zaki
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A 22-year-old nulligravid woman who takes oral contraceptives comes to your office because she did not have any withdrawal bleeding during her last pill-free week. She has a history of regular menses and has been taking ethinyl estradiol, 35 µg, and norethindrone, 1 mg (Ortho-Novum 1/35, Norinyl 1/35) for almost 1 year, without any problems. A serum pregnancy test is negative 2 weeks after the missed menses, and the patient insists that she takes her pills faithfully as prescribed. She is otherwise healthy and taking no other medications.
What would you do now?
(A) Perform laboratory evaluation of thyroid function and prolactin and follicle-stimulating hormone (FSH) concentrations.
(B) Advise her to stop oral contraceptive use if she plans to conceive in the future because the risk of post-pill amenorrhea is increased.
(C) Repeat the pregnancy test because the first test may have been done too early to detect a pregnancy.
(D) Continue to prescribe the same oral contraceptive formulation.
(E) Perform an ultrasonography to rule out a uterine abnormality.
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Maverick
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| alice8
Forum Guru
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(D) Continue to prescribe the same oral contraceptive formulation. :?:
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Dream on 'til your dream comes true.
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| helpful
Forum Junior
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D is the best option
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| destiny
Forum Senior
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A??
it may be hypothalmic pitutary insensitivity (hypothalmic amenorrhea) as many of these cases co incidentally follow the use of OCP
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| zaki
Forum Guru
Topics: 92
Posts: 398
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Answer: D
Educational Objective: Properly manage amenorrhea in a patient using combination oral contraceptive agents.
The development of amenorrhea while using combination oral contraceptive agents is a relatively frequent occurrence. The amenorrhea that women experience while taking combination pills is secondary to inadequate estrogenic stimulation of the endometrium or to endometrial atrophy caused by the progestational component. In this patient ingesting 35 µg of ethinyl estradiol as part of a “low-dose” pill, it is likely to be secondary to endometrial atrophy.
Because of the greater safety of oral contraceptives containing less than 50 µg of estrogen, women should be started on a 35-µg oral contraceptive and, if possible, maintained on such a “low-dose” preparation. If this patient is willing to accept being amenorrheic and does not fail to take her pills, there is no risk in her continuing oral contraceptive use in the normal fashion. The amenorrhea will not adversely affect her health. If she cannot be reassured and wants to have menses, switching to a preparation containing less progestogen (such as Brevicon or Modicon, which contains 0.5 mg of norethindrone, or to Ovcon 35, which contains 0.4 mg of norethindrone) may be effective. Alternatively, the amount of estrogen can be increased by switching to a preparation containing 50 µg of ethinyl estradiol (a so-called “moderate-dose” pill) for three cycles. One might also provide additional estrogen in the form of micronized 17b-estradiol (Estrace, 1 mg), conjugated equine estrogen (Premarin, 0.625 mg), or ethinyl estradiol (Estinyl, 20 µg) daily for the 21 days while taking the oral contraceptive for one to three cycles. Increasing the estrogen amount should rejuvenate the endometrium so that withdrawal bleeding will resume.
Other causes of amenorrhea, including hypothyroidism, ovarian failure, various forms of hypothalamic amenorrhea, and hyperprolactinemia, are masked by the use of oral contraceptives. Development of amenorrhea while using these pills is not an indication for endocrine testing.
Similarly, there is no evidence that oral contraceptives will lead to so-called post-pill amenorrhea after cessation of use. Women typically resume ovulating within 3 months of discontinuing oral contraceptive use, and 95% to 98% of women begin ovulating within 1 year. It is true that women who had amenorrhea or irregular menses before using oral contraceptive preparations may well return to their former pattern. Other women may develop medical problems while using oral contraceptives that result in amenorrhea only when the pills are discontinued. Women with chronic anovulation can use oral contraceptives, including those women with hypothalamic amenorrhea and polycystic ovarian syndrome. However, these patients should be aware that their anovulation will likely continue after they stop using oral contraceptives.
Because this patient’s serum pregnancy test is negative and she takes her pills faithfully, she is not pregnant. Commercially available tests for serum human chorionic gonadotropin (hCG) are sufficiently sensitive to detect a pregnancy before a missed menstrual period. By the time of a missed menses, serum hCG levels should be in excess of 100 mIU/mL.
It is unlikely that any uterine abnormality is the cause of the patient’s amenorrhea. The only abnormality likely to result in amenorrhea in a person with previously regular menses is Asherman syndrome, or intrauterine synechiae. It usually occurs only after an operative procedure, such as dilation and curettage, involving a gravid uterus. It does not occur spontaneously in this setting and has not been associated with amenorrhea related to oral contraceptive use. Thus, ultrasonography is not warranted in this patient.
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Maverick
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