drshvetasm wrote:
i'm not sure but i think it should be C..the first thing you would do in such a case as far as management goes is make the patient bleed by giving progesterone therapy...and then withdrawal folowed by bleeding. if the patient does bleed which would happen in most cases, it would tell u that the estrogen was normal and made the endometrium grow. D would be incorrect according to me because ovulation status wouldnt give you that much information...coz women have anovulatory cycles sometimes but they still bleed...so it doesnt matter whether she is ovulating or not in this case...its purely as to y she isnt bleeding. Whats the answer?
btw is this from uw step 3 or ck?? i guess the individual subject forums are common to ck and step 3...
Thanks for the explanation... You are right the answer is C... BUT I still don't understand why its NOT D. I'm a little confused here...
Well, as I know for Secondary Amenorrhea the work up starts with:
1. Pregnancy test, 2. TSH level, 3. Prolactin level. (all these 3 were already done in the questinon stem)...
SO next step is 4. Progesterone Challenge test -PCT (as you said)
-We give a single dose of IM progesterone or 7 days oral MPA and look for withdrawal bleeding. A POSITIVE PCT (withdrawal bleeding) is indicative of ANOVULATION (this is why I thought the answer was ovulation status)...
And a negative PCT is indicative or inadequate Estrogen.
Can someone please clear this up for me?
Thanks. 
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| drshvetasm
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Hi DrVirgo, thanks for bringing this to my attention with the pm. and thanks Ivonne.I'll try to answer this as best as I can...Y its not D is because you have this patient who is not bleeding and After having a normal pregnancy test, TSH and prolactin..this is how I would think about this problem
the reason behind order in which we send these tests is because u r going from up to down on the hypothalamo-pituitary axis...of course as everyone knows preg test is the first thing...then after that is negative...TSH and prolactin are the ones which act on the hypothalamo-pituitary level. after they r normal, we need to go lower down on to the ovaries to see if the progesterone (which is the hormone responsible for bleeding by its disappearance towards the end of the secretory phase) is being released (and withdrawn)normally or not. so now what we would do next is that we would give progesterone to see if the woman is lacking that and otherwise her endometrium is ok.we help her bleed with it and the problem is solved....if she doesnt even bleed with the progesterone(major hormone of post ovulatory and secretory phase) then we gotta think if her endometrium is even going thru the 4 menstrual cycle phases at all as it should....for the growth of which it needs estrogen (major hormone of proliferative phase)...so thats the hormone we last check for....so this is the line of thinking that one should develop. Negative PCT means that there was no endometrium there to shed! which could point to missing estrogen in the body or something like Ashermann's or menopause (premature/timely)
now coming to your specific question about the option D and y its not ovulation is because as i said before in my earlier post...a woman bleeds/ could bleed whether or not her cycle is ovulatory/anovulatory...like woman have anovulatory cycles in their teens and perimenopausal time but they still do bleed and many women with PCOD have anovulatory bleeds all the time...so u might find a woman who bleeds ok with an incidental finding of anovulation...so knowing about ovulation ,which may be added information that you gain from the PCT,doesnt tell u anything specific about y she isnt bleeding. and anovulation may be ONE of the causes of postive PCT...by postive i mean that she bleeds after we give her exogenous progesterone.
and this case is one of those where a trial of treatment works as a diagnostic test...like a trial of progesterone here tells us what the problem or what level of the axis the problem could be....another example is with acid peptic disease...many doctors go ahead with a trial of PPI rather than Hpylori/endoscopy to determine and treat it.
i have a very bad complicated way of explaining things and concepts...i hope i havent confused you more than you were before!! I would be happy to provide more explanation if needed of any specific part of my post.
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| inkspot
Forum Guru
Topics: 26
Posts: 559
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also remember sustained release of estrogen for 50hrs around 13-14th day causes the LH surge and results in ovolution. so no estrogen no ovolution. first check whether the uterus is primed or not.
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