Question of the Week # 389

389)  A 26 year old woman is seen in the outpatient clinic for amenorrhea of about 6 months. The patient ah d been on oral contraceptives but discontinued 6 months ago. She reports having regular menstrual cycles prior to  starting oral contraceptives. She denies any excessive stress or physical activity. She does not have any breast discharge, visual deficits or headaches. presents to your office with complaints of change in her menstrual cycles. On examination, her vitals are stable. Body mass index is about 28 . Breast examination is normal with out any discharge. Pelvic exam is normal. Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  The patient is started on  medroxyprogesterone acetate at 10 mg/ day for 10 days and experiences menstrual bleeding a week after stopping progesterone. Which of the following explains her amenorrhea?

A) Past use of Oral Contraceptive Pills

B) Uterine Adhesions

C) Hypothalamic amenorrhea

D) Polycystic Ovarian Syndrome

E) Premature Ovarian Failire

7 Responses

  1. That means Progesterone challenge test is positive. Amenorrhoea is due to an-ovulation.
    Ans is A) Past use of Oral Contraceptive pills

    Uterine adhesions is incorrect because there is bleeding after progesterone challenge test.

    Hypothalamic amenorrhea and premature ovarian failure is incorrect because FSH level is within normal limit.

    PCOS is incorrect because her BMI is within normal limit and no hirsute.

  2. a, the only possibility .

  3. THIS PATIENT HAS ANOVULATION. OCP should not cause amenorrhea for SIX months after discontinuation. This must be investigated. The question clearly indicates progesterone deficiency. Where do you have progesterone deficiency?

  4. Answer DDD…..this is from emedicine:

    “Amenorrhea with normal puberty with uterus present”

    Obtain a pregnancy test. If the pregnancy test result is positive, refer the patient to the appropriate specialist. If the pregnancy test result is negative, obtain TSH, prolactin, FSH, and LH levels.

    If the TSH level is elevated, the diagnosis is hypothyroidism. If the prolactin level is elevated, the diagnosis is hyperprolactinemia. Causes include prolactinoma, CNS tumors, and medications. MRI is indicated.

    If the FSH level is low, obtain head MRI. If MRI findings are abnormal, consider hypothalamic disease, pituitary disease, or pituitary tumor. If MRI findings are normal, proceed with clinical evaluation to exclude chronic disease, anorexia nervosa, marijuana or cocaine use, and social or psychological stresses.

    If FSH is elevated, premature ovarian failure is the diagnosis. Obtain a karyotype. If the karyotype is abnormal, mosaic Turner syndrome may be present. If the karyotype is normal (46,XX), the cause is premature ovarian failure. An association with fragile X syndrome may be observed.[43] If fragile X syndrome is present, family members should be offered genetic testing.

    Consider premature ovarian failure due to the following:

    Autoimmune oophoritis
    Exposure to radiation or chemotherapy
    Resistant ovary syndrome
    Multiple endocrine neoplasm (MEN) syndrome

    If TSH, prolactin, and FSH levels are within reference range, perform a progestin challenge test. If withdrawal bleeding occurs, consider anovulation secondary to PCO syndrome. If no withdrawal bleed occurs, proceed with estradiol (E2) priming, followed by a progestin challenge.

    If the challenge does not induce menses, consider Asherman syndrome, outlet obstruction, or endometrial thinning secondary to elevated androgens (PCO syndrome) or hypothalamic amenorrhea with decreased estrogen production.

    If the challenge induces menses, a hypothalamic dysfunction with low circulating E2 is present. Acquired hypothalamic causes of amenorrhea after puberty has been achieved is a diagnosis of exclusion. The FSH and LH levels may be low or may be below the reference range. The causes include eating disorders, caloric restriction, exercise, stress, and medications.

    If hirsutism and/or acne are present, check testosterone, dehydroepiandrosterone sulfate (DHEAS), and 17-hydroxy (17-OH) progesterone level. If the testosterone and DHEAS levels are within the reference range or are moderately elevated, perform a progesterone challenge. If withdrawal bleeding occurs, the diagnosis is PCOS. If the 17-OH progesterone level is elevated, the diagnosis is adult-onset adrenal hyperplasia.

    If the testosterone level or DHEAS is 2 or more times higher than the reference range, consider PCOS, hyperthecosis, or an androgen-secreting tumor of the ovary or adrenal gland

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