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79 CASE 79


A 24-year-old woman presents to her gynecologist with concerns regarding her menstrual cycle.


The patient complains of very irregular menstrual periods (fewer than eight a year) that are very heavy. She also noticed dark, coarse hair growing on her face, upper arms, chest, and abdomen, which she stated is extremely embarrassing. The patient also complains of persistent acne on her face. She is married without children. She and her husband have been trying for a pregnancy for about 3 months now but have been unsuccessful.



PHYSICAL EXAMINATION



VS: T 98.8°F, P 82/min, R 14/min, BP 125/80 mm Hg, weight 145 lb, height 5’3″

PE: Patient is overweight with a BMI of 26. The majority of the excess fat is centralized around her abdominal area. There is some dark, coarse hair.


LABORATORY STUDIES



Transvaginal ultrasonography: A 2-5 fold ovarian enlargement with thickened tunica albuginea and approximately 20 follicles 1 to 5 mm in diameter without a dominant follicle; endometrium is thin. The findings are consistent with polycystic ovary disease.

Blood test: Elevated LH/FSH ratio > 2.5

Testosterone: 130 ng/dL (normal: 20-80 ng/dL)

Prolactin: 18 ng/dL (normal: < 20 ng/dL)

Glucose tolerance test: Abnormal

Thyroid Hormone (TH): 7 μg/dL (normal: 5-12 μg/dL)


DIAGNOSIS


Polycystic ovary syndrome



PATHOPHYSIOLOGY OF KEY SYMPTOMS


During the reproductive years the ovaries undergo cyclic changes that are integral to normal reproductive function. After the onset of menstruation, follicle-stimulating hormone (FSH) from the hypothalamus stimulates the maturation of the primordial follicles. Numerous follicles begin the maturation process, but one follicle becomes dominant and continues to mature into a graafian follicle, surrounded by thecal cells that produce androgens and granulosa cells that produce estrogens and progesterone. The nondominant follicles regress and degenerate. Ovulation occurs on day 14, when the mature follicle ruptures, releasing the ova. The granulosa cells in the remnants of the ruptured follicle become the corpus luteum and secrete progesterone and estrogen.


Polycystic ovary syndrome is often called Stein-Leventhal syndrome. In this syndrome a number of primordial follicles begin the maturation process but no single follicle emerges as the dominant follicle. In the absence of the development of a primary follicle, ovulation does not occur. Polycystic ovary syndrome occurs in 10% of females in the United States and is the leading cause of female infertility.


Failure of the follicle to mature also causes reduced estrogen and progesterone production. The cyclic changes of the uterine endometrium associated with the menstrual cycle are normally stimulated by estrogen and progesterone. Consequently, women with polycystic ovary syndrome will have irregular or completely absent menses.


Androgen production by the thecal cells of the primordial follicles continues throughout the ovarian cycle, leading to many the external symptoms of polycystic ovary syndrome. These symptoms are generally thought of as male secondary sexual characteristics and include increased hair growth on the face and trunk, excessive oil production by the sebaceous glands leading to acne, and possibly male pattern baldness or thinning of hair.


The exact causes of polycystic ovary syndrome are not yet known, but the syndrome tends to occur in families. Cysts can occur in women without the disease, so the presence of cysts alone does not indicate the development of the syndrome.


Obesity is both associated as a risk factor for developing the syndrome and as a symptom of the disease. Part of this association may be due to the relationship between obesity and diminished insulin sensitivity. Women with polycystic ovary syndrome frequently have decreased insulin sensitivity and increased insulin production, as is characteristic with type 2 diabetes mellitus. The decreased insulin sensitivity likely accounts for the abnormal glucose tolerance test of this patient.


Treatment options depend on the desired clinical outcome. Estrogen-based birth control pills can help restore regular menstrual cycling but not ovulation. Ovulation can be restored by treatment with clomiphene. 5α-Reductase inhibitors such as finasteride can be used to block the intracellular conversion of testosterone into dihydrotestosterone and, in doing so, reduce the development of many of the male secondary sexual characteristics. Finally, weight loss has been effective at diminishing many of the symptoms of polycystic ovary syndrome.

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Jul 4, 2016 | Posted by in PHYSIOLOGY | Comments Off on 79

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