History Taking · Intermediate · O&G

Irregular Periods with Acne and Facial Hair

Practise this PLAB 2 history taking station on Polycystic Ovary Syndrome. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Miss Sandra Bond, a 23-year-old woman, has come in with a complaint of irregular periods, persistent acne despite treatment, and excessive facial hair. Please take a focused history to explore these symptoms and discuss the possible diagnosis of polycystic ovary syndrome.

Background notes: PMH: Menarche age 13, Regular periods until age 19, Now oligomenorrhoeic (6-8 weekly cycles, sometimes 8-12 weeks)

What this station tests

  • Rotterdam criteria: 2 of 3 (oligo/anovulation, hyperandrogenism, polycystic ovaries on USS)
  • Excluding other causes of androgen excess: thyroid, CAH, Cushing's, androgen-secreting tumour
  • Endometrial protection: unopposed oestrogen from anovulation increases endometrial cancer risk, OCP protects
  • Fertility reassurance: PCOS is the commonest cause of anovulatory infertility but most conceive with treatment
  • Metabolic risk: insulin resistance, T2DM screening, cardiovascular risk assessment

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Irregular periods with acne and hirsutism in a young woman is PCOS until proven otherwise. The candidate must apply the Rotterdam criteria, address the fertility concern (even if she is not currently trying), and provide practical management. Miss Bond is 23, with irregular periods since age 19, persistent acne, and facial hair growth. Open with: 'Miss Bond, tell me about the period changes and the other symptoms you have noticed.'

Core approach

Apply Rotterdam criteria (2 of 3 needed). Oligo/anovulation: her periods are 6 to 12 weeks apart since age 19 (oligomenorrhoea, confirmed). Hyperandrogenism: clinical (acne, hirsutism, possible alopecia) or biochemical (raised testosterone). She has acne and facial hair growth (clinical hyperandrogenism, confirmed). Polycystic ovaries on USS: >12 follicles per ovary or ovarian volume >10mL (may or may not be present). She meets 2 of 3 criteria clinically.

Exclude other causes of androgen excess. Thyroid dysfunction (check TFTs). Congenital adrenal hyperplasia (17-hydroxyprogesterone). Cushing's syndrome (if clinical features present). Androgen-secreting tumour (if rapid virilisation). Prolactinoma (if galactorrhoea or visual field defects).

She is not trying to conceive now (focused on career), but the fertility question looms. Address it proactively: PCOS is the commonest cause of anovulatory infertility, but most women with PCOS do conceive with appropriate treatment when they are ready.

Assess metabolic risk. PCOS is associated with insulin resistance, type 2 diabetes, and cardiovascular risk. Check BMI, glucose tolerance, lipids.

Closing and safety netting

Management depends on her priorities. For irregular periods: combined oral contraceptive pill regulates cycles and provides endometrial protection (unopposed oestrogen from anovulation increases endometrial cancer risk). For acne: co-cyprindiol (Dianette) combines OCP with anti-androgen. For hirsutism: topical eflornithine, physical methods (laser, electrolysis), or spironolactone (off-label, requires contraception as teratogenic). Lifestyle: weight loss (even 5 to 10% in overweight patients significantly improves ovulation and symptoms).

Address her concerns. Fertility: 'PCOS does not mean you cannot have children. Most women conceive with help when they are ready.' Acne and hirsutism: 'These are treatable.' The name 'polycystic ovary syndrome' is misleading: the 'cysts' are actually small follicles, not true cysts. Safety net: 'If your periods stop completely for more than 3 months, come back as we need to protect the lining of your womb.' Investigations: bloods (testosterone, SHBG, LH, FSH, TFTs, prolactin, glucose), pelvic USS.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for polycystic ovary syndrome. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1 (Primary focus)

Scores well: Rotterdam criteria applied. Differential causes excluded (thyroid, CAH). Metabolic risk assessed. Menstrual history detailed. Hirsutism and acne documented.

Costs marks: Not applying Rotterdam. Not excluding differentials. Not assessing metabolic risk.

Domain 2 (Primary focus)

Scores well: OCP for cycle regulation and endometrial protection. Anti-androgen options. Weight management. Investigations planned. Fertility discussed proactively.

Costs marks: No endometrial protection. No metabolic screening. Not addressing fertility.

Domain 3 (Throughout)

Scores well: Addressing all three symptom concerns (periods, acne, hair). Fertility reassurance. Explaining the misleading name. Empowering with treatment options.

Costs marks: Only addressing one symptom. Not reassuring about fertility. Not explaining the diagnosis.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not excluding other causes of androgen excess: PCOS is a diagnosis of exclusion for hyperandrogenism
  2. Not mentioning endometrial cancer risk: prolonged amenorrhoea without progesterone withdrawal risks endometrial hyperplasia
  3. Not addressing fertility proactively: even if she is not trying now, she will be worrying about it

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take a polycystic ovary syndrome history in PLAB 2?

Irregular periods with acne and hirsutism in a young woman is PCOS until proven otherwise. The candidate must apply the Rotterdam criteria, address the fertility concern (even if she is not currently trying), and provide practical management. Miss Bond is 23, with irregular periods since age 19, persistent acne, and facial hair growth.

Where are marks won and lost in this polycystic ovary syndrome station?

Examiners reward: Rotterdam criteria applied. Differential causes excluded (thyroid, CAH). Metabolic risk assessed. Menstrual history detailed. Hirsutism and acne documented. Candidates are penalised for: Not applying Rotterdam. Not excluding differentials. Not assessing metabolic risk.

Where do candidates most often go wrong in this station?

Not excluding other causes of androgen excess: PCOS is a diagnosis of exclusion for hyperandrogenism.

Can I do well in this station without real-world experience of polycystic ovary syndrome?

This station rewards process over personal experience. The skill being assessed: Excluding other causes of androgen excess: thyroid, CAH, Cushing's, androgen-secreting tumour. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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