Gynaecology Consultation

It was a pleasure to meet with Chloe Mitchell today. During the consultation, we discussed her oligomenorrhoea, worsening acne, and mild hirsutism over the past 18 months. We explored her menstrual history since menarche at age 12, alongside an unremarkable medical and surgical background. In summary, we will arrange a comprehensive hormonal profile, metabolic screen, and a pelvic ultrasound.

History

• Current medications: sertraline (Zoloft®) 50 mg PO daily (commenced 12/03/2023), ibuprofen (Nurofen®) 400 mg PO PRN for dysmenorrhoea (commenced 01/06/2022)
• Previous medications: levonorgestrel/ethinylestradiol (Levlen® ED) 150 mcg/30 mcg PO daily (discontinued 10/11/2023 due to mood changes)
• Menstrual cycle: menarche age 12; previously regular 28-day cycles on COCP, now irregular (45 to 60 days) since stopping COCP in November 2023
• Current flow: 5 days duration, moderate bleeding, mild Day 1 dysmenorrhoea, no flooding or clots
• Vaginal discharge: physiological only, nil offensive or pruritic discharge
• STI screen: negative chlamydia/gonorrhoea PCR (15/01/2024); currently not sexually active
• Hyperandrogenism: moderate inflammatory acne on jawline and upper back; mild terminal hair growth on upper lip and chin
• Past surgical history: appendicectomy (2018), tonsillectomy (2012)

Social History

Chloe is a 16-year-old Year 11 high school student living at home with her parents and younger brother. She plays netball twice a week and walks her dog most days. She currently takes sertraline 50 mg PO daily for mild anxiety and uses ibuprofen 400 mg PO PRN for menstrual cramps. She does not smoke, vape, or consume alcohol.

Investigations

• Previous: FBE and iron studies normal (15/01/2024), negative urine STI PCR (15/01/2024)
• Planned: fasting glucose, HbA1c, fasting lipids, TSH, prolactin, total testosterone, SHBG, FAI, DHEAS, 17-OH progesterone, LH, FSH, oestradiol, and a transabdominal pelvic ultrasound

Discussion

During the consultation, we discussed:

• Contraceptive options for cycle regulation and endometrial protection, including a trial of an anti-androgenic COCP (e.g., drospirenone/ethinylestradiol (Yaz®)) vs cyclic medroxyprogesterone (Provera®) or a levonorgestrel IUD (Mirena®)
• Adolescent PCOS diagnostic criteria, noting the caution required within 8 years of menarche, and the pathophysiology of insulin resistance and hyperandrogenism
• Long-term metabolic and reproductive health, reassuring her regarding future fertility treatments if anovulation persists, alongside the importance of monitoring for metabolic syndrome and T2DM
• The positive impact of regular physical activity and maintaining a healthy weight on insulin sensitivity, SHBG levels, and spontaneous ovulation
• Potential commencement of myo-inositol 2 g PO BD and colecalciferol (vitamin D3) 1,000 IU PO daily pending baseline blood results

Summary and Plan

In summary, Chloe Mitchell presents with secondary oligomenorrhoea and clinical hyperandrogenism querying adolescent PCOS and is currently taking sertraline 50 mg PO daily and ibuprofen 400 mg PO PRN. The plan moving forward includes:

• Fasting metabolic panel, androgen profile, thyroid function, and baseline gonadotrophins
• Repeat free androgen index and lipid profile in 6 months if therapy is initiated
• Continue sertraline (Zoloft®) 50 mg PO daily and ibuprofen (Nurofen®) 400 mg PO PRN
• Review in clinic in 4 weeks with blood and ultrasound results to finalise a management plan