A 26-year-old woman comes to the office for a follow-up visit. The patient was first seen 4 months ago for irregular menstrual periods and hirsutism. Laboratory results at that time showed mildly elevated levels of serum testosterone and LH but normal levels of FSH, prolactin, salivary cortisol, TSH, and 17-hydroxyprogesterone. Serum chemistry profile, including liver enzymes and glucose tolerance test, were normal. Based on symptoms and laboratory results, she was diagnosed with polycystic ovary syndrome and started on oral contraceptives.
After the patient's initial visit, she began eating a low-carbohydrate diet and started exercising for 30 minutes, 5 times a week, which has led to significant weight loss. Her menstrual cycles are now regular, every 28 days. In addition, her hirsutism has markedly improved. The patient is a medical assistant and does not use tobacco, alcohol, or illicit drugs. She is sexually active with her boyfriend and does not desire pregnancy. Family history is remarkable for type 2 diabetes mellitus, hyperlipidemia, and hypertension in both parents.
Blood pressure is 124/70 mm Hg and pulse is 78/min. BMI is 27 kg/m². The patient has moderate terminal hair growth on the face, chest, lower abdomen, and lower back. The remainder of the physical examination is within normal limits.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_97dc_091e_853d_954b0a182f2c_MD0002_00 Polycystic ovary syndrome (PCOS) can be diagnosed clinically once conditions that mimic it are ruled out (eg, nonclassic congenital adrenal hyperplasia). Treatment goals are to improve hyperandrogenism symptoms, prevent associated comorbidities, and attempt ovulation induction in women who desire pregnancy. Oral contraceptives (OCs) are first-line treatment for managing menstrual irregularities and hirsutism in patients without contraindications to their use. The estrogen component of OCs decreases free/bioavailable testosterone levels (via increased levels of sex hormone-binding globulin) and suppress LH secretion, resulting in reduced ovarian testosterone production. Some progestin components (eg, drospirenone) have anti-androgenic properties. Women with PCOS may require up to 6 months of therapy before a significant decrease in terminal hair is seen. In this patient, additional therapy is not required as she already has had a marked decrease in hirsutism with OCs. (Choice A) Metformin is no longer indicated for the treatment of hirsutism. Metformin is useful for patients with PCOS who have impaired glucose tolerance or diabetes mellitus, and can be used as an adjunctive therapy for ovulation induction. However, this patient has normal menstrual cycles and glucose tolerance and does not desire pregnancy. (Choice B) An anti-androgen (eg, spironolactone) is added if there is a poor cosmetic response after 6 months of OC therapy. In some women with severe hirsutism, an OC with an anti-androgen may be considered as initial therapy. (Choice D) Pelvic ultrasound is not needed as the PCOS diagnosis has been made based on hyperandrogenism and ovulatory dysfunction (ie, 2 of 3 diagnostic criteria). The risk of endometrial cancer is increased in PCOS, but routine monitoring of endometrial thickness by ultrasound is not recommended. Pelvic ultrasound may be required to rule out an androgen-producing ovarian tumor if hyperandrogenism progresses rapidly despite treatment. (Choice E) Progestin-releasing intrauterine devices (IUDs) are a good long-term contraceptive option for women with PCOS, as the progestin provides endometrial protection. However, IUDs do not contain estrogen to suppress ovarian testosterone production in women concerned about hirsutism. Educational objective: The treatment goals in polycystic ovary syndrome are improvement in hyperandrogenism symptoms, ovulation induction in women desiring pregnancy, and evaluation/treatment of comorbidities. Oral contraceptives are first-line therapy for hirsutism. An anti-androgen (eg, spironolactone) is added if there is an inadequate cosmetic response after 6 months of oral contraceptive therapy. __________ References: Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. (http://www.ncbi.nlm.nih.gov/pubmed/24151290) American Association of Clinical Endocrinologists, American College of Endocrinology, and Androgen Excess and PCOS Society disease state clinical review: guide to the best practices in the evaluation and treatment of polycystic ovary syndrome--part 1. (http://www.ncbi.nlm.nih.gov/pubmed/26509855) American Association of Clinical Endocrinologists, American College of Endocrinology, and Androgen Excess and PCOS Society disease state clinical review: guide to the best practices in the evaluation and treatment of polycystic ovary syndrome - part 2. (http://www.ncbi.nlm.nih.gov/pubmed/26642102)

A 26-Year-Old Woman Comes to the Office for a Follow-Up