zaki
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A 17-year-old girl seeks your advice about 3 months of amenorrhea. Since menarche at age 12, her menstrual periods have occasionally been regular, but she has had several episodes of amenorrhea, some lasting up to 3 months. In the past, medroxyprogesterone (10 mg/d for 5 days) had always resulted in menstrual bleeding. A similar course of this medication completed last week has so far not resulted in menstruation. Physical examination shows an adolescent female who stands 168 cm (66 in) and weighs 80 kg (176 lb). Her physical examination is also remarkable for some breast engorgement and tenderness, but no galactorrhea is seen. Pelvic examination, although limited by her weight, appears normal.
Her mother works in a clinical chemistry laboratory and is able to give you the following laboratory studies done on blood drawn 5 days ago: serum prolactin, 38.2 ng/mL; serum T4, 12.4 µg/dL; resin T3, 23.8% uptake.
What is the most appropriate first step for you to take
(A) Order magnetic resonance imaging of the pituitary with gadolinium.
(B) Prescribe bromocriptine, 2.5 mg at bedtime.
(C) Order measurement of her serum thyrotropin (TSH) level.
(D) Order measurement of her serum beta–human chorionic gonadotropin (hCG) level.
(E) Order measurement of her serum follicle-stimulating hormone (FSH) level.
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Maverick
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| alice8
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(D) Order measurement of her serum beta–human chorionic gonadotropin (hCG) level.
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Yes Order measurement of her serum beta–human chorionic gonadotropin (hCG) level as in any female with amenorrhea should have this level and in that is negative proceed further and Order measurement of her serum thyrotropin (TSH) level & Order measurement of her serum follicle-stimulating hormone (FSH) level.
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| zaki
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Answer: D
Educational Objective: Diagnose amenorrhea caused by pregnancy.
Pregnancy must be excluded in all patients presenting with amenorrhea. Although this patient’s past menstrual history suggests frequent anovulatory cycles, pregnancy is always a possibility that must be considered; measuring the patient’s serum beta–human chorionic gonadotropin (hCG) level is, therefore, the most appropriate first step. Maternal involvement in the patient’s care clearly confounds the situation. The lack of withdrawal bleeding following exposure to medroxy-progesterone is to be expected in pregnancy; because of teratogenic effects, medroxyprogesterone should not be prescribed unless the possibility of pregnancy is excluded.
The elevated prolactin level is characteristic of pregnancy and does not require further evaluation with magnetic resonance imaging or treatment with bromocriptine. The thyroid test results are characteristic of the binding protein changes that occur in pregnancy and do not require further evaluation. Once pregnancy is excluded, measuring the follicle-stimulating hormone (FSH) level would be an appropriate choice to evaluate the possibility of ovarian failure. In the face of pregnancy, however, the FSH level would be low and not helpful in the care of this patient.
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Maverick
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I think we should both the possibilities open in this patients that is Beta HCG positive but it can come negative in the face of all these investigation so in that case we should go for TSH as well and also keep the history of this patient of occasionally irregular period and weight can be due to PCO.
What are your comment on this Zaki Bahi
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| zaki
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Exclusion of pregnancy should always be the first step in evaluating amenorrhea.
if it come negative then u are right pco might be the posibility with all other dd in mind leads our way to investigation.
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Maverick
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any one apear in step 2 compare this question with real MLE question?
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