Case Study Diagnosis

A 32-year-old female came to see the NP with complaints of secondary amenorrhea along with

weight gain, fatigue and thick hair growth in her chin and has not been able to conceive with her

spouse after stopping her birth control pills six months ago. She complained of irregular menses,

menses after every 5-6 months since 12-15 years. Her flow was moderate and lasted for five days.

The patient is 5’ tall and weighs 238 lbs. She is concerned because she thought she was pregnant,

but all her pregnancy test have been negative.

1) Discuss the differential diagnosis for the patient.

When a patient experience menstruation six months after stopping to use birth control or

contraceptive pills, the patient may be most probably suffering from secondary or post-pill

amenorrhea. Amenorrhea is the absence of menstruation for a long time in a female metabolic

system. Although the patient seems to have been using birth control pills, apart from the use of

contraceptive pills, there are various contributing factors to secondary amenorrhea. Other factors

that contribute include are certain types of treatments, such as cancer treatments and psychosis.

Other factors include a hormonal imbalance in the female reproductive system, hypothyroidism,

body overweight, or lower weight amount. Based on the complaint displayed by the patient who

visited the NP, there is a various differential diagnosis for this patient. The first diagnosis involves

a historical examination of this patient. The patient-reported changes in weight. After carrying out

the pregnancy, the test was negative. Historically, the patient had no chronic illness in their family.
 A series of blood tests need to be done for this patient. The blood test includes hormonal

imbalance test. The hormonal imbalance test includes tests to measure the levels of testosterone,

estrogen, serum luteinizing hormone, follicle-stimulating hormone, prolactin, thyroid-stimulating

hormone, and other types of hormones in the circulation system. Other tests include imaging tests

to diagnose the presence of secondary amenorrhea. The imaging tests to be carried out are MRI,

CT scans as well as ultrasound test. These tests will enable us to analyze the internal organs of the

patient’s body.

Furthermore, the imaging tests help to identify structural abnormalities of the reproductive

parts. Physical diagnosis of the patients included measuring the patient’s body weight and height.

The patient height and weight were 5' tall and 238 lbs, respectively.

2) Discuss the main diagnoses that affect her fertility and secondary amenorrhea and how this

relates to metabolic syndrome.

The leading cause of secondary amenorrhea is a hormonal imbalance. After various test on

the patients, she was found to have a hormonal imbalance. Based on her historical examination,

there was no presence of chronic illness in their family as well as herself. The leading cause

of her infertility is Polycystic Ovary Syndrome (PCOS). The PCOS causes a hormonal

imbalance of the female reproductive system. Based on the analysis of the patient, she was

using birth control pills. She displayed weight and height gain.
Furthermore, she experienced menstruation six months after she stopped the use of

contraceptive. Besides, she said to have experienced a long period of menstruation, menses

that lasted for approximately five days. The menses were irregular and further took longer

cycles to come. She also displayed the presence of excess androgen evidenced by the growth

of thick hair in her chin. These are clear signs of PCOS which cause hormonal imbalance.

The PCOS is the major cause of her infertility and secondary amenorrhea. It causes hormonal

imbalance that leads to the growth of ovarian cysts. Ovarian cysts are noncancerous tissues

that grow in the ovaries. This scar tissue makes it difficult for menstruation to occur. The use

of contraceptive pills also contributes to hormonal imbalance. Some women who use such type

of medicines many times display such types of health conditions. The growth of hairs in her

chin is a clear indication of the presence of PCOS. The hormonal imbalance occurs where the

levels of reproductive hormones are low or high or not at the normal state. The reproductive

hormones play a more significant role in the maintenance of regular menstruation. When they

are interfered with, they also tend to interfere with the normal menstruation cycle.

The PCOS also relates according to medical research-proven, because of other types of

metabolic syndrome. Many patients with PCOS display many features of metabolic syndrome.

Likewise, metabolic syndrome is also increased when PCOS is a presence in infertile women.

Some of the metabolic syndrome associated with PCOS are central obesity, high blood

pressure, resistance to insulin, diabetes, extreme level of cholesterol, or triglyceride levels.

The most common type of diabetes displayed ina patient with PCOS is type 2 diabetes. Obesity

is medically proven to be a worsening factor of the PCOS condition. It is medically recognized

to a common perpetuator of the disease. It is usually as a result of several factors, namely

genetic predisposition, poor diet, and sedentary lifestyle. This hence leads to a compounding
of pre-existing metabolic derangements. As a result of the obesity condition, high blood

pressure may result in addition to other factors such as the increased insulin levels and free-

flowing fatty acids in the body.

The high insulin level may hence lead to diabetes condition to a patient. Patients with PCOS

are usually at high risk of experiencing cardiovascular diseases. Research studies have shown

that the probability of getting coronary heart diseases as well as stroke is often two times more?

Developed of cancerous may also be experienced in the female reproductive system. One type

of common cancer associated with PCOS is endometrial cancer. Endometrial cancer is a cancer

of the uterus. Other metabolic syndromes include a sleep disorder known as sleep apnoea and

other psychological issues.

The difficulty in getting pregnancy may be due to the abnormal ovulation caused by high

insulin levels in the body. Insulin resistance, as well as weight gain in a woman, are some of

the symptoms of PCOS. High insulin levels in the body interfere with normal ovulation. This

makes it difficult for a woman to catch pregnancy.

3) Discuss an imaging or specific labs you may order to conclude your diagnoses or to rule

out another disease process.

Various imaging scans can be used to identify the causes of other diseases. Such types of

imaging labs include magnetic resonance imaging (MRI), CT scans, and ultrasound tests. A

CT scan may be conducted to identify the growth of cancerous or tumor in the reproductive

system. Various types of cancer affect the female reproductive system. The most common is

the cervix cancer. Pelvic ultrasound tests are necessary. They will help to ascertain the

presence or absence of the uterus in the reproductive system.

Furthermore, it will help to identify structural abnormalities in the genital tract of the patient.

An MRI is essential to determine the presence of a tumor or cancerous tissue in the pituitary

gland. Presence of a tumor in the pituitary gland may be the primary cause of hormonal

imbalance. This hormonal imbalance leads to irregular menstruation due to interference with

the secretion of the reproductive hormones that regulate menstruation. Lastly, hysteroscopy

may be carried out in the vagina and cervix to assess the inner side of your uterus.

Specific laboratory blood tests such as blood sugar test may be carried out to test the insulin

level in the blood. Such types of test include the fasting plasma glucose (FPG) and the A1C

test. If the insulin levels are very high, then they could possibly be the main reason for her

infertility. High insulin interferes with normal ovulation making it difficult for pregnancy to

occur.

4) Provide and algorithm to follow for appropriate labs, medications and follow up visit

scheduled for optimizing patient with this conditions overall health care needs in a form of

an educational tool tobe used for other health care providers.

The treatment for secondary amenorrhea is based on the major contributing factors of this

disease. The hormonal imbalance, for instance, can be addressed through regulation of

hormones by use specified medicines. From the analysis of the tests done, PCOS was

suspected to be the leading cause of the disease. Treatment for PCOS mainly begins with

a change in the diet as well as lifestyle routines. One of the steps is to advise the patient to

address diet and lifestyle issues. Nutritionist services are heavily needed to reduce weight.

Controlling your diet will help to reduce the amount of cholesterol and insulin increase.
The research studies have shown that losing approximately 5-10 of patient body weight

significantly help to address the regulation of the irregular menstrual cycles. Besides,

weight loss reduces the risk of getting metabolic syndromes such as diabetes and

cardiovascular-related diseases such as stroke. PCOS patients should consider low

carbohydrates diets since they are useful in assisting to lower body weight as well as

reducing insulin levels. Embarking on exercise is also crucial and more beneficial.

Together with a healthy diet, significantly help in weight loss hence lowering diabetes and

cardiovascular diseases risks. Diet and weight control regulation is the first step that should

be undertaken. Generally, it is included in the steps of the treatment and regarded as the

physician primary care stage or gynecologists.

As shown in the patient in this case study, PCOS patients experience growth of thick hairs

on her chin. This is one of the most common signs of PCOS. It shows that hormonal

imbalance is present in the patient’s body due to factors such as the presence of a tumor in

the pituitary gland, which interferes with reproductive hormones secretion. This, in turn,

leads to hormonal imbalance. During this moment, male’s hormones are more than female

hormones hence leading to a patient experiencing male characteristics such as the growth

of thick hairs on her chin. Taking estrogen and progesterone daily medication can help in

improving the levels of these hormones in the body. Furthermore, they help in regulating

ovulation, relieve and may prevent the growth of hairs and most importantly offers

protection against the emergence of endometrial cancer.

Besides, administration of Metformin containing Glucophage or Fortamet can also be

done. Although this drug is used to treat type ii diabetes, it can also greatly assist in the

treatment of PCOS by regulating insulin levels. The patient in this case study found it

difficult to get pregnant. Use of clomiphene, for instance, will help in assisting the patient

in getting pregnant. However, its side effects are increased chances of getting twins. To

remove the hair growth experienced due to this condition, Eflornithine cream may be

suggested for the patient to slow down the hair growth. Laser hair growth, as well as

electrolysis, can be carried out to remove the hairs on the chin or face.

Surgical operations can also be done to address the issue if other treatments methods do

not work. Ovarian drilling can be done. The latter methods involve the drilling of tiny holes

in the ovary that helps to restore the normal ovulation process in the female reproductive

system. Surgery may also be done to remove the cysts, scar tissues, or uterine adhesions.

Dilation and Curettage are usually done to remove cysts caused by PCOS. If the patient is

found to have a tumor or cancerous growth in the pituitary gland, certain types of

medications may be prescribed to shrink the pituitary tumor. If the medicines do not show

any improvement, surgery in the theater may be recommended to remove the pituitary

tumor. Medical evidence has proven that pituitary tumors are not cancerous, but when left

to multiply in the brain, they may cause problems. Surgery is done with great precaution.

Not all people have to undergo surgery.

5) Discuss the relationship with diabetes in this patient, does this patient need to be

concerned?

Patients with secondary amenorrhea are likely to have diabetes. Secondary amenorrhea

caused by PCOS is strongly related to diabetes. Excess insulin is a significant contributor

to the PCOS symptoms in the body. Insulin is a sugar hormone secreted by the pancreas

due to stimulation by the pituitary gland. PCOS presence in the body may be accompanied

by insulin resistance. Insulin hormone allows the body cells to use sugar as the body

primary source of energy. However, when PCOS symptoms are present, patient body cells

may show resistance to insulin. This may lead to accumulation of too much-secreted

insulin, which is unused by the cells this, in turn, leads to high blood sugar levels.

Furthermore, this may prompt the body to produce more insulin. This leads to diabetes.

The patient needs to be concerned since the excess insulin is causing difficulty in ovulation

and diabetes. Metabolic syndrome associated with PCOS furthermore confers a five-fold

rise in chances of getting diabetes type ii. Due to the presence of secondary amenorrhea

caused majorly by PCOS, the patient is at risk of maybe having diabetes ii due to body

cells resistant to insulin. Furthermore, diabetes may lead to cardiovascular problems such

as stroke. The patient can need to address the issue through proper diet and healthy lifestyle

accompanied by regular exercise.