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Case History

image A 25-year-old woman, para 1 (normal vaginal delivery 18 months previously), wants to conceive a second time. She is otherwise fit and well, but since her first child was born her periods now only occur every six to ten weeks. They are heavy but not painful. There is no intermenstrual bleeding. She gained about 12.5 kg during her pregnancy and has never been able to lose it.

What is the most likely explanation for her irregular cycle?

How could the diagnosis be confirmed?

How should this be treated if she did not want to conceive?

What interventions would help to restore her fertility?

What are the long-term implications for her health and fertility?


What is the most likely explanation for her irregular cycle?

image The first point is to establish from the history that the pattern of the bleeding is irregular periods and not a chaotic bleeding pattern (Table 8.1). Chaotic bleeding may be due to infection, particularly chlamydia, or to an abnormality within the uterus such as a polyp or endometrial carcinoma. Abnormalities on the cervix, such as an ectropion or a carcinoma, may also present with irregular bleeding but this would often be associated with post-coital bleeding as well.

Table 8.1Features in the history and examination

The commonest cause of irregular menstruation is polycystic ovaries (PCO), accounting for 80% of cases. Other causes include premature menopause and anovulation, perhaps due to hormonal contraception. With polycystic ovary syndrome (PCOS) the fundamental lesion appears to be increased insulin resistance, perhaps due to an inherited defect in the insulin receptor. Hormone production within the ovary is abnormal. There is also a reduction in the level of sex hormone binding globulin which leads to an increase in free testosterone. Ovulation fails to occur and without the progesterone produced by the corpus luteum, the menstrual cycle tends to be prolonged and irregular.1

How could the diagnosis be confirmed?

To make the diagnosis of PCOS, two out of the following three criteria should be met: ultrasound evidence of PCO on transvaginal ultrasound scan; clinical or biochemical evidence of hyperandrogenism; and evidence of anovulation (see Table 8.2). Blood tests may show evidence of hyperandrogenism. Testosterone levels of 3–5 nmol/l would not be unusual in PCOS, but levels above this raise the possibility of an androgen-secreting tumour. Androstenedione is an androgen ...

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