December 17, 2024

A 30-year-old obese patient presents with irregular menses and reports inability to become pregnant

By Med-Challenger · 2 minute read

A 30-year-old obese patient presents with irregular menses every 6-12 weeks, acne on her face and back, coarse dark hair on her lower abdomen, and a report of an inability to become pregnant despite unprotected intercourse for the past 3 years.

Your workup, including thyroid-stimulating hormone, urine pregnancy test, total testosterone, dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, and pelvic ultrasound, is normal. A progesterone challenge test results in 3 days of uterine bleeding.

The patient states she has decided not to attempt pregnancy at the present time because she just split from her long-time partner and she does not need contraception.

Which of the following best describes how you should counsel this patient?

She should take oral contraceptive pills (OCPs) to regulate her menstrual cycle.
She should take oral contraceptive pills (OCPs) for pregnancy prevention even if she does not have a current sexual partner.
She does not need any interventions at this time.
She should take oral contraceptive pills (OCPs) or cyclic progesterone to protect her endometrium.
She is clearly infertile based on her history and should seek immediate fertility treatments.

The correct answer is:

She should take oral contraceptive pills (OCPs) or cyclic progesterone to protect her endometrium

The patient described has polycystic ovarian syndrome (PCOS) based on the description of menstrual irregularity due to oligoovulation and clinical evidence of hyperandrogenism. The other causes can be excluded by the noted laboratory studies. OCPs have been the mainstay of long-term management of PCOS and offer benefit through the suppression of ovarian androgens, increased circulating sex hormone-binding globulin, and endometrial protection. In a woman who desires contraception, OCPs would be the best treatment option. However, in this patient, who does not desire contraception, cyclic progesterone would also be a reasonable treatment option to protect the endometrium, although it would not provide the same antiandrogen benefits as combination OCPs. Regulation of the menstrual cycle is an added benefit of using OCPs; however, it is not the primary reason to initiate this treatment strategy. Although this patient may need ovulation induction with clomiphene or other agents to conceive, she is not interested in getting pregnant at the present time and fertility treatments are not currently indicated.

References:

Welt CK, Barbieri RL. Etiology, diagnosis, and treatment of secondary amenorrhea. In: Basow DS, ed. UpToDate. Waltham, MA: Wolters Kluwer Health; 2012. http://www.uptodate.com/contents/etiology-diagnosis-and-treatment-of-secondary-amenorrhea . Accessed August 7, 2012.

Polycystic ovary syndrome. In: American College of Obstetricians and Gynecologists. ACOG 2008 Compendium of Selected Publications. Volume 2. Washington, DC: ACOG Press; 2008: 1121-1130.

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