Polycystic Ovarian Syndrome

Chief Complaint

Oligomenorrhea

Patient Profile

Name: Maria Urbino

Age: 27 years old

Gender: female

History of Present Illness

M.U. is a 27-year-old woman who presents today for evaluation of oligomenorrhea. She reports that her menstrual periods have been irregular for many years. She is seeking care for this issue because she is now in a serious relationship with her boyfriend and they have been discussing getting married and having children. She has never been pregnant or tried to become pregnant before, but she is concerned about her ability to conceive on account of her very irregular menstrual cycle.

She reports that she experienced menarche at age 13. Her periods occurred regularly, every 28 days for the first several years. She recalls that around age 15-16 her periods became irregular with the interval between periods lasting anywhere from 3 weeks to 4 months. She estimates that she has had 4 menstrual periods over the past year. She was not so concerned about this because her mother told her that she has always had the same problem. Many of her friends in high school also had irregular menstrual cycles.

She reports that her menstrual periods usually last about 4-5 days when they occur. She denies any unusually heavy bleeding. She reports some mild lower abdominal cramps and lower back pain with her periods, which are successfully managed with acetaminophen and ibuprofen.

Maria reports that she has been sexually active with one male partner for the past 8 months. Prior to this she reports 3 lifetime partners, all males. She denies any history of sexually transmitted infection. She and her current partner use male condoms for barrier protection against STIs and pregnancy prevention. She is nulliparous. She reports that she had 1 Pap smear, shortly after she turned 21 years. She recalls being told that the results were “normal.”

Maria reports that during later adolescence, around the time that her periods became irregular, she gained a considerable amount of weight. She reports that although her weight has fluctuated slightly over the years, she has been overweight since then. She became tearful as she explained that she has felt very self-conscious of her body since adolescence.

She tearfully explains that she is very anxious about her fertility. She has been very happy in her relationship with her boyfriend, but remains self-conscious about her weight and appearance. She is afraid that he will lose interest in their relationship if she is not able to have children.

Medications

Women’s prenatal multivitamin: 1 tablet daily

Acetaminophen: 500 mg tablets, takes 2 tablets every 6-8 hours as needed for headaches

Social History

• Smoking: Never a smoker, her parents smoked in the house when she was a young child but quit by the time she was in high school.
• Alcohol use: 2-3 glasses of wine on weekend nights.
• Illicit drug use: Denies any current use of illicit drugs. She reports occasional use of marijuana via edibles and smoking, as well as cocaine via snorting during college. Denies ever engaging in intravenous drug use. She has not used cocaine or marijuana for at least the past 5 years.
• Living situation: Lives alone in an apartment.

Social History

Elementary school teacher

Family History

• Father: Hypertension, COPD, obesity, diabetes mellitus (type 2)
• Mother: Diabetes mellitus (type 2), obesity

Review of Systems

• General: Denies weight loss or gain over the past 6 months, but reports that she gained significant weight over several years during her later adolescent years. She denies fevers, chills, fatigue, and generalized weakness.
• Skin: Reports frequent issues with acne on the face since adolescence. Denies rash and wounds.
• HEENT:
  • Head: Denies headache and recent trauma.
  • Eyes: Denies pain, double vision, blurred vision, excessive teary, drainage, and changes in visual acuity.
  • Ears: Denies changes in hearing acuity, tinnitus, vertigo, pain, and drainage
  • Nose: Denies nasal drainage, epistaxis, and sinus pain
  • Mouth and throat: Denies throat pain, difficulty swallowing, and hoarse voice. Denies any active tooth pain. She sees a dentist regularly; last visit was 4 months ago.
• Neck: Denies pain, stiffness, and swollen lymph nodes.
• Breasts: Denies pain, lumps, nipple discharge, and change in size.
• Respiratory: Denies cough, shortness of breath, hemoptysis, and chest pain.
• Cardiovascular: Denies chest pain, palpitations, shortness of breath, and swelling in the extremities.
• Gastrointestinal: Denies nausea, vomiting, diarrhea, abdominal pain, constipation, bloody or black tarry stools.
• Peripheral Vascular: Denies leg pain, varicose veins, swelling in the extremities, and changes in temperature or color of the extremities.
• Urinary: Denies dysuria, hematuria, frequency or urgency of urination, incontinence, and suprapubic pain.
• Genital: Denies increased vaginal discharge, vulvovaginal itching, genital lesions, and dyspareunia.
• Musculoskeletal: Denies any joint redness, pain and swelling in any other joint. Denies back pain.
• Psychiatric: Reports feeling anxious and depressed. Denies memory changes and hallucinations. Denies suicidal and homicidal ideation.
• Neurological: Denies confusion, headaches, syncope, numbness in any extremity, weakness in any extremity, tremors, and seizures. Reports dizziness.
• Hematologic: Denies easy bruising or bleeding.
• Endocrine: Denies heat or cold intolerance, excessive sweating, excessive thirst, excessive hunger or increased urine output.

Physical Assessment

Vitals

• Heart rate: 75 bpm
• Respiratory rate: 14 bpm
• Blood pressure: 115/62 mm Hg
• Oxygen saturation: 99% on room air
• Temperature: 98.8°F
• Height: 5ft 6 in (167.6 cm)
• Weight: 165 lb.
• BMI: 26.6

General Survey

• Well-appearing woman. She appears well-groomed and is dressed in clean-appearing professional clothes, which are appropriate for the weather.
• HEENT:
  • Head: Head is normocephalic/atraumatic. Scalp is without lesions. Hair is of normal texture, but there is evidence of some hair loss with thinner distribution at the posterior vertex.
  • Eyes: Pupils 4 mm constricting to 2 mm with exposure to light, round, regular bilaterally. Sclera are white bilaterally. No conjunctival injection. Optic disc margins are sharp bilaterally. No arteriolar narrowing or AV nicking bilaterally.
  • Ears: Tympanic membranes are intact with visible cone of light bilaterally. Hearing acuity is good with whispered voice test. No tenderness with palpation of the external ear structures.
  • Nose: Mucosa are pink. Septum is midline. No sinus tenderness.
  • Oral: Mucus membranes are pink, moist, and intact. Dentition appears to be in good repair with no obvious areas of decay or broken teeth. Gingival tissue is pink and without swelling. Tongue is midline. Pharynx is without exudate.
    

    

• Neck: Supple; trachea is midline. No enlarged cervical lymph nodes. Full active range of motion with flexion, extension, tilt bilaterally and rotation bilaterally
• Respiratory: Respiratory rate is normal and breathing appears unlabored with no use of accessory muscles. Thorax expansion is symmetric. Lung sounds are clear to auscultation in 3 lobes on the right and 2 lobes on the left.
• Cardiovascular: S1/S2 with no murmur or rub. No edema in extremities bilaterally.
• Abdomen: Rounded, soft, non-tender; bowel sounds active in all quadrants. No masses. No pain with palpation. Liver span is 7 cm at the right midclavicular line, liver edge is smooth and palpable 1 cm below the right costal margin. The spleen is not palpable. Negative CVA tenderness bilaterally.
• Musculoskeletal: No erythematous, edematous, or deformed joints on inspection. No spinal tenderness with palpation.
• Neurological: Alert and cooperative. Oriented to person, place, time, and situation. Cranial nerves II-XII intact. 5/5 strength in bilateral upper and lower extremities.
• Skin: She has numerous small pustules scattered over the forehead and parotid cheeks bilaterally. There is growth of coarse hair on the upper lip and chin of the face.
• There is an area of darkened skin in the skin folds at the base of the neck and in bilateral axillary skin folds.

Pelvic Exam Findings

No inguinal adenopathy. There is acanthosis nigricans in the inguinal skin folds. No lesions, erythema or masses of the external genitalia. Pubic hair of normal distribution for adult female. Vaginal mucosa is pink with no visible lesions. There is a moderate amount of whitish/clear discharge in the vaginal canal. Uterus is anterior, midline, smooth, and not enlarged. Cervical os is visualized with no drainage noted. No cervical motion tenderness with bimanual exam. Slight tenderness with adnexal palpation bilaterally. Ovaries are not palpable. No adnexal masses palpated.

Diagnostic Reasoning

You have included polycystic ovarian syndrome (PCOS) in your differential diagnosis. The Rotterdam criteria are the recommended diagnostic tool for identifying patients with PCOS (Barbieri & Ehrmann, 2024b).