adolescent case presentation kelli l. mcdermott lt mc usnr
TRANSCRIPT
Adolescent Case Presentation
Kelli L. McDermottLT MC USNR
Case history 14 y/o female CC: 3-6 months of irregular periods
and unexplained weight gain In USOH, has not been ill in last few
months PMH- not significant
Case History HEADS interview negative
Home: lives with parents, no sibs, gets along fine
Education: 9th grade, A-B student, has good group of friends
Activities: rows for school crew team, movies & hanging out with friends
Case History Drugs: never smokes, drank, or tried any
drugs, no friends hace either Diet: parents MD’s and help her eat a
balanced diet, she reports no increased eating habits since weight gain
Sex: never been active, never had a girl/boyfriend
Suicide: no h/o depression
Case History
Menstrual hx- menarche at age 12 Regular periods over past year and
then irregular for about 6months; no periods for about 3 months now
Never been sexually active
Case History FHx- NC, no female family member
with abnormal periods, no problems with cycle, fertility. No cancers
Physical Exam VS: HR 65; RR18; BP112/80; wt 93.5kg
(>99th%); ht 160cm (50th%); BMI= 36 HEENT: fat pad behind neck, thickening &
slight hyperpigmentation of posterior neck skin, nl thyroid
CV: S1+S2, no R/G/M, RR Lungs: CTA bilat Abd: obese, soft, +BS, striae across
abdomen and lower hips
Physical Exam Ext: FROM, nl muscle tone, 2+ cap
refill, pulses normal Skin- dry but no lesions, rashes,
acne noted over face, chest, back, no excess hair.
GU- no external abnormalities, Tanner 5, normal clitoris
QUESTIONS on H& P???
How about a differential for secondary amenorrhea?
Differential Diagnosis Pregnancy PCO Hypothyroidism Ovarian tumor Pituitary tumor
Less likely differential CAH
Female Athlete Triad (hypothalamic amenorrhea)
Turner’s syndrome
Testicular Feminization
Which labs would you think about at this initial presentation?
Laboratory Tests B-HCG Thyroid LH/FSH
Prolactin Free/total testosterone
Laboratory Tests Fasting glucose Fasting Insulin level Fasting Lipid profile Androstenedione Fasting 17-OPH and cortisol DHEAS Karyotype
Our patient Nl TFT’s Glucose 81 Lipid profile all
WNL LH 4.17 FSH 6.8
PRL 5.75 Andro 181 17-OHPS 58 Insulin 5.1 Ttest 36 Free test 6.7 (only
abn lab)
What is PCOS? Increased androgen production from
ovaries and adrenal glands
What does it mean to have PCOS? Well, unfortunately, it means a lot of difficult things for many women. I started to have facial hair growth in early highschool -- this was pretty embarassing, especially when I realized that it wasn't "normal" compared to my other friends. Of course, I had lots of hair on my legs and arms too, at an even younger age -- growing up in Southern California meant that I was doing a lot of hair removal all the time so as to not look like a freak in shorts or a bathing suit. My skin just didn't ever seem to clear up -- I spent many hours at the dermatologist. I also "learned" early on that I couldn't eat very much at all -- if I did, I immediately gained a lot of weight and it didn't want to come off. My cycles were horrible, when I had them, I understood why some women called it "the curse".
I was diagnosed when I was 17 and immediately went on birth control pills to control my symptoms. This was the only practical "treatment" known at that time. Later on, PCOS was the reason I couldn't easily conceive and then miscarried the 2 times I did conceive naturally. I think this is the most acutely painful aspect of this syndrome, and it is certainly the focus of many women's pain. Wanting a child and being unable to have one was one of the most difficult times of my life. Needing to take in order to conceive and carry a pregnancy can have some very subtle effects on how a woman thinks about herself, and when she has a condition that already makes her feel less attractive, less desirable and less feminine (at least by our culture's standards), she can end up seeing herself as pretty defective. Later in life, PCOS presents some serious health problems. Women with PCOS are significantly more likely to have type II diabetes and heart disease and there appears to be a link to breast and colon cancer, so it isn't just a "cosmetic" or "infertility" condition -- it can be ugly.
PCOS Spectrum of clinical d/o’s not
diagnosed by lab Clinical presentation includes:
Hirsuitism & acne Obesity Oligomenorrhea Anovulation Infertility
PCOS
Pituitary gland is heightened to GnRH Exaggerated pulsatile LH release LH/FSH ratio may be elevated LH stimulate ovary to secrete androgen
Androgens are converted to estrone and estradiol
Estrogens secreted tonically
Augment pituitary sensitivity to GnRH
And vicious cycle continues to LH
ovaries overproduce androstenedione and testosterone
Other interesting findings Androgens SHBG; free testosterone Anovulation and insulin resistance- exact
pathogenesis unclear in basal insulin secretion in hepatic uptake B-cell dysfunction insulin has direct effect on pituitary in LH
secretion and the ovary for androgen production
Problems associated with high levels of sex hormones:
Anovulation results in amenorrhea & infertility
Hirsuitism, acne Male pattern
baldness/thinning Obesity- android-type
with waist-hip ratios Cancer- endometrial
Problems associated with high levels of sex hormones:
Insulin resistance
Hyperinsulinemia
Diabetes
Cardiovascular disease
Theories to etiology of PCOS
Genetic predisposition is most likely although no gene isolated; believe in 2-hit hypothesis
Premature adrenarche (<8 y/o) Heterozygosity for CAH IUGR
Treatment Cosmetic interventions
OCP’s: suppress LH androgens SHBG free testosterone adrenal production of androgen 5alpha-reductase
Spironolactone
Treatment Cyclic progestins
GnRH agonists
Weight control Low carb diets
Exercise to reduce weight and CV risk factors
Treatment- controversial
Insulin sensitizing drugs: biguanides & thiazolidinediones insulin R hirsuitism restore nl ovulatory patterns
Metformin Reduces hyperinsulinemia Decreases risk factors for CHD Improved weight-loss Normalization of circulating
androgens Resumption of normal ovulatory
menses and therefore reversal of infertility
Resources and Websites www.pcosupport.org www.pcosupport/pcoteen www.obgyn.net/pcos/pcos.asp