Revision on cases of reproductive endocrinology

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Revision on cases of reproductiveendocrinolog
y
DR MANAL Behery
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CASE 1

• A 23-year-old G0 P0 female presents to the office
  with complaints of irregular cycles since
  menarche.
• She has noticed an increase in facial hair and
  acne for many years.
• She denies any history of medical problems and
  has a strong family history of diabetes.

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On examination,

• (B P), pulse, respiratory rate, and temperature
  are normal
• She is obese ,her (BMI) 34.
• She have some hirsutism and acanthosis nigricans
  (of neck and inner thighs).
• Her pelvic examination is normal.
• She does not desire pregnancy,and her pregnancy
  test is negative.

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• ? What is the most likely diagnosis?
• Polycystic ovarian syndrome.
• ? What complications is the patient at risk for?
• Diabetes mellitus, endometrial cancer, and
• cardiovascular disease.
• ? What is your next diagnostic step?
• TSH, prolactin, serum testosterone, (DHEA-S),
  and, pelvic ultrasound.

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? What is your therapeutic plan for this patient?

• 1.Regulate menstrual cycles with combination oral
  contraceptives
• 2. Protect the endometrium from unopposed
  estrogen and reduce risk of endometrial cancer
• 3. Encourage weight loss and healthy lifestyle
  changes
• 4. Induce ovulation when pregnancy is desired
• 5. Monitor for the development of diabetes and
  cardiovascular disease

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A 32-year-old G0 P0 woman is noted to have
irregular menses and hirsutism

• Which of the following is consistent with
  polycystic ovarian syndrome?
• A. Elevated 17-hydroxyprogesterone level
• B. Finding of a 9-cm right ovarian mass
• C. Vaginal bleeding after a 5-day course of
  progesterone oral therapy
• D. DEXA scan showing osteopenia

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A 30 y old women present reporting difficulty in
becoming pregnant

• She always has irregular menses that regulated
  with COC pills .
• System review reveal occasional palpitations that
  she attribute to anxiety attacks.
• She has increased hair growth on face and is
  overweight, making evaluation of her adnexa
  difficult.

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In addition to pelvic ultrasound ,appropriate
lab evaluation should include all of the
following except

• A DHEAS and 17 hydroxy progesterone.
• B prolactin and TSH
• C- insulin function test
• D testosterone and androstendione
• E basic metabolic panel

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• A 29-year-old G0 P0 woman with a diagnosis of
  PCOS is being counseled about the dangers of her
  condition. In particular, about the possibility
  of developing metabolic syndrome.
• Which of the following is the most significant
  consequence of metabolic syndrome?
• A. Hyperthyroidism
• B. Cardiovascular disease
• C. Breast cancer
• D. Renal insufficiency

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• A 28-year-old G0 P0 woman has a chronic history
  of oligomenorrhea,and amenorrhea.
• She undergoes an endometrial biopsy in light of
  her long history of anovulation, which returns as
  Grade 1 adenocarcinoma of the endometrium.
• MRI imaging seems to indicate that the
  endome-trial cancer is isolated to the uterus.
• The patient desires to have children if possible.

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Which of the following is the best therapy for
this patient?

• A. Endometrial ablation
• B. Radical hysterectomy
• C. Cervical conization
• D. High-dose progestin therapy
• E. Oral contraceptive agen

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Case2

• A 16-year-old adolescent female is referred for
  never having menstruated. She is otherwise in
  good health.
• She has an older sister who experienced menarche
  at age 12 years. She denies excessive exercise or
  having an eating aversion. There is no family
  history of depression.

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On examination,

• She is 50 in tall and weighs 100 lb. The neck is
  supple and without masses.
• Her breasts appear to be Tanner stage I, and her
  pubic hair pattern is also consistent with Tanner
  stage I.
• Abdominal examination reveals no masses. The
  external genitalia are normal for a prepubescent
  female.

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Tanner Staging
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Stage1 stage2

• Prepupertal elevation of papilla- no pubic hair

• Elevation of breast and papilla on asmall
  mount,increase in areola libial hair

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Stage 3 stage4

• Further breast enlargment,
• hair extend to mons pubis

• Secondary mound of areola and papilla ,hair
  extend laterl
• And increases pigmention

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Stage5

• Recession of arola to contour of the breast
• Adult pubertal hair with striaght upper borded

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• ? What is the most likely diagnosis?
• Gonadal dysgenesis (Turner syndrome).
• ? What is the next step in diagnosis?
• Serum follicle-stimulating hormone (FSH)

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Patients with turners syndrome will most
commonly display which of the following endocrine
profiles?

• A elevated TSH ,normal FSH,normal prolactin
• B elevated FSH,normalTSH,normal prolactin
• C elevated prolactin,normal TSH,normal FSH
• D- normal FSH,normal TSH,normal Prolactin

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Which of the following statement about
amenorrhea is the most correct ?

• A -The majority of amenorrheic patients have an
  abnormal physical exam ,prolactin or TSH
• B imperforate hymen is the second most common
  cause of primary amenorrhea
• C Gondal dysgensis is the most common causec of
  primary amenorrhea
• D the term hypothalemic amenorrhea applies to
  normal GNRH secretion but elevated FSH level

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The first evidence of pubertal development in the
female is usually

•  
• a. Onset of menarche
• b. Appearance of breast buds
• c. Appearance of axillary and pubic hair
• d. Onset of growth spurt

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The events that occur in changes from a child to
adult female usually occur in the following
sequence

• 1 Growth spurt
• 2 Breast development
• 3 Pubic hair growth
• 4 Menstruation

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• A 15-year-old adolescent female is diagnosed with
  gonadal dysgenesis based on delayed puberty,
  short stature, and elevated gonadotropin levels.
  
• Which of the following is generally present?
• A. Secondary amenorrhea
• B. 69,XXY karyotype
• C. Tanner stage IV breast development
• D. Osteoporosis
• E. Polycystic ovaries

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A 15-year-old adolescent female is brought into
the pediatricians office due to no breast
development.

• The patients mother notes that both of patients
  sisters had onset of breast development at age
  10, and also all of her friends have already
  begun menstruating.
• Examination reveals Tanner stage I breast and
  pubic/axillary hair, and is otherwise unremarkable

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Which of the following is the most likely
diagnosis?

• A. Delayed puberty
• B. Development is within normal limits and should
  be observed
• C. Primary amenorrhea
• D. Likely craniopharyngioma

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• A 16-year-old adolescent female is evaluated for
  lack of pubertal development. She is diagnosed
  with gonadal dysgenesis.
• Which of the following laboratory findings is
  likely to be elevated in this patient?
• A. Follicle-stimulating hormone levels
• B. Estrogen levels
• C. Progesterone levels
• D. Prolactin levels
• E. Thyroxine levels

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• A 20-year-old individual with a 46,XY karyotype
  is noted to be sexually infantile phenotypic
  female and diagnosed as having gonadal
  dysgenesis.
• Which of the following is the most important
  treatment for this patient?
• A. Progestin therapy to reduce osteoporosis
• B. Estrogen and androgen therapy to enhance
  height
• C. Progesterone therapy to prevent endometrial
  cancer
• D. Gonadectomy
• E. Estrogen therapy to initiate breast
  development

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Case 3

• A 26-year-old G2P2 woman with LMP 6 months ago
  presents with a concern regarding no periods.
• She delivered two full term healthy children
  vaginally and their ages are 5 and 3. She stopped
  breastfeeding 2 years ago.
• She has noted a persistent breast discharge, but
  no breast masses.
• Occasional hot flashes. Fatigue. Headaches.
  Difficulty losing the pregnancy weight gain.
• She is not using any contraception

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• Surgical and family history are irrelevent
• Past medical history Postpartum depression,
  which resolved after one year on an SSRI.
• Physical exam
• VS BP 120/80, P 64, R 18, Ht 58, Wt 160
  pounds
• Breasts bilateral milky white discharge with
  expression. No masses, dimpling or retraction

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What investigation you need to do ?

• Serum pregnancy test
• FSH
• TSH
• Serum prolactin
• MRI pitutary if serum prolactin gt100 ng/ml

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• Laboratory/studies
• HCG negative
• FSH,TSH are normal
• Prolactin 130 ng/mL repeat on fasting, 100ng/mL
• MRI of the head reveals a 0.8 cm mass in the
  anterior pituitary
• What is the most likely diagnosis?
• Amenorrhea
• Galactorrhea
• Prolactinoma (Pituitary microadenoma)

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What is the best treatment option for her ?

• This patient was treated with Cabergoline (a
  dopamine agonist) on a weekly basis and the dose
  was increased until her prolactin level was in
  the normal range.
• She tolerated the medication well.
• She had return of menses within a few months
  time.
• Her galactorrhea slowly resolved.

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Case4

• A 42-year-old parous woman has noticed increasing
  hair growth on her face and abdomen over the past
  8 months.
• She denies the use of steroid medications, weight
  changes, or a family history of hirsutism.
• Her menses previously had been monthly, and now
  occur every 35 to 70 days.
• Her past medical and surgical histories are
  unremarkable

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On examination,

• thyroid is normal to palpation.
• She has excess facial hair and male pattern hair
  on her abdomen. Acne is also noted on the face.
• cardiac and pulmonary examinations are normal.
• The abdominal examination reveals no masses or
  tenderness. Examination of the external
• genitalia reveals possible clitoromegaly.
• Pelvic examination shows a normal uterus and
  cervix and an 8-cm, right adnexal mass.

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• ? What is the most likely diagnosis?
• An ovarian tumor, probable SertoliLeydig cell
• ? What is the probable management?
• Ovarian cancer (surgical) staging.

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Ferriman galawey score
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• A 6-year-old girl is noted to have breast
  development and vaginal spotting. No abnormal
  hair growth is noted.
• A 10-cm ovarian mass is palpated on rectal
  examination.
• Which of the following is the most likely
  diagnosis?
• A. Benign cystic tumor (dermoid)
• B. Idiopathic precocious puberty
• C. SertoliLeydig cell tumor
• D. Congenital adrenal hyperplasia
• E. Granulosa-theca cell tumor

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• A 15-year-old G0 P0 complains of
• increasing hair over her face and chest.
• She also has a deepening voice and clitoromegaly.
  
• There have been two neonatal deaths in the
  family.
• Which of the following is the best diagnostic
  test for the likely diagnosis?
• A. Testosterone level
• B. Dexamethasone suppression test
• C. 17-hydroxyprogesterone level
• D. LH and FSH levels
• E. Karyotype

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Adrenal gland zone and hormons
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Congenital Adrenal Hyperplasia
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• A 22-year-old nulliparous woman with irregular
  menses of 7 yearsduration complains of primary
  infertility. She has a family history ofdiabetes.
  And mild hirsutism on examination.
• Which of the following is the most likely
  therapy?
• A. Cortisol and mineralocorticoid replacement
• B. Excision of an adrenal tumor
• C. Surgical excision of an ovarian tumor
• D. Oral clomiphene citrate
• E. Intrauterine insemination

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• A 24-year-old woman complains of bothersome
  hirsutism and skipping periods.
• She does not have evidence of voice changes,
  hair loss, or cli-toromegaly.
• The pelvic examination does not reveal adnexal
  masses.
• The serum DHEA-S, testosterone,
• and 17-hydroxyprogesterone
• Levels are normal.
• The LH to FSH ratio is 21.

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Which of the following is themost likely
diagnosis?

• A. Polycystic ovarian syndrome
• B. Familial hirsutism
• C. Ovarian tumor
• D. Adrenal tumor
• E. Cushing syndrome

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Case 5

• A 46 y old women comes to your office worried
  about her decreased sexual desire and
  perimenopausal symptoms.
• Her medical and surgical history are significant
  only for Rt salpingo oophrectomy 10 years ago.
• On examination you feel Lt adnexal fullness ,and
  pelvic sonogram show 8 cm cyst.
• After discussion of potential removal of the
  ovary , sho worried that this will leave her
  without testosterone

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You tell her that

• A nearly all testosterone production is from her
  remaning ovary and her concern are justified
• B one fourth of her testostrone production is
  from her ovary ,one fourth from her adrenals,and
  the remaning half from prepheral conversion
• C testosterone production is not linked to the
  womans ovary
• D given that she is perimenopausal ,she likely
  has testosterone circulating any way

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The patient asks you if she is going through
menopause which of the following statement is is
the SINGLE best answer?

• A the patient past menstrual history is not
  important in reaching diagnosis .
• B serum FSHgt50 IU/ML is diagnostic of menopause
• C- serum estradiol level lt0.11 mmol /L indicate
  ovarian failure
• D Teastosterone level lt60 decline is the best
  predictor of menopause

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• 50 years old healthy women present to the office
  for routine gynecologic visit complaining of new
  onset episodes of intense heat through her neck
  and chest followed by profuse sweating.
• This episodes interfere wake her up from sleep
  and interfere with her ability to work

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What is the most effect therapy for her symptoms

• A Venlafxine(sertonine reuptake inhibitors)
• B Clonidine
• C Estrogen replacement
• D- progesterone

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• Cause of hot flushes
• Caused by noradrenalin, which disturbs the
  thermoregulatory system.
• Oestrogen deficiency reduces hypothalamic
  endorphins, which release more norepinephrine and
  serotonin.
• This leads to inappropriate heat loss mechanism.

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A 58 years old ,healthy G0P0 comes to your office
complaning about her vaginal bleeding

• She reports hot flushes and mood swings starting
  about 10 years age.
• She stopped bleeding a few years ago and then
  started having irregular peroids 6 months ago
• The most likely diagnosis is
• A endometrial polyp
• B endometrial hyperplasia
• C- endometrial cancer
• D endometrial atrophy

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• 57 years old Aferican Aamerican woman has been 7
  years ago.
• She denies any medical problems but had fracture
  hip 2 years ago .
• On exam she is 5 feet,5 inches tall,and 165
  pounds weight
• PV slightly atrophic vaginal mucosa and
  otherwise normal exam

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You give this patient referal for DEXA because of
her

• A- race
• B postmenopausal state combined with physical
  exam finding
• C history of a fracture
• D height and weight

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Case 7
Case 6 7

• A 58 year old women .menopause 6 7 years
  ago.
• 2 months ago she had a few days of vaginal
  bleeding which was like the end of period and
  since then she has continued to spot most days.
• She has no pain or any associated symptoms.
• She has never been on hormone replacement therapy
  (HRT).

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What are the most likely causes of her
bleeding?

• Endometrial cancer
• Atrophic vaginitis
• Local cervical lesion
• Cervical cancer
• Iatrogenic
• Chlamydia i n f e c t i o n

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What further questions would help to
establish the diagnosis?

• A -woman ' s last normal menstrual period.
• B -amount and duration of bleedingand any
  associated symptoms.
• C -Try to clarify the site of bleeding to con?rm
  that it is vaginal and not rectal or urinary
• D -Drug like tamoxifen or HRT
• E -all of the above

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On examination

• Her vulva is normal and she has mild atrophic
  changes of her vagina and her cervix.
• She has some laxity of the vaginal walls but no
  signi? ant prolapse.
• She has a small anteverted mobile uterus.
• You are unable to feel any adnexal masses

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What further investigations must you now
consider?

• Transvaginal ultrasound scanning
• Report of TV US results The uterus contains a
  regular thickening measuring 8 mm thickness.
• (This could represent a polyp).
• Neither ovary can be identi?ed and there are no
  adnexal masses or free ?uid.

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What do you do next?

• As her endometrial thickness is gt 4 mm, she
  requires further investigation.
• 1- Saline sonohystrography
• better delination of cavity
• 2- Endometrial biopsy.
• However If the scan ?nding
• represents a polyp, it is unlikely to
• be removed by EB.

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3- Hysteroscopy.

• Allows direct inspection of the endometrium.
• It is a sensitive means of identifying polyps
  and submucous fibroid .
• It can be used in the outpatient setting using
  a paracervical block for anaesthetic

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Patient agrees to have an outpatient hysteroscopy
with a paracervical block.

• At hysteroscopy
• the cervical canal is normal,
• the uterine cavity is smooth and
• regular with a fundal polyp.
• Both uterine coruna are seen.
• The polyp is removed using biopsy forceps and
  sent for histology
• The pathology report con?rms a simple endometrial
  polyp with no evidence of hyperplasia or
  malignancy.

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Is any further management required?

• Pt does not require any further treatment.
• Polyp formation after the menopause can be
  related to tamoxifen or oestrogens.
• As she is not on HRT this may be related to
  obesity because of peripheral conversion of
  androgens (androstenidione) in subcutaneous fat
  to oestrogens.
• Polyps may recur but there is no need for follow
  up .

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Imaging of 38 ys old G2p2,with post menstrual
spotting ,Is best performed by which of the
following?

• A TVS alone,because this is abettor
• diagnostic tool in perimenopausal women
• B saline infusion sonography as it is the most
  senstive non invasive to diagnose polyp.
• C CT scan of the pelvis due to its ability to
  diagnose rtiologies
• D hematology consult ,giving your high suspecion
  of coagulopathy

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A 43 ys old G1P1 with morbid obesity
,hypertension ,and COPD comes to office
complaning of heavy vaginal bleeding

• Work up reveals normal lab work, ultrasound, and
  Endometrial biopsy.The patient desires the safest
  long term management of her bleeding.The best
  option is
• A OCP taper and then long term OCP use
• B NSAID because they reduce menstrual volume by
  80-90
• C -Admission to hospital for hystrectomy
• D discussion and placement of Mirna IUD

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