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INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please read the following scenario, and then take a focused history from Shantelle. Ask the facilitator for the results of a relevant physical examination and surgery tests. Outline the most likely diagnosis and discuss further testing required, your initial management, and recommendations with Shantelle.

Scenario

Shantelle Kickett is a 31-year-old Noongar woman from Western Australia. She has moved in with her long-term partner and is planning a family soon. She is concerned about her fertility as she only gets five periods a year. A colleague ordered tests and Shantelle has come to you for the results today.

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Pelvic USS
The uterus and both ovaries were clearly identified. No abnormality demonstrated. No hydronephrosis.
FSH 6 (5–20) mIU/mL
LH 18 (5–20) mIU/mL
FSH/LH ratio 1:3 (elevated)
FAI 12 (normal 7–10)
SHBG 20 (18–114) nmol/L

The following is on her summary sheet:

  • Past medical history

  • Acne

  • Medications

  • On Ethinyloestradiol 35 mcg/cyproterone 2 mg (Diane 35) until 12 months ago

  • Tretinoin cream 0.05% (Retin-A) nocte

  • Immunisations

  • Childhood immunisations as per schedule.

  • Cervical screening

  • Last pap negative September 2017

  • Family history

  • Mother and maternal grandparents—type 2 diabetes

  • Sister—gestational diabetes mellitus

  • Father—high cholesterol

  • Social history

  • Lives with de facto partner David (34)

  • Works as a school teacher

  • Non-smoker

  • Alcohol three to fourth drinks one day a week

  • Not taking any recreational drugs or OTC medications.

INSTRUCTIONS FOR THE PATIENT, SHANTELLE KICKETT

You and David have started to think about the long-term and planning kids. You stopped the contraceptive pill 12 months ago as you had irregular periods in your twenties and wanted to check your natural cycle before trying to fall pregnant. You have never been pregnant and use condoms for contraception.

Your period tracker shows you have had five periods in the last year. You are worried because the app suggests you are not ovulating and you need to see a doctor.

Your periods started at age 13 and were irregular until you started ethinyloestradiol 35 mcg/cyproterone 2 mg (Diane) for moderately severe acne when you were 20. You have always struggled with your weight. Your family are all big people. You thought that stopping the pill might help with this but you haven’t lost any weight despite your efforts to do so.

You have a good knowledge of nutrition and eat healthy meals most of the time but admit there is room for improvement.

You are physically active and play tennis twice a week and walk around a lot at school.

Your mood is good. You are not lethargic or tired and get a good amount of sleep, six to eight hours a night, feeling refreshed when you wake. You do not snore. ...

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