Gynecological Bleeding Disorders Across the Lifespan
Case 4: Young Adult With Irregular, Heavy Menses
This case involves a 28-year-old female, presenting for annual exam. Her past medical history includes:
- Irregular cycles: every 21-60 days.
- On COCPs in past; stopped due to migraines and leg cramps.
- Healthy professional dancer.
- Height: 5’6″, weight: 118 lbs.
- Sister has polycystic ovary syndrome (PCOS).
- Waxes upper lip and abdomen regularly.
The audience was asked to develop a differential list and offer their most likely diagnosis. They quickly decided she also had PCOS, although she certainly did not present in a typical manner.
Discussion. The “take home” message from this case is that PCOS should be at the top of the differential list in women with very erratic menstrual cycles. Classically, PCOS presents in the reproductive-aged woman who is obese (usually central obesity), hirsute, and has significant acne. The initial work-up includes a sonogram to evaluate endometrial stripe thickness and to look for “classic” ovarian characteristics and bloodwork; specifically, the following:
- fasting blood sugar (FBS),
- fasting insulin,
- thyroid-stimulating hormone,
- follicle-stimulating hormone (FSH)/luteinizing hormone (LH) ratio,
- testosterone, and
- dehydroepiandrosterone sulfate
The normal insulin:FBS ratio is 5 or more to 1 and a normal LH:FSH ratio is 3 or more to 1. If the ratios are not consistent with this, referral to an endocrinologist or reproductive endocrinologist (if she’s infertile or considering pregnancy) should be considered. Treatment for PCOS includes weight reduction, if the patient is overweight, correction of insulin resistance, cycle control to reduce the risk of endometrial hyperplasia, and management of hirsutism with COCPs, spironolactone, or leuprolide acetate.