A 30-year-old nulliparous woman comes to the office for evaluation of infertility. She has been attempting to conceive with her partner of 10 years for the past 2 years. Menarche was at age 11, and her menstrual cycles occur 2-3 times per year and last 7-10 days. The patient does not use tobacco, alcohol, or illicit drugs. Her blood pressure is 128/84 mm Hg and pulse is 84/min. BMI is 35 kg/m². Physical examination shows mild acne and hair growth on the upper lip and chin. This patient is at greatest risk for which of the following complications?

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11ec160b_3cbd_b71c_9249_0d22018d88ad_MD0001_00 This patient has polycystic ovary syndrome (PCOS), a condition characterized by at least 2 of the following 3 criteria: signs of hyperandrogenism, irregular periods, and/or polycystic ovaries on ultrasound. PCOS results from increased activity of 17α-hydroxylase; 17,20 lyase; and 3β-hydroxysteroid dehydrogenase. The overexpression of these enzymes results in elevated androgen levels (eg, testosterone, androstenedione, DHEA) and the clinical consequences of hirsutism and acne. Excess androgen prevents development of a monthly dominant follicle, resulting in anovulatory cycles. In turn, menstrual irregularity (most often oligomenorrhea) results in decreased progesterone secretion. Progesterone has growth-inhibitory effects on the endometrium and counters estrogen-driven proliferation. The resulting imbalance of estrogen and progesterone places the patient with PCOS at long-term risk for endometrial hyperplasia and adenocarcinoma. In addition, anovulatory cycles often result in fertility difficulties as seen in this patient. (Choice A) Autoimmune-mediated destructive adrenal atrophy is the most common cause of Addison disease, which presents as severe fatigue, weight loss, and low blood pressure due to glucocorticoid and mineralocorticoid deficiency. In contrast to PCOS, women may experience axillary and pubic hair loss due to adrenal androgen deficiency. (Choice B) Patients with Cushing syndrome have symptoms similar to those of patients with PCOS such as obesity, menstrual irregularities, and increased body hair. However, hypertension, abdominal striae, and supraclavicular fat pads are also typically seen in Cushing syndrome due to excess cortisol. (Choice C) PCOS is a risk factor for type 2 diabetes mellitus (T2DM) due to increased insulin resistance. In contrast, patients with a family history of T1DM are at increased risk of developing T1DM, which results from decreased insulin secretion. (Choice E) Vaginal adenosis is the persistence of glandular columnar epithelium in the vagina and is a precursor for clear cell adenocarcinoma of the vagina. Female offspring exposed to diethylstilbestrol in utero are at increased risk and may present with vaginal discharge or vaginal cysts/fleshy colored lesions. Educational objective: Polycystic ovary syndrome (PCOS) is associated with oligomenorrhea, hirsutism, and polycystic ovaries. Disruption in intraovarian steroidogenesis causes anovulatory cycles and results in chronic estrogen stimulation with decreased progesterone secretion, placing PCOS patients at risk for endometrial hyperplasia/carcinoma. __________ References: ACOG Practice Bulletin No. 108: Polycystic Ovary Syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/19888063) Catch It Before It Kills: Progesterone, Obesity, and the Prevention of Endometrial Cancer (http://www.ncbi.nlm.nih.gov/pubmed/23021376)

A 30-Year-Old Nulliparous Woman Comes to the Office for Evaluation