25 year old nulligravid came to your clinic because of primary infertility. She and her husband have been trying to conceive for the past 2 years. She came with some lab results: semenanalysis: Normal; transvaginal ultrasound: polycystic ovarian morphology; On quick assessment, she has normal vital signs, obese with BMI 30 kg/m2, and she has multiple cystic and nodular acne all over her face, chest and back.
Tell me (in a few words), how you propose to manage this case. Pls type your short reply below 😊
Doc Ina Ob Gyne 
The patient has the classic signs of PCOS – hyperandrogenism (multiple cystic and nodular acne over the face, chest and back), chronic anovulation (primary infertility for 2 years), and polycystic ovaries. After ruling out other hormonal disorders such as Cushing syndrome and male infertility problems, treatment planning is directed towards patient’s chief complaint – infertility. Infertility is one of the main effects of anovulation and management is focused on ovulation induction using Clomiphene, the first line treatment. Moreover, obesity as a contributing factor in insulin resistance, the central pathology for PCOS, must be addressed through lifestyle modification, diet and metformin. PCOS patients are twice at risk for endometrial and ovarian cancer and taking oral contraceptives must be advised. In addition, screening for type 2 diabetes mellitus using 75g-OGTT is equally important for obese patients (BMI >25kg/m2) diagnosed with PCOS. Finally, patient must be aware that there is no cure for PCOS, the goal of management is symptom-based. Thank you!
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very good! thank you for your excellent response
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The patient presents with a hyperandrogenism (multiple cystic and nodular acne all over her face, chest and back) and polycystic ovaries as stated on ultrasound. To manage this patient, advise with exercise regimens (obese with BMI 30 kg/m2) to lose weight prior to ovulation induction therapy which include Clomiphene citrate or Metformin or Letrozole.
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very good response!!
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The case presented above is a type A phenotype of PCOS with signs and symptoms of hyperandrogenism, chronic anovulation and polycystic ovaries. Salient features in the history and physical exams are as follows: Chronic anovulation, chief complaint of primary infertility as evident by inability to conceive for 2 years; polycystic ovarian morphology on transvaginal ultrasound; and hyperandrogenism presented by multiple cystic and nodular acne all over her face, chest and back. The patient is also obese with BMI 30 kg/m2. I will advise the patient that the first line of treatment for PCOS is always lifestyle management. To address the reason for consultation which is primary infertilty, I can prescribe Clomiphene for ovulation induction.
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very good answer!
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The patient presents with the classic signs of PCOS having polycystic ovaries seen on utz, multiple cystic and nodular acne all over her face, chest and back (hyperandrogenism) and primary infertility (chronic anovulation). Treatment plan of this patient should be based on the chief complaint- infertility. For the management, first encourage the patient for lifestyle management like diet and exercise since the she is obese (BMI of 30kg/m2). Next, treatment directed at the specific complaint which is infertility will be ovulation induction medications particularly Clomiphene citrate or Letrozole which has been effective in initiating menstruation and ovulation in women who have irregularities in menstrual cycle. Also advise the patient for follow up consultation.
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very good response!
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In the case above, the patient exhibits the signs of PCOS:
1. Hyperandrogenism – presence of multiple cystic and nodular acne over the face, chest and back
2. Primary infertility- due to anovulation; this is the patient’s chief complaint
3. Polycystic ovaries- seen via ultrasound
In the management of this case, Clomiphene (first line to induce ovulation) is used to to address the patient’s infertility. Next is to address the patient’s obesity because it greatly contributes to insulin resistance, the central pathology for PCOS. This is done through exercise, lifestyle and diet modifications. Also advise the patient for a follow up check up for monitoring. 😀
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very good answer!
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With anamnesis, PE, and lab results, we can identify that the wife is the one that we have to address for primary infertility. The primary infertility is mainly caused by the anovulation of the patient, which is concluded because the patient manifests PCOS, type A phenotype particularly.
First of all, I will explain what is PCOS to the patient- how it presently affects her, and how it will still affect her in the future. Then, we will plan the management for her condition which would initially consist of normalizing glucose intolerance and diet/lifestyle modification with the aid of Metformin to encourage weight loss. Once these conditions are met, our management will proceed with ovulation induction with the use of Clomiphene. If Clomiphene is not desirable or ineffective, alternative treatments will be given to the patient.
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very good answer!
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The case presented is a a case of classic sign of PCOS which is hyperandrogenism- multiple cystic and nodular acne over the face, chest and back, chronic anovulation- primary infertility for 2 years and polycystic ovaries. First, we need to rule other possible causes of anovulation like hormonal disorders. After ruling out hormonal disorders, my adcise to the patient is to initiate a weight loss management programs like exercising since the BMI is BMI 30 kg/m2 to lose weight prior to ovulation induction therapy which include Clomiphene citrate or Metformin. We should remember that obesity is a contributing factor to PCOS.
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The case presented is a a case of classic sign of PCOS which is hyperandrogenism- multiple cystic and nodular acne over the face, chest and back, chronic anovulation- primary infertility for 2 years and polycystic ovaries. First, we need to rule other possible causes of anovulation like hormonal disorders. After ruling out hormonal disorders, my advise to the patient is to initiate a weight loss management programs like exercising since the BMI is 30 kg/m2, thus to lose weight prior to ovulation induction therapy which include Clomiphene citrate or Metformin or Letrozole. We should remember that obesity is a contributing factor to PCOS
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very good answer!
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