CCE-CBD-208

CASE INFORMATION

Case ID: PCOS-001
Case Name: Jessica Martin
Age: 24 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: X99 (Polycystic Ovary Syndrome)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Creates a safe and supportive environment for discussing reproductive health 1.2 Uses clear, non-judgmental language to explain the condition and management options 1.3 Addresses patient concerns about fertility, weight, and long-term health risks
2. Clinical Information Gathering and Interpretation2.1 Takes a thorough menstrual, metabolic, and reproductive history 2.2 Conducts an appropriate physical examination 2.3 Orders and interprets relevant investigations to confirm the diagnosis
3. Diagnosis, Decision-Making and Reasoning3.1 Applies the Rotterdam Criteria for diagnosing PCOS 3.2 Differentiates PCOS from other causes of irregular periods and hyperandrogenism 3.3 Assesses long-term risks, including metabolic syndrome and infertility
4. Clinical Management and Therapeutic Reasoning4.1 Develops an individualised, evidence-based management plan 4.2 Provides lifestyle modification advice for weight management and metabolic health 4.3 Discusses pharmacological options, including hormonal and non-hormonal treatments
5. Preventive and Population Health5.1 Screens for associated conditions (diabetes, dyslipidaemia, cardiovascular risks) 5.2 Provides preventive health strategies for long-term metabolic health
6. Professionalism6.1 Demonstrates empathy and patient-centred care, addressing emotional concerns
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate follow-up and referrals to endocrinology, gynaecology, or dietetics 7.2 Provides clear documentation and patient education resources
9. Managing Uncertainty9.1 Recognises when further specialist referral is required for diagnostic uncertainty or fertility concerns
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies and manages metabolic and cardiovascular risks associated with PCOS

CASE FEATURES

  • Young woman with irregular periods, hirsutism, and weight concerns.
  • Discussion about fertility, lifestyle modifications, and long-term metabolic risks.
  • Need for a structured diagnostic approach using the Rotterdam Criteria.
  • Multidisciplinary management involving dietetics, endocrinology, and psychology.

CANDIDATE INFORMATION

INSTRUCTIONS

Review the following patient record summary and scenario.

Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time for each question will be managed by the examiner.

The time allocation for each question is roughly as follows:

  • Question 1 – 3 minutes
  • Question 2 – 3 minutes
  • Question 3 – 3 minutes
  • Question 4 – 3 minutes
  • Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Jessica Martin
Age: 24 years
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • No known allergies

Medications

  • None

Past History

  • Menarche at 13 years, always had irregular cycles (every 35-50 days)
  • Mild acne in adolescence, worsening in adulthood
  • Gradual weight gain over the past 3 years (BMI now 30 kg/m²)

Social History

  • Works full-time as an accountant
  • Engaged, planning to start a family in the next few years
  • Diet: Reports poor dietary habits, often eating processed foods
  • Exercise: Minimal physical activity
  • No smoking or illicit drug use
  • Alcohol: Occasional (1-2 drinks per week)

Family History

  • Mother has type 2 diabetes
  • Sister diagnosed with PCOS at age 22
  • No history of cardiovascular disease

Vaccination and Preventative Activities

  • Cervical screening up to date (normal results 1 year ago)
  • No previous diabetes screening

SCENARIO

Jessica, a 24-year-old woman, presents to her GP with concerns about irregular periods and difficulty losing weight. She also reports increased facial hair growth (hirsutism) and persistent acne despite using over-the-counter treatments.

She is worried about her fertility because she and her fiancé plan to start trying for a baby in the next couple of years. She is also concerned about her health, as her mother has type 2 diabetes.

Your role is to assess Jessica’s symptoms, confirm the diagnosis, discuss management options, and provide guidance on fertility and long-term health risks.

EXAMINATION FINDINGS

General Appearance: Well-groomed, mildly anxious
Vital Signs: BP 125/80 mmHg, HR 76 bpm, BMI 30 kg/m²
Skin: Mild acne, some coarse facial hair on upper lip and chin (modified Ferriman-Gallwey score: 9)
Abdomen: No tenderness, no masses, no hepatosplenomegaly
Pelvic Exam (if performed and consented): No obvious ovarian enlargement, no adnexal tenderness
Mental Health Screening: Reports mild distress about appearance and fertility, no clinical depression (PHQ-9 score 3)

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess Jessica for PCOS?

  • Prompt: What key aspects of history would you explore?
  • Prompt: What clinical criteria are used to diagnose PCOS?

Q2. What investigations would you order, and how would you interpret them?

  • Prompt: What blood tests and imaging are required?
  • Prompt: How do these investigations guide management?

Q3. What management options would you discuss with Jessica?

  • Prompt: How would you approach lifestyle modifications?
  • Prompt: What pharmacological treatments may be considered?

Q4. How would you address Jessica’s concerns about fertility?

  • Prompt: How does PCOS affect fertility?
  • Prompt: What treatment options are available for conception?

Q5. What long-term health risks are associated with PCOS, and how can they be managed?

  • Prompt: What are the risks of metabolic syndrome, diabetes, and cardiovascular disease?
  • Prompt: How would you counsel Jessica on long-term preventive health strategies?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess Jessica for PCOS?

A structured assessment for PCOS involves a thorough history, examination, and application of diagnostic criteria.

1. History-Taking

  • Menstrual history: Irregular cycles since menarche, now 35-50 days.
  • Signs of hyperandrogenism: Hirsutism, acne, scalp hair thinning.
  • Metabolic risk factors: Weight gain, family history of diabetes.
  • Reproductive health: Fertility concerns, previous pregnancies.
  • Lifestyle factors: Diet, exercise, stress levels.
  • Medication use: Any hormonal contraceptives.

2. Physical Examination

  • BMI and waist circumference: BMI 30 kg/m² suggests metabolic risk.
  • Skin: Hirsutism, acne, acanthosis nigricans (suggests insulin resistance).
  • Abdomen: Check for hepatomegaly (NAFLD risk).
  • Pelvic exam (if indicated): Ovarian enlargement.

3. Application of Rotterdam Criteria

Diagnosis requires 2 out of 3:

  1. Oligo- or anovulation (irregular cycles).
  2. Hyperandrogenism (clinical or biochemical).
  3. Polycystic ovaries on ultrasound.

Conclusion: Jessica meets at least two criteria (irregular cycles and hirsutism), making PCOS the likely diagnosis.

Q2: What investigations would you order, and how would you interpret them?

1. Blood Tests

  • Hormonal panel:
    • Testosterone, SHBG, FAI (to confirm hyperandrogenism).
    • LH, FSH (LH:FSH ratio >2 suggests PCOS).
    • Prolactin, TSH (rule out prolactinoma, thyroid dysfunction).
    • 17-OHP (rule out CAH).
  • Metabolic screening:
    • Fasting glucose, HbA1c (screen for insulin resistance).
    • Fasting lipids (risk of dyslipidaemia).

2. Pelvic Ultrasound (if needed)

  • Polycystic ovarian morphology: ≥20 follicles per ovary or increased ovarian volume.

Conclusion: Investigations help confirm hyperandrogenism, rule out mimics, and assess metabolic risks.

Q3: What management options would you discuss with Jessica?

1. Lifestyle Interventions (First-line)

  • Weight management: 5-10% weight loss improves ovulation.
  • Exercise and diet: Low-GI, high-protein diet and regular physical activity.

2. Pharmacological Management

  • Oral contraceptive pill (OCP): First-line for irregular cycles and hyperandrogenism.
  • Metformin: For insulin resistance, metabolic benefits.
  • Anti-androgens (spironolactone, cyproterone acetate): For hirsutism and acne.
  • Topical treatments: Eflornithine cream for facial hirsutism.

3. Psychological and Supportive Care

  • Screen for anxiety/depression.
  • Referral to dietitian/exercise physiologist.

Conclusion: Management is individualised, with lifestyle interventions as first-line therapy.

Q4: How would you address Jessica’s concerns about fertility?

1. Reassurance and Education

  • PCOS is a common cause of anovulatory infertility.
  • Most women can conceive with lifestyle modification or treatment.

2. Optimising Natural Fertility

  • Regular ovulation tracking.
  • Healthy weight, reduced stress, folic acid supplementation.

3. Fertility Treatment Options

  • First-line: Letrozole (ovulation induction).
  • Alternatives: Clomiphene, metformin (if insulin resistance present).
  • IVF is rarely needed unless other infertility factors exist.

4. Referral to Fertility Specialist

  • If no pregnancy after 6-12 months of active trying.

Conclusion: Jessica has good fertility prospects, and early intervention can improve outcomes.

Q5: What long-term health risks are associated with PCOS, and how can they be managed?

1. Metabolic and Cardiovascular Risks

  • Insulin resistance → Type 2 diabetes risk.
  • Dyslipidaemia, hypertension, NAFLD risk.
  • Regular screening: HbA1c, lipids, BP monitoring.

2. Endometrial Cancer Risk

  • Due to anovulation and unopposed oestrogen.
  • OCP or cyclic progestins protect the endometrium.

3. Mental Health Risks

  • Higher rates of anxiety, depression, eating disorders.
  • Routine mental health screening and support.

4. Long-Term Preventative Strategies

  • Weight management is key.
  • Regular GP follow-up for screening and lifestyle counselling.

Conclusion: Early intervention reduces long-term complications.

SUMMARY OF A COMPETENT ANSWER

  • Structured history and examination based on the Rotterdam Criteria.
  • Appropriate investigations to confirm PCOS and exclude differentials.
  • Evidence-based, multidisciplinary management.
  • Clear, reassuring discussion about fertility options.
  • Preventative care for metabolic and reproductive health.

PITFALLS

  • Failing to consider differential diagnoses (e.g., CAH, prolactinoma).
  • Over-relying on ultrasound for diagnosis (not needed if clinical criteria met).
  • Not addressing metabolic risks or lifestyle interventions.
  • Inadequate discussion of fertility concerns.
  • Not screening for psychological impacts of PCOS.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD