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History of Present Illness (hpi)

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29-year-old Caucasian female, gravida 0 presented for evaluation of her irregular menstrual periods. She has a history of irregular menstrual periods since her menarche also complaints of mood swings usually 3-4 day before her menstrual periods, weight gain around 6 kg over the last 2 years. Pt is worried that she has only 1 period every 4-5 months. When she has her period, she uses 3-4 pads per day and passing large clots,. Pt mentioned that it affects her working activity as she needs to miss 1-2 days of her work during her heavy cycles.

She has been obese since age 13 y when she started having her 1st menstrual period.

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Medication-Pt currently taking Spironolactone 200 mg once daily for her acne and hirsutism, Metformin 500 mg OD

Supplements Vit D3 -1000 IU, Omega -3 1000mg , Selenium 200 mg .

ROS

Pt denies any headaches, blurred vision, voice change or discharge from her nipples.

FH. Pt stated that her sister also had irregular periods and improved when started birth control pills Yaz that pt doesn’t think is a good alternative for her case as she rather was “looking for less chemical and less hormonal approach “.

SH Lives with her husband, married for 3 years, feels happy in her marriage, has never conceived, despite a fact that she has never used any form of contraception.

She has a few good friends who also like hiking and active lifestyle.,

Lifestyle – Active, Gym -1-2 times per week and jogging 20 min almost every other day or walking with her dog 20-30 min.She likes her IT job and also helps her husband to run his small software company.

Has 1 adopted dog and multiple home plants that make her feel happy when she takes care of them.

On examination, facial hirsutism noted, BMI was 32, HEENT – normal. CVS, Resp, Abdo – normal.Pelvic exam was unremarkable, no clitoromegaly,. The rest of her physical exam was unremarkable

A uterine ultrasound revealed a normal appearing uterus, with an endometrial thickness of 5 mm and finding consistent with bilateral polycystic ovaries- the presence of multiple follicles in the left and right ovary with signs of ovarian enlargement

Laboratory studies showed Her FSH was normal, but her LH was elevated. Her TSH, prolactin, chemistry panel, cholesterol, triglycerides, HDL, and low-density lipoprotein (LDL) were all within normal limits.; fasting blood sugar was 6.3(normal up to 6),. Her total testosterone was2.5 nmol/ l, and her free testosterone 44(normal range, 1-43.4 pmol/l)

The previous SHG and endometrial aspirate were normal.

Dear Mxxxx,

I am writing you this letter to sum –up our communication and some investigation and laboratory tests that done so far.

As we underwent and discussed with you your blood work –we noted only minor changes such as hyperandrogenism –your male hormone –testosterone on an upper level of normal as it pretty common in PCOS. You are on Metformin and spironolactone(Water pills ) tabs, however, your dream at some point to stay off of meds and continue your healthy style and sport instead –that is sound great and a good plan for me as well.

Rest of your labs looks good.

Let’s go through the concerns that I heard.

Mxxxx, you told that your goal is to balance your hormonal disruption as a result of PCOS and plan your further pregnancy.

Please allow me to review the consult notes that you provided. I really appreciate your patience as you had a long way of investigations and you told that you still have a feeling of uncertainty if you have PCOS as you felt that your gynecologist rushed in his explanation and you didn’t understand it clearly.

I am agreeable to you as there is some diversity in the clinical symptoms that may confuse you. However, I called your gynecologist and he confirmed your diagnosis based on a variety of finding –your clinical symptoms, labs, and the US. I attached handouts (Rotterdam Criteria) for PCOS diagnosis where you can see that 2 of 3 criteria needed for diagnosis. You have all 3 criteria –irregular menstrual periods, increased androgens (testosterone)and polycystic ovaries on the US.

You also asked if there are new tests more specific for PCOS and asked if it covered by the health plan . Yes, there is Antimullerian hormone test that has high sensitivity. I clarified that this test is not currently covered by the provincial health plan, however, it may be covered by an extended or private plan.

4You told that you had a lot of tests and found that some of them not helpful.

We had long discussion recons and pros of multiple labs investigations and you wisely choose to minimize labs and switch your concentration and effort to your prevention of undesirable metabolic abnormalities such as prediabetes, overweight and possible complications of PCOS.

Management and lifestyle modification plan

Your BMI is above 30. Good news that even 5 % of weight loss may cause significant improvement in your metabolism and clinical symptoms

Exercise.

Studies show that it can improve ovulation, insulin resistance, and weight loss. You do a great job by doing your regular exercise, I encouraged you to continue doing this and gradually try to go up to 5 times per week at least 30 min of aerobic exercise. For sure to continue your routine and walking with your dog and jogging is also good for general wellbeing and stress reduction.

Nutrition.

You may get better results on anti-inflammatory or low carb diet with inclusion of low GI food, I attached hands out.

Some food such as Brewer yeast, liver, oysters, fruit and mushrooms may bring some benefits as they are rich in Chromium picolinate –natural glucose regulator.

You mentioned that sometimes you feel bloated and think that unable to tolerate some food.

Elimination diet and real food may be also a good choice. Eliminate dairy, sugar, corn, processed food. Eat unprocessed food and food with a low GI. We discussed in details the process of elimination and you found that is not difficult.

Supplements.

You started taking Drops of Vit D3 1000 Iu, I put you requisition and we will recheck the blood level of 25-OH Vit D level in 3 months, In some rare cases, Vit D3 may cause mild gastrointestinal (stomach) symptoms. Let me know if any concerns.

Omega-3, you already take it, you bought NFH brand that is good, we can also add flaxseed as a natural product at the lignans in flaxseed may help regulate androgen levels in women with PCOS. If you choose to add flaxseed to your diet, ground seeds are preferred, especially fresh prepared, as they allow better absorption of the omega-3 fats and the lignans. Most people start with 1 tablespoon a day, mixing it in oatmeal, yogurt, salads.

Botanicals.

Cinnamomum cassia -1 g powdered cinnamon (1/4 teaspoon) daily .. Cinnamon is one of the best natural remedies for managing blood sugar levels to help prevent insulin resistance. Has a nice taste and easy to tolerate, again, as a rare side effect, some people may have mild gastric symptoms

Medications

You previously tried Tab .spironolactone 200 mg and told me that you dream to take the brake from tabs. In all case, I suggest stopping spironolacton3 months before conception (your planning pregnancy) as this medication is teratogenic and can cause birth defects.

You have been on Metformin 500 mg once daily and we increased it to twice daily to get more benefits as you able to tolerate it well.You noted some improvement –more regular periods and better glucose control.

Because you desire a pregnancy in the future, metformin not only good for control of your blood sugar but also to help regulate your menstrual cycles and prepare your body for this important in your life step.

Please pay attention that there are no diarrhea or nausea .as possible side effect. Of metformin. We also will recheck Vit B12 in 3 mo as metformin can decrease its level.

We talked also about optional medication Cap. Inositol 600 mg twice per day for 3 months that you might take with your supplements if symptoms persist but you decided to postpone it for now. You also asked me about L-carnitine, as you took it as per your friend recommendations for weight loss. Also, the mechanism of l-carnitine makes it seem like it could benefit weight loss, the effects are small and research is mixed. I know that you are recently on a vegetarian diet and no studies on vegetarian done with this supplement.

Mind-Body medicine. After our discussion you are eager to start a mindfulness course, that is great. Studies show that 8 weeks mindfulness and stress management program increases the quality of life, decrease anxiety, increase the quality of life and even can help to reduce weight. It is only too often that we find ourselves torn between ruminating about the past and worrying about the future, thus, missing the only reality that we have – the present. Mindfulness is simply the ability to be aware and awake in the present moment. It involves directing purposeful attention to the present moment and watching it unfold, without judging it.

To be mindful is to be truly alive and present in whatever you are experiencing. Mindfulness therapy has been shown effective for a variety of physical and emotional problems, such as stress, anxiety, depression, chronic pain, and eating disorders.

Benefits of mindfulness practice include developing the following qualities:

  • Stability of mind
  • Flexibility of mind
  • Self-awareness
  • Non-reactivity (acting instead of reacting)

Mindfulness can be practiced through meditation, as well as through everyday activities. We can stay harmoniously in the present by eating mindfully, walking mindfully, driving mindfully, washing the dishes mindfully, as well as by practicing mindfulness through any other activity. Mindfulness also teaches us to be fully present in interactions with others. I know that you still have some worries that you can gain your weight back but you can correct it by using mindful eating.

Most patients find the practice of mindfulness helpful in dealing with the issues they experience. Some benefit the most from integrating concepts of mindfulness with other treatment modalities, while others prefer to undergo the full mindfulness meditation training.

It is often advisable to use mindfulness practice in conjunction with cognitive-behavioral therapy (CBT)) when treating anxiety disorders, depression, and OCD. Whatever your preference is, you will find that practicing mindfulness through meditation and everyday life activities will bring you a greater sense of well-being and profound positive changes in your life.

And a few more tips.

Try to Sleep at least 8hours

Tai Chi also can help you normalize your sleep . as

Tai Chi and CBT (cognitive therapy ) can help with sleep disturbance as per a recent randomized trial. We have Tai Chi grope and CBT group in our clinic and your welcome to join us.

fun (lough therapy) can also reduce stress.I put you some names of providers in case you would be interested in.

Yoga may be a good addition to your current sports as it provides stretching with some relaxation effect. You told that you like to eat more when you stressed. Let’s try yoga for your stress reduction as research support yoga as a compliment to traditional treatment. You asked what type of yoga is better

There is not enough evidence to recommend specific styles of yoga so you can choose one that you feel that fits your body.

You also talked to me that you like jazz music. So why we would not add music therapy as a combination with already added meditation, relaxation, yoga, massage.

Just to finalize our plan,

Firstly, I was happy to know that you feel pretty satisfied with our “more natural “ plan as it built and adjusted based on your personal preference and some appropriate to your situation tests.

I am glad to encourage you to continue your physical activity and healthy lifestyle modifications with your new beginning of mindfulness meditation. You told that your few lessons went well and you feel less stressed. What might be better to feel that mind-body medicine works.

You also mentioned that your endocrinologist told that he will see you in 1 year only for f/u as he also thinks that you are well balanced and have a good lifestyle plan for your weight and hormonal corrections.

So, looks like we have a good plan to continue.

Will be more than happy to see you back in 3months with the results of Labs (Gl, Vit D, B12 level ).

Please do not hesitate to contact me if you have further questions or concerns,

Regards,

Dr. Xxxx Xxxxxx.

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