New Gynaecology Consult

Dear ,

Reason for Referral:
Medication management for PCOS and insulin resistance

History of Present Illness:
Anna presents for follow-up regarding medication management for polycystic ovary syndrome and insulin resistance. After initiation of metformin, she experienced gastrointestinal discomfort, which has since improved. She has been taking a low-dose combined oral contraceptive for menstrual regulation and notes her most recent menstrual cycle was approximately 32 days in length, which she identifies as an improvement. She reports mild breakthrough bleeding during the first month of oral contraceptive use, described as mild spotting. She has been attempting to increase physical activity by walking more frequently, though dietary modifications have been less consistent. She denies any new symptoms or adverse effects related to her current medication regimen.

Gynecologic History:
Anna is currently using a low-dose combined oral contraceptive for menstrual regulation. She reported improvement in her menstrual cycle length, with her last cycle being approximately 32 days. She experienced mild spotting during the first month of use, which has since resolved. She is not trying for pregnancy at this time but may consider it in approximately one year.

Past Medical History:
Anna has a history of polycystic ovary syndrome (PCOS) and insulin resistance. She has been prescribed metformin for insulin resistance and a low-dose combined oral contraceptive for menstrual regulation. She has reported improvement in her menstrual cycle length since starting the oral contraceptive.

Current Medications:
Anna is currently taking metformin for insulin resistance and a low-dose combined oral contraceptive for menstrual regulation. She reported initial gastrointestinal discomfort with metformin, which has since improved. She also experienced mild spotting during the first month of oral contraceptive use, which has resolved.

Allergies:

Social History:
Anna has been increasing her physical activity by walking more frequently. Dietary modifications have been less consistent.

Review of Systems:
General: No headaches, no nausea, no mood changes.

Assessment and Plan:
1. Polycystic ovarian syndrome (E28.2)
2. Other insulin resistance (E88.818)
   • Continue metformin and low-dose combined oral contraceptive.
   • Advise low-carbohydrate diet and regular exercise.
   • Reassess blood sugar and hormone levels in three months; lab orders to be sent to preferred laboratory.
   • Instructed to contact office if any changes in condition or medication side effects.

Sincerely,
Dr. Jamie Lin