Snapshot A 25-year-old woman presents with excessive hair growth and abnormal menses. She reports shaving mulitple times to remove hair from her chin and chest, states that her menses has been irregular, and is currently sexually active and only uses condoms as a form of contraception. She is not on any medications. The patient is 5' 1" (155 cm) and weighs 165 lbs (75 kg). On physical examination, there is hair in the periareolar and linea alba region. There is also acanthosis nigricans in the posterior neck. Introduction Clinical definition an acquired endocrinopathy characterized by ovarian dysfunction can lead to primary or secondary amenorrhea and oligomenorrhea which prevents formation of the corpus luteum, impairing progesterone synthesis which leads to unapposed estrogen proliferative effect on the endometrium that results in bleeding increased risk of endometrial hyperplasia and cancer hyperandrogenism may present as acne and hirsutism polycystic ovaries Epidemiology incidence ~7% of reproductive-aged women demographics females only risk factors family history obesity Pathophysiology mechanism is unclear peripheral insulin resistance leads to hyperinsulinemia ovarian stimulation leading to excess androgen production Associated conditions infertility the most common cause of infertility in woman menstrual dysfunction hyperandrogenism obesity insulin resistance Prognosis natural history of disease patients may present for hirsutism, irregularities in their menses, obesity, and acanthosis nigricans prognostic variable favorable weight loss Presentation Symptoms menstrual dysfunction e.g., dysfunctional uterine bleeding and amenorrhea infertility hirsutism acne Physical exam obesity hirsutism acne acanthosis nigricans a sign of insulin resistance bilateral enlarged ovaries on pelvic exam Imaging Ovarian ultrasonography indications can be performed when pelvic examination is inadequate findings may show polycystic ovaries affecting one or both ovaries Studies Labs total and free testosterone level LH/FSH > 3 Differential Cushing syndrome Non-classical congenital adrenal hyperplasia Androgen-secreting tumor Pregnancy Premature ovarian failure Thyroid disease hyper- or hypothyroidism Prolactinoma Treatment Lifestyle weight loss indications for obese patients, weight loss is the first-line of treatment for obese patients pursuing pregnancy Pharmcologic hormonal contraceptives indications first-line of treatment for anovulation first-line of treatment for hirsutism/acne metformin indications first-line of treatment for the insulin resistance associated with PCOS also known to improve ovulation and assist in reducing androgen levels to improve regular menstrual cycles clomiphene citrate indications first-line of treatment for infertility caused by PCOS can cause heterotopic pregnancy Operative bariatric surgery indications for treatment of obesity ovarian-drilling indications can be considered in patients who are refractory to clomiphene citrate Complications Complications infertility endometrial hyperplasia and cancer due to unopposed estrogen exposure associated with increased insulin resistance
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.GN.13.255) A 27-year-old woman presents to her primary care physician for difficulties getting pregnant. She and her husband have been having unprotected intercourse once per day without success for the past year. She reports irregular menses. She is otherwise healthy and is not taking any medications. Her temperature is 98.0°F (36.7°C), blood pressure is 144/88 mmHg, pulse is 83/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical examination is notable for acne and the finding in Figure A. The patient has a notable abdominal pannus without any rashes noted. The patient is subsequently worked up with a TSH, prolactin level, and hysterosalpingogram, all of which are normal. She is instructed to lose weight and given a prescription for metformin. The patient returns 3 months later, and her urine hCG is negative. The treating physician is considering prescribing a second line medication. What potential side effect must the physician warn the patient about? Review Topic | Tested Concept QID: 106211 FIGURES: A Type & Select Correct Answer 1 Facial hair 0% (0/10) 2 Heterotopic pregnancy 10% (1/10) 3 Hypoglycemia 80% (8/10) 4 Increased insulin sensitivity 10% (1/10) 5 Weight gain 0% (0/10) L 3 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2
All Videos (1) Podcasts (0) Login to View Community Videos Login to View Community Videos Polycystic Ovarian Syndrome Luigi Bonini Gynecology - Polycystic Ovarian Syndrome 2/8/2016 142 views