Gynecology

SGD
 Case
This is a case of G.N., a 28 year old, nulligravid who came in due to inability
to conceive after 3 years.
Past Medical History:
She has no history of surgeries or admissions.
She has no known allergies.
Family Medical History:
+ DM-Mother and Sister
No family history of cancer, hypertension, infertility
Personal and Social History:
She is a teacher, non smoker and non alcoholic beverage drinker.
Menstrual history:

She had her menarche at 12 years old, with subsequent menses at

intervals of 40-80 days,

lasting for 5-7 days, consuming 2-3 pads per day, with no dysmenorrhea.

LMP February 18, 2024

PMP: December 25, 2023

Obstetric History:

She is a Nulligravid

Gynecologic History:

She had her first sexual contact at 24 years old, with 1 partner. She has
no history of STI’s. No

pap smear.

Male partner history:

32 years old, engineer, unremarkable past history, normal BMI, no vices,

no sexual dysfunction.
Physical examination:

BP: 140/90 mmHg

BMI: 28
Laboratory results/ Diagnostics
Transvaginal ultrasound:

TSH: normal

Prolactin: normal

75 g OGTT: 2nd hour 220

Lipid profile:

TG 250 mg/dl

HDL 20 mg/dl

Hysterosalpingogram: patent bilateral

tubes
 Salient features
Patients information: G.N
● Age: 28 year old( nulligravid) Laboratory results/ Diagnostics Transvaginal
CC: inability to conceive after 3 years ultrasound
Past Medical History: TSH: normal; Prolactin: normal; 75 g OGTT:
● No history of surgeries 2nd hour - 220 (greater than 153 mg/dL (8.5
Family Medical History mmol/L) (gestational diabetes)
● + DM-Mother and Sister Lipid profile: TG 250 mg/dl (high risk)
● No family history of cancer, hypertension, HDL 20 mg/dl (high risk)
Hysterosalpingogram: patent bilateral tubes
infertility
(normal)
Personal and Social History
● Non smoker and non alcoholic beverage drinker
Menstrual history:
● Menarche at 12 years old,
● Menses at intervals of 40-80 days lasting for
5-7 days, consuming 2-3 pads per day, with no
dysmenorrhea
● LMP February 18, 2024
● PMP: December 25, 2023
First sexual contact at 24 years old, with 1 partner
Upper lip - 1 - Few hair at outer margin
● no history of STI’s. No pap smear
Chin - 2 - Scattered hair with small
Physical examination: concentrations
● BP: 140/90 mmHg Chest - 1- Circumareolar hair
● BMI: 28
 Differential diagnosis
DDX RULE IN
Congenital adrenal ● Oligomenorrhea
hyperplasia ● Obesity (BMI 28)
● Hirsutism
Cushing’s Syndrome ● Obesity (BMI 28)
● Metabolic abnormalities
● Impaired glucose
tolerance (220 mg/dL)
● Hypertension (140/90
mmHg)
Androgen secreting tumors ● Oligomenorrhea
● Hirsutism
● Infertility
RULE OUT
● Salt-wasting crisis (in
severe cases)
● Early onset of puberty
● Short stature
● Hypoglycemia
● Absence of clinical
features (moon facies
or buffalo hump)
● Fatigue
● Easy bruising
● Thinning of skin
● Virilization
 Final Diagnosis and Rule
in criteria :

POLYCYSTIC OVARY ●
●
Anovulation
Infertility
SYNDROME (PCOS) ● Oligomenorrhea
● Obesity
● Diabetes Mellitus
● Increase TG
● Decreased HDL
● Hypertension
● Hirsutism
What is your diagnosis? What is the basis of your diagnosis?
Nulligravida, Primary infertility for 3 years
secondary to Polycystic ovarian syndrome
(PCOS)

Patient met the diagnostic criteria:

● Abnormal menstrual pattern

● Clinical or biochemical signs of
hyperandrogenism (Ferriman Gallwey -Doppler ultrasound of a polycystic
ovary showing increased blood flow.
score >\= 4 to 6 is effected)
● Polycystic ovaries on ultrasound
Other factors patient have which are associated to PCOS:
● Overweight (BMI=28)
● Elevated OGTT
● Elevated Triglycerides 250 mg/dl (>\=150mg/dl)
● Low HDL 20 mg/dl (desirable- 60mg/dl)
NCEP ATP III criteria for metabolic syndrome in women with PCOS
● Elevated BP 140/90 (>130/>85)
 Pathophysiology of PCOS
Altered Gonadotropin dynamics Insulin resistance (diabetes/obesity)

Hyperandrogenism

Arrest in antral follicle

development

Anovulation

Anovulatory Subfertility Polycystic ovaries

bleeding (Obstetrical
(Irregular cycles) complications)
Causes

● Excess Androgen Levels

-hirsutism
● Heredity
● Excess Insulin
● Low-Grade Inflammation
Signs & symptoms

● Irregular Menstrual Cycles

● Ovulatory Dysfunction
● Hyperandrogenism
● Weight gain
● Pelvic pain or discomfort, especially during
menstruation
● Elevated insulin and glucose levels, leading to
insulin resistance.
● Skin changes like darkening of the skin
(acanthosis nigricans) in body folds due to
insulin resistance.
● Polycystic Ovaries
 RISK FACTORS
● Family history
● Age between 15 to 30 years
● History of premature pubarche
● Irregular menstrual cycles
● Insulin resistance
● Peripubertal Obesity
● Hormonal Imbalance
● Sedentary lifestyle
● Stress
● Medical conditions
 COMPLICATIONS
Complications of PCOS can include:

● Infertility
● Gestational diabetes or pregnancy-induced high blood pressure
● Miscarriage or premature birth
● Nonalcoholic steatohepatitis
● Metabolic syndrome
● Type 2 diabetes or prediabetes
● Sleep apnea
● Depression, anxiety and eating disorders
● Cancer of the uterine lining (endometrial cancer)
● Obesity commonly occurs with PCOS and can worsen complications of
the disorder.
 DIAGNOSTIC TESTS
● Pelvic exam : To check reproductive organs for masses,
growths.
● Pregnancy test
● TVS/TRS : Ultrasound imaging to evaluate the ovaries for
the presence of multiple small follicles and increased
ovarian volume, which are characteristic findings in
PCOS
● Serum Prolactin: Measurement of serum prolactin levels
to rule out hyperprolactinemia.
● Hba1c/75g OGTT : Assess glucose metabolism and
screening for insulin resistance
● TSH, FT3, FT4 : Evaluation of thyroid function
(hypothyroidism or hyperthyroidism)
● 3-alpha-diol-glucuronide: This metabolite reflects
androgen activity. Elevated levels may suggest increased
androgen production.
 Treatment and Management

● Lifestyle modifications such as Healthy eating, Regular physical activity, adequate

sleep and rest, Stress management
● First line Treatment is Combined OCPs containing 20ug of Ethinyl estradiol +
Progesterone with Low androgenic activity.
● Cyclic progestin [10 mg MPA 10 to 14 days every 2 to 3 months]
● Metformin or OCP With metformin
● COCPs in Combination With anti androgens such as Cyproterone acetate,
spironolactone, finasteride
● For Infertility

1. First line options ; Clomiphene citrate and Letrozole

2. Second line options; Gonadotropins and Ovarian Drilling

3, Third line options; InVitro Fertilization and Invitro maturation

Thanks po!
CREDITS: This presentation template was created
by Slidesgo, and includes icons by Flaticon, and
infographics & images by Freepik