSIS

Working Diagnosis: Polycystic Ovary Syndrome (PCOS)

All three criteria are fulfilled. Other causes excluded (TSH normal, prolactin normal, 17-OHP normal, no features of Cushing's).

DIFFERENTIAL DIAGNOSIS

1. Non-classical Congenital Adrenal Hyperplasia (CAH) — excluded by normal 17-OH progesterone
2. Hyperprolactinemia — excluded by normal prolactin
3. Hypothyroidism — excluded by normal TSH
4. Cushing's Syndrome — no striae, no proximal myopathy, no moon face
5. Androgen-secreting ovarian/adrenal tumour — testosterone not markedly elevated (>200 ng/dL would raise suspicion); onset gradual

PATHOPHYSIOLOGY (Viva Points)

Genetic predisposition + Obesity
         ↓
Insulin Resistance → Compensatory Hyperinsulinemia
         ↓
↑ LH pulsatility from hypothalamus
         ↓
Theca cells → ↑ Androgen production (testosterone, androstenedione)
         ↓
Excess androgens → Inhibit follicular maturation → Follicular arrest
         ↓
Multiple small antral follicles (≤9 mm) → Polycystic appearance
         ↓
Anovulation → No corpus luteum → No progesterone
         ↓
Oligomenorrhea / Amenorrhea + Unopposed estrogen → Endometrial hyperplasia risk

MANAGEMENT

1. Lifestyle Modification (First-Line)

• Caloric restriction (500 kcal/day deficit) + regular aerobic exercise
• Even 5% weight loss improves menstrual regularity, insulin sensitivity, and fertility outcomes
• Target BMI <25 kg/m²

2. Medical Management

"Letrozole is the preferred therapy; 75–80% of women conceive with such therapy." — Goldman-Cecil Medicine

3. Monitoring and Complications Screening

• Endometrial protection: Progesterone-induced bleed ≥4×/year if not on OCPs; ultrasound/biopsy if risk factors
• Metabolic syndrome: Annual fasting glucose, HbA1c, lipid profile
• Hypertension: Regular BP monitoring
• Obstructive sleep apnoea: Screen with Epworth Sleepiness Scale (obesity + PCOS)
• Mood disorders: Screen for depression/anxiety (common in PCOS)

4. Surgical (Last Resort)

• Laparoscopic ovarian drilling (LOD): Multiple ovarian punctures by diathermy/laser; achieves unifollicular ovulation; reserved for medical treatment failure; risk of adhesions

DIAGNOSTIC FLOWCHART

LONG-TERM COMPLICATIONS (Important for Viva)

VIVA VOCE QUESTIONS