LEARNING OBJECTIVES: 1. Diagnose polycystic ovary syndrome (PCOS). 2. Restore fertility in the setting of PCOS and subclinical hypothyroidism. 3. Recognize and manage the potential long-term sequelae of PCOS. CASE INFORMATION: A 28 year-old G0P0 Asian woman presented for a new patient appointment concerned about 7 months of amenorrhea. She recalled that her menstrual cycles since menarche at age 13 had often been irregular-varying in length from 28 to 45 days-but she had never gone more than two months without a period. Her last menstrual period was shortly before an extended and stressful trip back to her family in Taiwan. After several months without a period, a basic workup in Taiwan revealed a negative pregnancy test, elevated blood pressure, and a slightly increased TSH. She returned to the U.S. and had no subsequent followup. She made her appointment when she and her husband had become increasingly concerned about her fertility. Her past medical history was remarkable only for elevated triglycerides several years ago. She took no medications and denied any use of tobacco, alcohol, or drugs. Born in Taiwan, she emigrated to the U.S. as a child. She lived with her husband and worked as a psychiatric nurse. Her family history was unremarkable. Review of systems was notable for weight gain of about 15 pounds over the last year, intermittent fatigue and mood swings, frequent frontal headaches and lower abdominal cramping, bilateral hand numbness at night, and increased hair loss. She denied heat or cold intolerance, fevers, night sweats, nausea, vomiting, diarrhea, dysuria, vocal or visual changes. On exam, she was mildly obese and well-appearing. Compared with her driver's license photo from two years before, she had apparently gained some weight but showed no obvious changes in her facial structure. Her blood pressure was 110/70 and her heart rate was 80. Her BMI was 30. Her thyroid gland was slightly enlarged. There were terminal hairs present on her upper back but no other evidence of hirsutism. Her abdomen was slightly obese without striae. Bimanual exam revealed slight enlargement of her ovaries and associated mild tenderness. Initial laboratory data included normal CBC and renal panel, undetectable serum beta-HCG, TSH 5.02, free T4 14, FSH 6.4, LH 11.5, prolactin 9.3, fasting glucose 103, total cholesterol 167, triglycerides 314, LDL 66, and HDL 38. Pelvic ultrasound revealed bilateral polycystic ovaries. Additional blood tests were obtained. Daily administration of 10mg of medroxyprogesterone acetate yielded a normal menstrual period on day nine. She was also started on thyroxine and a program of weight reduction. DISCUSSION: PCOS is the most common endocrinopathy among women of reproductive age with an estimated prevalence of 4±7%. Though a clear consensus about diagnostic criteria for PCOS has not been achieved, the clinical hallmarks include evidence of hyperandrogenism, menstrual dysfunction, and polycystic ovaries. The diagnosis also requires the exclusion of other functional and neoplastic disorders with similar clinical features. Fertility may be restored in obese patients with PCOS through weight reduction alone. Metformin and clomiphene are other therapeutic options. In the unusual circumstance in which subclinical hypothyroidism may be contributing to menstrual disturbances, treatment with thyroxine has been demonstrated to restore normal function. Proper management of women with PCOS requires recognition of the long-term health risks associated with unopposed estrogen, insulin resistance, and lipid abnormalities including endometrial cancer, overt type 2 diabetes mellitus, and coronary artery disease.