A 26-year-old woman attends her general practitioner with difficulty conceiving. She has been having regular unprotected intercourse with her 27-year-old husband for six months. She has never taken any hormonal contraception. She describes her periods as "a bit irregular" with a 50-75 day cycle.



On examination, she is 170cm tall and weighs 72kg. She has notable facial acne and has dark hair on her chin and around her areola.




Her blood tests results are as follows:


||||
|---------------------------|:-------:|------------------------------|
|Testosterone|1.9 nmol/L|(M) 9.9 - 27.8, (F) 0.2 - 2.9|
|Androstenedione|15.8 nmol/L|1.3 - 5.8|
|Luteinising Hormone|9.1 IU/L|1 - 11 (Luteal)|
|Follicle Stimulating Hormone|5.4 IU/L|2 - 8 (Luteal)|
|LH/FSH ratio|1.7||
|Dehydroepiandrosterone sulfate (DHEAS)|6.7  µmol/L|2.7 – 9.2|



A pelvic ultrasound shows bilateral ovary are enlargement, with multiple peripheral follicles.



What is the most appropriate management?

Options:
explanation: This woman has polycystic ovary syndrome (PCOS). PCOS can be diagnosed using the Rotterdam criteria, where two of the following three are present:
 

 - Oligo- or amenorrhoea
 - Clinical or biochemical evidence of hyperandrogenism
 - Polycystic appearance of the ovaries on ultrasound
 

 Although her general practitioner has performed multiple hormone blood tests and ordered an ultrasound scan, these are not necessary to provide a diagnosis. She has evidence of oligomenorrhoea (long, irregular cycles) and clinical evidence of hyperandrogenism (acne, hirsutism).
 

 PCOS does not cause absolute infertility, as often the woman still ovulates, but less frequently. The advice is to refer to the fertility clinic where a couple has been trying to become pregnant for two years.
name: Advise the woman to continue having unprotected intercourse and ask to be referred to the fertility clinic if she has not become pregnant after 1 year in total
label: a
answer: yes
explanation: BMI is calculated as weight (kg)/height m<sup>2</sup>. Her BMI is 24.9 kg/m<sup>2</sup>, just within the normal range. Women with a BMI over 25kg/m<sup>2</sup> may benefit from weight loss to increase the chances of pregnancy.
name: Advise the woman to lose weight
label: b
answer: no
explanation: Couples trying to conceive should be advised that sexual intercourse every 2 to 3 days optimises the chance of pregnancy.
name: Advise having sexual intercourse daily to increase the chance of conception
label: e
answer: no
explanation: BMI is calculated as weight (kg)/height m<sup>2</sup>. Her BMI is 24.9 kg/m<sup>2</sup>, just within the normal range. Women with a BMI over 25kg/m<sup>2</sup> may benefit from weight loss to increase the chances of pregnancy.
name: Advise a trial of combined oral contraception to regulate her periods
label: d
answer: no
explanation: Referral to the fertility clinic is only warranted where the couple have been trying to conceive for two years.
name: Advise the woman's husband to ask for a referral to the fertility clinic for semen analysis
label: c
answer: no

Correct answer: a

Advise the woman to continue having unprotected intercourse and ask to be referred to the fertility clinic if she has not become pregnant after 1 year in total