Clinical quiz 2: “The pill has stuffed up my periods”

Aimee, a 23 year old university student, comes to see you because she hasn’t had a period for 5 months. She has only had 3 periods since she came off the OCP 10 months ago. She originally started taking the pill (Juliet-35ED) at age 15 for acne, and then continued it for contraception. She stopped it because she came out of a relationship and wanted a break from medication. Her acne is also a  bit worse than it was and she wants to discuss treatment options. She’s not too keen to go back on the pill because her mother had problems falling pregnant after taking the pill for years, and Aimee is worried the same thing might happen to her.

PMH: Nil significant

Gynae Hx: Menses age 13. No pregnancies. Last pap 3 years ago.

Medications: Nil

Family Hx: Type 2 diabetes (maternal grandmother), IHD (uncle).

Oe: BP 115/70, Pulse 70, BMI 23

Mild acne on forehead and chin.

Abdo – Soft non-tender

Spec – NAD. Pap smear taken.

Questions:

1. What is the most likely diagnosis and what do you need to rule out?

2. What investigations would you perform?

3. What is your management approach?

Please comment below. My suggestions to follow in the next couple of days.

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13 thoughts on “Clinical quiz 2: “The pill has stuffed up my periods”

  1. 1. PCOS
    2. Pelvic u/s; hormone screen incl SBG and free Testosterone
    3. Discuss diagnosis with pt and future implications; eg fertility probs, increased risk for type 2 DM (24%)
    4. Metformin will help with weight loss and usually helps with return to normal cycle.
    5. Hormonal treatment will depend on when she is ready to start a family; if she is not keen to start soon, Mirena IUCD has shown to be treatment of choice.

  2. Agree with all the others Penny, and great case! Definitely need to do pregnancy test, then check for PCOS with serum androgens and pelvic/TV ultrasound. Can check 17-OH progesterone in case of late congenital adrenal hyperplasia, as well as checking prolactin. Also good idea to do OGTT if PCOS confirmed/likely. Lifestyle management e.g. healthy diet, regular exercise, weight loss if indicated are first-line treatments for PCOS, as well as some progesterone to protect the endometrium, e.g. OCP, Implanon, Mirena.

  3. Love the suggestions but I’ll pretend I haven’t seen them.

    Ammenorhoea ? cause

    ddx PCOS, pregnancy, prolactinoma, athletic amenorrhoea

    ix serum: SHBG, FAI, Free-testosterone, fasting glucose, fasting lipids,prolactin, b-hcg,
    ix uss: pelvic ultrasound

    mx: non pharm: exercise 30mins 5/7, balanced diet,
    pharm: metformin 500mg daily + OCP (cypeterone acetate) for regular cycle if wants to become pregnant -> regular folate
    For acne consider above OCP and possibly spironolactone 25mg daily

    Never really see PCOS!

  4. check if preg
    discuss acne Rx options and need for contraception
    counsel re PCOS and consent for further Ix for amenorrhoea
    Whilst the exam answer is PCOS, in reality this could be a number of things…Cushings, exercise induced amenorrhoea,
    agree with pelvic USS as first line and androgen profile.
    all that would take about 10-15 min on a good day so rebook for further review pending first line investigations.

    She in fact needs no Rx started on this first visit unless looking for contraception.

  5. Ahmen to that – the ‘exam’ answer and the reality answer of primary care mean that better to exclude pregnant, initiate Ix and then safety net/follow up later…

    Somedays is like juggling kittehs

  6. haha yeah agree, the above is the exam answer. In reality, there’s always something else going on. Is she depressed? Anxiety? Stress with exams? I bet she’s got a list of questions!
    Think bio-psycho-social- think alcohol, STI too. :-p
    Just my rant before OSCE!!!

  7. Thanks everyone for your great comments. Yes it could indeed be a number of things and while it’s unlikely that she is pregnant it’s definitely important to do a u-HCG at the very least to make sure and also in her case consider stress (she is a uni student after all).

    The most common and therefore most likely cause is PCOS (confirm with FAI or free testosterone and USS) but you do need to exclude other causes with the investigations mentioned above (17-OH prog, TSH, prolactin, +/- FSH).
    In terms of management, as a couple of people mentioned, lifestyle management is key and metformin can be really useful too. Good work Mel for also mentioning endometrial protection.

    Yes – think biopsychosocial and also short/medium/long term management. Particularly
    important to discuss family planning for the future (ie don’t leave it too late, and don’t put on too much weight) and also screen her regularly for metabolic complications with GTT, lipids and BP.

    This condition is really conducive to a team approach and you can put her on a GPMP and TCA to get involvement of dietician / exercise physiol / psychologist / gynae / endocrinologist as required.

    I’m just in the process of uploading a video tutorial on PCOS which I hope is useful. (It took AGES to put together so sorry it’s been a bit of a delay since this original post).

  8. Penny, this stuff is so so great! Going into the everyday GP side of things (GPMP, TCA) is a massive tick too. Can’t wait for the video, did you sort out the recording voice bit? I sent an email a few days ago!

  9. Also – let her know that the pill has NOT stuffed up her periods. The menstrual problem was there all along and has just been masked by taking the pill’s regular withdrawal bleeds (not true menstrual periods at all). The same thing probably happened to her mother, as it tends to run in families.

  10. Just stumbled upon this site through mutual friends… While I am not in the medical profession I have had some recent exposure as a patient… I wish my fertility specialist took this much care and thought into diagnosis and management instead of making me feel like every time I see him my file is brand new to him!

  11. Thanks, pincushion! Ahh fertility treatment is hard enough without feeling like you’re not being cared for. Just remember that your doctor is human too and there may be other factors at play… but in the end, if you’re not happy, it’s always your right to seek a second opinion. Good luck!

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