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A 25-year-old woman presents with irregular periods (every 45 to 60 days) for 5 years, increasing facial hair growth, and acne. BMI 32. She has velvety dark skin in her axillae. Pelvic ultrasound shows 14 follicles in each ovary (3 to 7mm each). Testosterone mildly elevated. 17-OH progesterone, TSH, and prolactin are normal.
Questions
a) What is the diagnosis and which diagnostic criteria are met? (2 marks)
Diagnosis: Polycystic ovary syndrome (PCOS). Rotterdam criteria (2 of 3 required, she has all 3): (1) oligo/anovulation (cycles 45 to 60 days), (2) hyperandrogenism (clinical: hirsutism and acne; biochemical: elevated testosterone), (3) polycystic ovarian morphology (14 follicles per ovary).
b) What is the dark skin in her axillae called and what does it indicate? (1 mark)
Acanthosis nigricans — velvety, darkened, thickened skin in skin folds (axillae, neck). It indicates insulin resistance, which is central to PCOS pathophysiology.
c) Describe the pathophysiology of PCOS. (3 marks)
- Insulin resistance → compensatory hyperinsulinaemia.
- High insulin stimulates ovarian theca cells to produce excess androgens (testosterone).
- High insulin reduces hepatic SHBG → more free (active) testosterone.
- Elevated LH (relative to FSH) further stimulates androgen production.
- High androgens cause follicular arrest → multiple small cysts → anovulation.
- Visceral obesity worsens insulin resistance → vicious cycle.
d) Outline the management for this patient (not trying to conceive). (4 marks)
- Lifestyle: weight loss (target 5 to 10%), exercise (150 min/week), low-GI diet. First-line for ALL PCOS patients.
- Combined OCP: for menstrual cycle regulation, endometrial protection (against hyperplasia/cancer from unopposed oestrogen), and improvement of hirsutism/acne (anti-androgenic progestin preferred).
- Spironolactone (anti-androgen): if hirsutism does not improve with OCP alone. Ensure contraception (teratogenic).
- Metformin: for insulin resistance (may improve menstrual regularity and aid weight management).
- Monitoring: annual fasting glucose, HbA1c, lipid profile (increased T2DM and CVD risk).