Secondary Amenorrhea and Infertility in a 33-Year-Old Woman with PCOS
Hello Jude
Great post!! Your post was very educative and insightful; you have clearly explained the rationale for PCOS diagnosis for 33-year-old, obese female patients. The rationale is based on the fact that infertility and amenorrhea are significant symptoms of PCOS among women of childbearing age, just like in our patient’s case. The symptoms of PCOS include infertility, insulin resistance, hyperandrogenism, obesity, anovulation, hirsutism, and excessive androgens. Since the patient exhibits some major symptoms, this led to the diagnosis (Escobar-Morreale, 2018).
Metformin and Progesterone (Prometrium) hormonal treatments constitute the recommended treatment and management procedures for PCOS. I want to add that the recommendation is to take one and not a combination of these drugs, particularly for diabetic patients. This is because progesterone can interfere with blood glucose levels, rendering diabetic medication useless, as well as metformin. Other drug-substances interactions in the body that may cause the hormone treatment to be ineffective or lead to complications include alcohol and metformin, vitamins, herbs, and grapefruit juice with Prometrium.
References
Escobar-Morreale, H. F. (2018). Polycystic ovary syndrome: definition, etiology, diagnosis, and treatment. Nature Reviews Endocrinology, 14(5), 270-284.
Hello Natasha
Thank you for your post. Your discussion was excellent and insightful; the diagnosis reveals hypogonadism for the 16-year-old male presenting the symptoms of delayed pubertal signs and social immaturity. The rationale is based on the lack of production of LH even after the administration of exogenous hormones and the low levels of testosterone. Impaired response of the gonads LH stimuli makes the pituitary gland fail in signaling the testicles to produce testosterone, which would explain why the patient test results show low levels of testosterone. The use of HCG in this seems to be the need to help the patient produce sufficient endogenous testosterone.
Independent administration of Exogenous testosterone is not encouraged because even though it enhances sexual development, it can impair spermatogenesis. Subsequently, it can create negative feedback systems within the pituitary and hypothalamus (Jayasena et al., 2021). HCG therapy is therefore encouraged to enhance the outcomes. There is a problem with the hypothalamus because LH hormones are lacking, and they are produced through the secretion of gonadotropic hormones found in the hypothalamus.
References
Jayasena, C. N., Anderson, R. A., Llahana, S., Barth, J. H., MacKenzie, F., Wilkes, S., … & Quinton, R. (2021). Society for Endocrinology guidelines for testosterone replacement therapy in male hypogonadism. Clinical endocrinology.
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Question 
1. Jude
33-year-old obese female suffers from amenorrhea and infertility. After a thorough work, PCOS is diagnosed.
According to Klein et al. (2019), two pertinent types of amenorrhea occur in women. Primary amenorrhea is a lifelong absence of menses that requires evaluation if menarche has not occurred by 15 years of age or three years post-thelarche (Klein et al., 2019). Secondary amenorrhea is a cessation of previously regular menses for three months or previously irregular menses for six months, which certainly requires evaluation (Klein et al., 2019). In addition, infertility is a biological inability to conceive after one year of actively attempting to have children (Dlugasch & Story, 2021).
Secondary Amenorrhea and Infertility in a 33-Year-Old Woman with PCOS
Discuss 2 additional symptoms associated with PCOS in terms of pathophysiological principles.
Polycystic ovary syndrome (PCOS) is a common gynecological endocrine disease in women of childbearing age, with a high risk of developing endometrial cancer (Dlugasch & Story, 2021). PCOS is characterized by excessive androgens, insulin resistance hyperinsulinemia, persistent or chronic anovulation (ovulation dysfunction), and infertility (Dlugasch & Story, 2020). Symptoms of PCOS arise during the early pubertal years and affect 6% to 20% of women of reproductive age (Witchel et al., 2019). Diagnostic features for adolescent girls with PCOS are menstrual irregularity, clinical hyperandrogenism and/or hyperandrogenemia, anovulation, hirsutism, acne, obesity, ovarian cysts and male pattern baldness. Hyperandrogenism is a persistently elevated testosterone level, which is responsible for hirsutism, and can inhibit fertility (Dlugasch & Story, 2021).
How does Metformin contribute to treatment?
Patients with PCOS have high prevalence of obtaining insulin resistance hyperinsulinemia, therefore metformin medication can effectively assist in the metabolism of organs such as the liver, muscle, and adipose tissue, by reducing the clinical symptoms of insulin resistance and excessive androgen expression (Liu et al. 2021). There are health benefits to taking metformin for PCOS, such as improving blood sugar, decreasing blood lipids lab, and improving sex hormone drive (Liu et al., 2021).
How does progesterone aid in treatment?
Progesterone hormonal treatments are given to patients with PCOS to reduce the occurrence of amenorrhea and decrease the chance of getting endometrial cancer (Shirin et al., 2020). Progesterone treatment also effectively maintains the uterine lining, preparing for possible pregnancy (Shirin et al., 2020). Unfortunately, there are adverse effects of PCOS patients taking progesterone because some progestins can mimic androgens, which can elevate blood androgen, worsening PCOS amenorrhea symptoms (Shirin et al., 2020).
How is infertility a symptom of PCOS?
Individuals with PCOS, especially women, have a high rate of infertility because of the occurrence of irregular menses that persist for two years after menarche (Aversa et al., 2020). Therefore, this incidence of irregular menses can delay sexual reproductive immaturity (Aversa et al., 2020). Finally, increased levels of androgens can inhibit the production of progesterone hormones, which helps maintain the lining of the uterine wall in preparation for pregnancy (Dlugasch & Story, 2021).
2.Natasha
A 16-year-old male presents with delayed pubertal signs and social immaturity. His lab values show low testosterone. He was administered GnRH, and no LH was produced. HCG was administered, which restored testosterone to normal levels.
Neuroendocrine activity that occurs during puberty stimulates the secretion of gonadotropins from the pituitary gland that help transition the body from childhood to adulthood (Bozzola et al., 2018). This is considered delayed when the signs of sexual maturation are more than 2-2.5 standard deviation values greater than the average population (Bozzola et al., 2018). In this case study, this 16 year old male is exhibiting signs of hypogonadism.
Discuss male hypogonadism
Hypogonadism can be categorized into two groups: primary and secondary hypogonadism. In the primary type, there is a dysfunction in the testicles that leads to an impaired response of the gonads to GnRH or LH stimuli (Hackney, 2020). In secondary hypogonadism, the hypothalamus or pituitary gland fails to signal the testicles to produce testosterone, meaning that GnRH or LH are not adequately produced (Hackney, 2020). This is referred to as hypogonadotropic hypogonadism and leads to low testosterone levels and decreased sperm production (Dlugasch & Story, 2021).
Explain hormone administration
In hypogonadism, there is a lack of production of LH despite exogenous hormone administration (Lee & Ramasamy, 2018). The use of human chorionic gonadotropin (hCG) can help to recover endogenous testosterone production in patients who cannot produce their own or an amount that is insufficient (Lee & Ramasamy, 2018). Exogenous testosterone can improve some aspects of physical sexual development but can actually impair spermatogenesis when used independently, as it can promote a negative feedback pattern on the hypothalamus and pituitary (Lee & Ramasamy, 2018). By bypassing the production of LH, the intratesticular testosterone levels can remain low (Lee & Ramasamy, 2018). hCG therapy, however, preserves spermatogenesis in patients receiving testosterone replacement therapy.
Is there a problem with the hypothalamus? Why or why not?
The activation of the hypothalamus-pituitary-gonadal axis stimulates the gonads in males to produce testosterone (Bozzola et al., 2018). Luteinizing hormone or LH, is produced by the anterior pituitary gland after the secretion of gonadotropic releasing hormone, which originates from the hypothalamus (Lee & Ramasamy, 2018). the dysfunction in this patient originates in the hypothalamus and has a cascading effect on the production of sex hormones in the individual and the progression through puberty.
Length: A minimum of 150 words per post, not including references