I’ve always struggled to put out consistent content. Mostly because I worry about making inaccurate or false claims. Not backed by data or studies. Hormone imbalance is always complex.
The whole point of this blog is to bring up deeper discussions, normalize health education. I believe women can connect on these issues. Read studies or women in similar situations so they know it’s not just them. They can see what worked or others and start creating their own personalized treatment plan using data. So I’m starting Case Study Fridays! Pulled straight from medical journals or people who want to share them with the public.
Case Study:
Summary:
19 year old girl. Irregular period for 4 years.
She had undergone puberty that was normal in both timing and development, with menarche at 12 years of age. At 16 years of age, she started irregular bleeding.
With the cycle length varying between 20 and 60 days and bleeding for about 6 days. She reports feeling depressed about facial acne.
Her weight is 80 kg and height 1.75 m; the body-mass index is 26.2. Physical examination confirms no hirsutism but she does have severe facial acne.
Investigations show that her follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels are in the normal ranges with low levels of estradiol (OEST2) and progesterone.
Total testosterone is 1.1 nmol/L (NR 0.6–2.5), dehydroepiandrosterone sulfate (DHEAS) 5.1 umol/L (NR 3.3–12), and androstenedione 7.7 nmol/L (NR 4.9–14).
The calculated free testosterone 33.6 pmol/L (NR 3.5–46.0) level is in the normal range but the serum SHBG concentration is only 8 nmol/L (NR 20-118).
Her fasting plasma glucose is 4.9 mmol/L, HbA1c 5.1%, and fasting insulin level is raised at 35 mU/L (NR < 10). The lipid profile is normal but liver function tests are raised. Serum ALT 58 U/L (NR < 30)
Unremarkable ultrasound.
The criteria for PCOS is that the patient meets two of the points.
Presence of two of the following three findings—hyperandrogenism (physical consequences of high androgens), ovulatory dysfunction, and polycystic ovaries (from the ultrasound) —plus the exclusion of other diagnoses that could result in hyperandrogenism or ovulatory dysfunction. Some studies suggest using testosterone as the marker for hyperandrogenism and the need of symptoms.
A reasonable question raised by this case history is whether she should have a PCOS diagnosis?
If yes, how do we prevent progression from early stages to the more classic and severe phenotype (HA + M + PCO)?
Her SHBG level was very low, thereby increasing androgen activity which may adversely affect her skin. Investigations also revealed this young woman had evidence of NAFLD and insulin resistance.
The diagnosis may be overlooked if total-testosterone and androstenedione levels are normal.
Young women often have a low level of SHBG as an early indicator of PCOS. But it’s hard to determine since follow-up is often not required. They send you on the pill and on your way.
One clinical study suggested that girls presenting with menstrual irregularity and acne at 16 years of age, with or without hyperandrogenism, were more likely to suffer from PCOS and infertility problems 10 years later.
Possible other solutions:
Therapeutic intervention with metformin, Myo-inositol and D-chiro-inositol in women with PCOS increased serum levels of SHBG and were associated with improved ovarian function and metabolism (reduction of BMI, HOMA-IR and LDL-C).