OB/GYN
A 24-year-old woman is complaining of failure to conceive over the last 16 months despite regular intercourse.
She has infrequent menstruation occurring once every 6 to 8 weeks along with increased facial hair and acne. On ultrasound, her ovaries had multiple small follicles each is 2-5 mm diameter on the surface. She indicated that her main aim is getting pregnant. Body mass index 37 kg/m2 Which of the following is the initial step in management?
Explanation
Core Concept: In an obese woman with PCOS seeking pregnancy, treatment is stepwise: lifestyle first, then insulin sensitisation, then ovulation induction. Nothing invasive is offered before those have been tried.
Clinical Presentation:
- Anovulatory infertility with oligomenorrhea, hirsutism and acne.
- BMI 37 — weight is the single most modifiable driver of her anovulation.
Diagnosis:
- Rotterdam criteria met on cycle history, hyperandrogenism and ovarian morphology.
- Confirm anovulation with a mid-luteal progesterone; assess the partner and tubal patency before escalating.
Management:
- Acute: weight reduction (a 5-10% loss can restore ovulation), metformin to improve insulin sensitivity, and clomiphene citrate as first-line ovulation induction.
- Why not the others: danazol is an androgenic agent used in endometriosis and is contraindicated in a woman trying to conceive; IVF is not a first step; laparoscopic ovarian drilling is reserved for clomiphene-resistant cases, and wedge resection is obsolete because of adhesion formation.