Case Summary: Ms.

XX is a 28-year-old Irish female who was referred to UHG

Gynaecology Department by her GP with complains of reduced frequency of periods for the
past 12 months. Her periods only happened twice in the 12 months.
She complained of weight gain and her clothes are tighter than usual. She noticed it 3 months
ago.
She has had acnes since age 20 but has not tried any topical creams for it.
She denies post-coital bleeding, intermenstrual bleeding, dyspareunia, and vulval skin
changes or itching.

Other relevant parts of history:

Past Obstetric History/Menstrual History: Menstruation 2 times in the past 12 months, lasting
for 5 days, LMP 4 months ago.
Past Gynae History: Normal
Past Medical History: Normal
Medications: NKDAs.
Past family history: Mother has diabetes, father has hypertension and colon cancer.
Social history: Works as a clerk. Has a husband, no children but trying and failing.

Learning points:
In this case, I learned a lot about the following:
1. PCOS diagnosis
2. Pregnancy related outcomes
Polycystic ovary syndrome (PCOS) affects 5%–20% of women of reproductive age
worldwide and is characterized by hyperandrogenism, ovulatory dysfunction and polycystic
ovarian morphology. The 2003 Rotterdam criteria are currently the internationally accepted
criteria by which PCOS is diagnosed. Patients are diagnosed with PCOS when two out of
three criteria are satisfied: oligoovulation or anovulation, clinical and/or biochemical signs of
hyperandrogenism and/or the presence of polycystic ovaries (PCO) and exclusion of other
aetiologies (congenital adrenal hyperplasia and androgen secreting tumours) [1]. Some
hormonal changes associated with PCOS are an increased testosterone (both total and free),
increased LH (LH: FSH > 2: 1) and a normal or slightly increased levels of oestrogen. A
clinical picture of hyperandrogenism overrules any normal hormone levels and can fulfil a
diagnostic criterium of PCOS [2].

There is an increased risk in maternal complications for women with PCOS. The extent of the
increase in incidence of gestational diabetes (GDM), pregnancy-induced hypertension (PIH),
preeclampsia (PET) and caesarean section (CS) differs slightly among studies but are
increased even when data are adjusted for BMI [1]. In one study, a twofold to threefold
increase in GDM was seen, and PIH/PET were increased threefold to fourfold in women with
PCOS, which corresponds to a 50% increase in PET [3]. Reproductive outcomes, on the other
hand, are also important to note in PCOS. PCOS causes an increase in subfertility, ectopic
pregnancy and early pregnancy loss (EPL) which could be because of altered endometrial
environment due to hyper-insulinemic environment and concurrent hyperandrogenism

Reflection:
As with my patient last week, this lady also faces something very tough every day – the
thought of not being able to bear her own child. Surprisingly, she seemed less worried about
her fertility issues as compared to the lady who had the dermoid ovarian cyst I wrote about
last week. I would think that the seriousness of a PCOS would far outweigh that of dermoid
cysts. Nevertheless, I used the knowledge I had equipped myself with last week to have a
chat with her about her condition, in an attempt to build rapport and gain trust.

Besides that, I learnt a lot about how a patient with PCOS presents. It was tough trying to
diagnose PCOS as I was not familiar with the clinical features of it. Then again, at that point,
I realised that it was tough trying to diagnose any condition because I am incredibly
inexperienced. However, I will work hard by talking to as many patients as I can, because I
learn better from experience as compared to paper. In the future as a doctor, I will strive to
expand my knowledge on topics I am unfamiliar with, in order to help patients get well
quicker.

References:
1. McDonnell R, Hart R. Pregnancy-related outcomes for women with polycystic ovary
syndrome. Women's Health. 2017;13(3):89-97.
2. UpToDate [Internet]. Uptodate.com. 2020 [cited 23 February 2020]. Available from:
https://www.uptodate.com/contents/definition-clinical-features-and-differential-diagnosis-of-
polycystic-ovary-syndrome-in-adolescents
3. Joham AE, Palomba S and Hart R. Polycystic ovary syndrome, obesity, and
pregnancy. Semin Reprod Med 2016 34(2): 93–101.