Endocrinology
A 54-year-old man is evaluated for increasing fatigue and loss of libido. He
reports no headache, diplopia, visual loss, rhinorrhea, or changes in thirst,
urination, or weight. The patient underwent transsphenoidal surgery 6 years
ago to remove a nonfunctioning pituitary adenoma; results of postoperative
pituitary testing were normal. He had stereotactic irradiation to treat the
residual tumor 3 months after surgery. He has no pertinent family history and
takes no medications. An MRI performed 18 months ago showed no growth
of the residual pituitary tumor.
Physical examination reveals a pale man. Blood pressure is 106/70 mm Hg,
pulse rate is 60/min, respiration rate is 14/min, and BMI is 27.4. Other
findings are unremarkable.
100%
Results of routine hematologic and serum chemistry studies are normal,
except for a hemoglobin level of 11.8 g/dL (118 g/L).
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
Diabetes insipidus
Hydrocephalus
Hypopituitarism
Regrowth of the adenoma
0%
1
2
0%
3
0%
4
Hypopituitarism
Genetic defects
•
Hypothalamic hormone gene defects
•
Hypothalamic hormone receptor gene defects
•
Pituitary hormone gene defects
•
Pituitary hormone receptor gene defects
•
Transcription factor gene defects (affecting multiple pituitary hormones)
Embryopathies
•
Anencephaly
•
Midline cleft defects
•
Pituitary aplasia
•
Kallmann syndrome (anosmin gene defect)
Acquired defects
•
Tumors (pituitary adenomas, craniopharyngiomas, dysgerminomas, meningiomas, gliomas, metastatic
tumors, Rathke cleft cysts)
•
Irradiation
•
Trauma (neurosurgery, external blunt trauma)
•
Infiltrative disease (sarcoidosis, Langerhans cell histiocytosis, tuberculosis)
•
Empty sella syndrome
•
Vascular (apoplexy, Sheehan syndrome, subarachnoid hemorrhage)
•
Lymphocytic hypophysitis
•
Metabolic causes (hemochromatosis, critical illness, malnutrition, anorexia nervosa, psychosocial
deprivation)
•
Idiopathic causes
Hormone
Treatment
TSH
Levothyroxine, 50-200 mg/d; adjust by measuring free T4 levels.
ACTH
Hydrocortisone, 10-20 mg in AM and 5-10 mg in PM, or prednisone, 2.55.0 mg in AM and 2.5 mg in PM; adjust clinically. Stress dosage,
hydrocortisone, 50-75 mg IV every 8 hours.
LH/FSH
Men
Testosterone: 1% gel, 1-2 packets (5-10 g) daily; transdermal patch, 5 g
daily; or testosterone enanthate or cypionate, 100-300 mg IM every 1-3
weeks. Adjust by measuring testosterone levels. May need injectable
gonadotropins (LH, FSH) or GnRH (if a primary hypothalamic lesion) for
spermatogenesis.
Women
Cyclic conjugated estrogens (0.3-0.625 mg) and medroxyprogesterone
acetate (5-10 mg) or low-dose oral contraceptive pills. Estrogen patches
also available. May need injectable gonadotropins (LH, FSH) for ovulation
or in vitro fertilization techniques.
GH
Adults start at 200-300 µg subcutaneously daily and increment by 200
µg at monthly intervals. Adjust to maintain IGF-1 levels in the
midnormal range. Women receiving oral estrogens require higher doses.
Vasopressin
Desmopressin: metered nasal spray, 10-20 µg once or twice daily; or
tablets, 0.1-0.4 mg every 8-12 h; or injected, 1-2 µg SC or IV, every 6-12
h.
Pituitary Tumors
• Micro < 10mm
• Macroadenomas > 10mm
• Goals of therapy
– reduce tumor mass
– Prevent tumor recurrence
– Correct any hormone oversecretion witout damaging
normal pituitary
• All surgery is primary mode of therapy EXCEPT
prolactinoma
• Radiation is adjunctive therapy for residual tumor
and or continued hormone hypersecretion
A 34-year-old man is evaluated for a 1-year history of impotence. He reports mild
fatigue but no headaches or visual symptoms. Personal and family medical histories
are noncontributory. He takes no medications.
Physical examination reveals an obese man. Blood pressure in 132/80 mm Hg, pulse
rate is 80/min, respiration rate is 16/min, and BMI is 32.3. He has normal secondary
sexual characteristics.
Labs:
Prolactin: 11,420, Testosterone: 134, TSH: 0.6, Thyroxine Free: 0.52, Cortisol: 4.3.
An MRI shows a 3.2 x 1.7 x2.8cm macroadenoma invading the cavernous sinus and
wrapping around the right carotid artery. Results of visual field testing are normal.
50%
50%
In addition to treating the hypopituitarism, which of the following is the most
appropriate initial therapy for this patient?
1.
2.
3.
4.
5.
Cabergoline
Pituitary Surgery via a craniotomy
Radiation therapy
Somatostatin analogue
Transsphenoidal surgery
0%
1
2
3
0%
0%
4
5
Prolactinoma/Hyperprolactinemia
•
•
•
Most common type of pituitary
adenoma
hyperprolactinemia caused by drugs
and other non-prolactinoma causes
level is usually < 150ng/mL
Drugs that block dopamine release or
action will often cause increased
prolactin:
– Antipsychotics
– Verapamil
– Metoclopramide
•
•
•
Dopamine can also be decreased by
compression of the hypothalams or
pituitary stalk
Pregnancy causes hyperprolactinemia
by estrogen causing lactotroph
hyperplasia
Idiopathic hyperprolactinemia
Hyperprolactinemia
• Symptoms: galactorrhea, oligomenorrhea,
amenorrhea in women, ED in men, in both sexes:
decrease libido, infertility, and osteopenia
• Treatment: dopamine agonist (Carbegoline or
Bromocriptine), in idopathic hyperprolactinemia
you can try OCPs in women not interested in
being fertile.
• Dopamine agonists can decrease size of tumor by
50% so ok to use in patients with visual
symptoms
Acromegaly and GH excess
• Occurs before epiphyseal closure gigantism
• After epiphyseal closureacromegaly
• Prognathism, enlargement of nose, lips, and tongue, frotnal bossing, malocclusion, sleep apnea,
enlargemtn of hands and feet, arthritis, carpal tunnel
• 2-3 fold increase in mortality because of CV and CVA
• IGF1 levels
• Tx: surgery, adjunctive radiation or medical therapy
Cushing Disease and ACTH excess: discuss in adrenal disorders
Gonadotropin-Producing adenomas and nonfunctionign adenomas
• Both present with local mass effects
• Treatment is surgery
Incidentalomas
• Screen for hormone overproduction (prolactin, IgF 1, overnight dexamethasone suppresion test
• Treatment indicated for hormone over or underproduction or visual fielf defects
• Periodic monitoring is appropriate if no symtpoms and normal hormones
TSH excess
• Rare
• Somatostatin analogues are effective as adjunctive treatment of patients with TSH secreting
adenomas
Disorders of the Thyroid
• Free T4 and T 3 are
active
• Thyroid produces
mostly T4 and most
T3 comes from
peripheral conversion
• Inactive bound to
albumin, prealbumin,
or TBG
A 26-year-old woman is evaluated for a 5-day history of constipation, fatigue,
and weight gain. Two months ago, she began experiencing nervousness, heat
intolerance, and weight loss but says these symptoms abated after 6 weeks.
The patient delivered a healthy infant 14 weeks ago. After thyroid function
tests performed 8 weeks postpartum revealed a thyroid-stimulating hormone
(TSH) level of 0.02 µU/mL (0.02 mU/L) and a free thyroxine (T4) level of 3.5
ng/dL (45.2 pmol/L), she was placed on atenolol, 25 mg/d.
On physical examination, blood pressure is 115/70 mm Hg, pulse rate is
50/min, respiration rate is 14/min, and BMI is 23.3. No proptosis or
inflammatory changes are noted on ocular examination. Examination of the
neck reveals no tenderness or bruits; the thyroid gland cannot be palpated.
Which of the following is the best next step in management?
1.
2.
3.
4.
Methimazole
Repeat measurement of TSH and free T 4 levels
Thyroid scan and 24 hour radioactive iodine uptake test
Thyroid ultrasound
Thyrotoxicosis
Acute
Subacute
Postpartum
Silent
Hashimoto
Drug-induced
Traumatic
Riedel
• Encompasses all forms of
thyroid hormone excess
• Where as hyperthyroidism
refers to thyroid gland
over activity
Graves Disease
Toxic MNG
Toxic Adenoma
TSH secreting
Thyroid Hormone
Resistance
Exogenous T4/T3
Iodine Load
Hyperthyroidism
Other
TSH Mediated
Thyroiditis
Graves
Toxic
Adenoma/
MNG
Subactue
thyroiditis
Thyrotoxic
Phase
Postpartum
Thyroiditis
Exogenous
T4
Exogenous
T3
TSH
TSHsecreting
pituitary
Tumor
Nml/
FT4
Nml/
Nml/
Nml/
Nml/
Nml/
Nml/
Nml/
FT3
Nml/
Nml/
Nml/
Nml/
Nml/
TPO Ab
+/-
+/-
+/-
+/-
-
-
-
TG Ab
+/-
+/-
+/-
+/-
-
-
-
TSI
+
-
-
-
-
-
-
TB II
+
-
-
-
-
-
-
Nml/
Nml/
<5%
<5%
<5%
<5%
Nml/
Nml/
TG
RAIU
An 18-year-old woman is evaluated for tachycardia, nervousness, decreased
exercise tolerance, and weight loss of 6 months’ duration. She has otherwise
been healthy. Her sister has Graves disease. She takes no medications.
On physical examination, blood pressure is 128/78 mm Hg, pulse rate is
124/min, respiration rate is 16/min, and BMI is 19.5. There is no proptosis. An
examination of the neck reveals a smooth thyroid gland that is greater than
1.5 times the normal size. Cardiac examination reveals regular tachycardia
with a grade 2/6 early systolic murmur at the base. Her lungs are clear to
auscultation.
Labs:
HCG: negative, TSH: <0.01, Free T4: 5.5, Free T3: 9.1
Which of the following is the most appropriate treatment regiment at this
time?
1.
2.
3.
4.
Atenolol
Methimazole
Atenolol and Methimazole
Radioactive iodine and methimazole
Graves Disease
• Autoimmune process with production
of antibodies against TSH receptor
• Treatment:
– Antithyroid Drugs
• PTU
• Methimazole
• Side effects: hepatotoxicity,
agranulocytosis
• Use PTU first line only in pregnancy
– Radioactive iodoine (131-I)
• Usually hypothyroid after administration
– Thyroid Surgery
• Reserved for concurrent nodules,
goiters or opthalmopathy in whom
radiactive iodine has aggraved
Toxic Multinodular
Goiter and Toxic
Adneoma
• TMG: thyroid scan reveals
patchy uptake of
radioactive iodine
• Adenoma: thyroid scan
reveals “hot” nodule
• Treatment: 131I
Destructive
Thyroiditis
Drug Induced
Thyrotoxicosis
Subclinical
Hyperthyroid
• Subacute, silent,
postpartum
• Transient destruction of
thyroid tissue
• Lithium, interferon alpha,
IL2, amiodarone, Iodine
loads
• Twp types with
amiodarne: type 1 (iodine
induced) type 2
(destructive)
• Treat when TSH < 0.1 or
symptoms
• Start with antithyroid
medications
Hashimoto
Thyroiditis
Subclinical
SAT
Hypothyroid Recovery
ism
Phase
Postpartum Central
Thyroiditis
Hypothyroid
Hypothyroid ism
Phase
TSH
Nml/
FT4
Nml/
Nml
Nml/
Nml/
Nml/
FT3
Nml/
Nml
Nml/
Nml/
Nml/
TPO Ab+
+
+/-
-
+
-
TG Ab +/-
+/-
+/-
+/-
+/-
-
A 23-year-old woman comes to the office for follow-up. The patient has a 5year history of hypothyroidism and has been on a stable dose of
levothyroxine for the past 3 years. She is now 6 weeks pregnant with her first
child.
Physical examination findings are noncontributory.
Results of laboratory studies 1 month ago showed a serum thyroidstimulating hormone (TSH) level of 2.9 µU/mL (2.9 mU/L) and a free thyroxine
level of 1.4 ng/dL (18.1 pmol/L).
Which of the following is the most appropriate management?
50%
1.
2.
3.
4.
50%
Add iodine therapy
Measure her free triiodothyronine (T3) level
Recheck her serum TSH level
Continue current managment
0%
0%
Hypothyroidism
• Hashimoto thyroiditis most frequent cause
• Iatrogenic second most frequent (post radiation,
post radioactive iodide, post surgical)
• Treat with levothyroxine therapy
– Always take on empty stomach, 1 hour before or 2-3
hours after intake of food
– Goal TSH of 1-2.5
• Subclinical Hypothyroidism: don’t treat unless
TSH > 10
A 35-year-old woman comes to the office for her annual physical
examination. The patient says she feel well. She has no pertinent personal or
family medical history and takes no medications.
On physical examination, vital signs are normal. Palpation of the thyroid gland
suggests the presence of a nodule. All other findings of the general physical
examination are normal.
Laboratory studies show a thyroid-stimulating hormone level of 1.3 µU/mL
(1.3 mU/L) and a free thyroxine (T4) level of 1.3 ng/dL (16.8 pmol/L).
An ultrasound of the thyroid gland reveals a normal-sized gland with a 2-cm
hypoechoic right midpole nodule.
Which of the following is the most appropriate next step in management?
1.
2.
3.
4.
5.
Fine needle aspiration biopsy of the nodule
Measurement of anti-thyroperoxidase and anti-thyroglobulin antibody titers
Neck CT with contrast
Thyroid scan with technetium
Trial of levothyroxine therapy
Structural Thyroid Disease
•
•
•
•
Factors associated with
increased cancer risk: <20,
or >60, male, history of H/N
irradiation, family history of
thyroid cancer, rapid
nodule growth, hoarseness,
hard nodule, local
lymphadenopathy, fixation
to adjacent tissue and vocal
cord paralysis
Don’t need to measure
antibodies
Ultrasound characteristics:
> 3 cm, speckled
calcification, high
intravascular flow
Biopsy all nodules > 1cm or
with worrisome US feaures
A 55-year-old woman is evaluated for new-onset fever, productive cough, palpitations,
and hyperdefecation. The patient has Graves disease treated with methimazole. She
has been nonadherent to her medication regimen, not having refilled her
methimazole prescription 6 weeks ago.
On physical examination, temperature is 39.4 °C (102.9 °F), blood pressure is 140/85
mm Hg, pulse rate is 138/min, and respiration rate is 16/min. Examination of the neck
reveals a smoothly symmetrical thyroid gland that is three time its normal size.
Auscultation of the lungs reveals crackles in the left lower lobe. Cardiac examination
shows tachycardia and a regular rhythm.
Labs:
WBC: 14,300, ALT: 100, AST: 75, Alk Phos: 135, TSH: <0.1, Free T4: 4.4, Free T3: 7.8
A chest radiograph shows a left lower lobe infiltrate. Electrocardiography reveals sinus
tachycardia.
Ceftriaxone and azithromycin are begun.
Which of the following is the most appropriate next step in management?
1.
2.
3.
4.
Atenolol
Propanolol, prophylthiouracil, and hydrocortisone
Thyroid ablation with radioactive iodine
Thyroid scan with a radioactive iodine uptake test
Thyroid Storm
Thyroid Storm
Medication
Comment
Cardiovascular
(tachycardia, Afib, CHF)
Inhibit hormone
production
PTU, MTX
Inhibits T4-T3 conversion
Gastrointestinal-Hepatic (Diarrhea,
abdominal pain, jaundice)
Inhibition of hormone
release
Iodine-potassium
solutions (SSKI)
Begun >1 h after first
antithyroid drug
B blockers
propanolol
Inhibits T4-T3 conversion
at higher doses, also
blocks beta adrenergic
receptors
Supportive therapies
hydrocortisone
Inhibtis T4 to T3
conversion; used with
possible adrenal
insufficiency for
hypotension
CNS (agitationseizure/coma)
Precipitant History (storm previously)
Thermoregulatory Dysfunction
(temperature)
Scores Totaled
Thyroid Storm: >45
Impending Storm: 25-44
Storm unlikely: < 25
A homeless man is brought by ambulance to the emergency department. He was
found unconscious in an abandoned, unheated house by city workers. The
temperature has been below freezing for the past 24 hours. No medications were
found on the patient.
Physical examination reveals an obese, poorly arousable older man. Temperature is
33.3 °C (92.0 °F), blood pressure is 120/90 mm Hg, pulse rate is 50/min, and BMI is 34.
His pupils are equal, round, and reactive to light. Examination of the neck reveals a
well-healed surgical scar at the base. His lungs are clear to auscultation. Distant heart
sounds are heard on cardiac examination. There is 2+ edema bilaterally in the lower
legs. Neurologic examination shows bilateral ankle jerk reflexes with delayed tendon
relaxation recovery.
Labs: Creatinine: 1.5, Sodium: 130, Potassium: 3.8, Cl: 101, Bicarb: 27, TSH: pending,
free T4: pending, ABG: pH: 7.31, Pco2: 55, Po2: 60, Oxygen Saturation: 90%
Blood, urine, and sputum cultures are obtained.
Findings on chest radiography are within normal limits. Electrocardiography reveals
sinus bradycardia with low voltage throughout.
In addition to beginning intravenous normal saline and passively warming the patient,
which of the following is the most appropriate next step in management?
1.
2.
3.
4.
Intravenous Levothyroxine
Intravenous Levothyroxine and intravenous hydrocortisone
Intravenous levothyroxine, intravenous hydrocortisone, and empiric antibiotics
Review of results of TSH and free T4 level measurements
Myxedema Coma
• Extreme manifestation of hypothyroidism
systemic decompensation
• Common precipitating factors: hypothermia,
stroke, heart failure, infection, metabolic
disturbances, trauma, GI bleeding, acidosis,
hypoglycemia, hypercalcemia
• Hallmark findings: hypothermia and mental
status changes, hypoventilation and
hyponatremia
• Treatment: IV levothyroxine, liothyronine (oral of
IV) ** more controversial
A 32-year-old woman is evaluated for a 3-month history of fatigue, nausea,
poor appetite, and salt craving. She also reports a 6.0-kg (13.2-lb) weight loss
over this same period.
On physical examination, temperature is normal, blood pressure is 92/62 mm
Hg supine and 78/58 mm Hg sitting, pulse rate is 88/min supine and 110/min
sitting, respiration rate is 16/min, and BMI is 25. Her skin is tanned, and
hyperpigmentation is noted in the gum line.
Labs: Na: 127, K: 5.9, Chloride: 101, Bicarb: 24, ACTH: 155, Cortisol (8am):
8ug/dl (normal 5-25)
Which of the following is the most appropriate next diagnostic test?
1.
2.
3.
4.
Cosyntropin stimulation test
Insulin-induced hypoglycemia test
Measurement of morning salivary cortisol level
24 hour urine free cortisol measurement
Disorders of the Adrenal Glands
Adrenal Insufficiency
• Primary Adrenal
Insufficiency
– Impaired secretion of
ALL adrenal hormones
– Causes: autoimmune
adrenalitis, infection (TB,
fungal, bacterial, HIV),
Metastatic disease,
Medications,
Hemorrhage
• Central Adrenal
Insufficiency
– Impaired production of
ACTH-dependent
corticosteroids (cortisol,
DHEA, and DHEA sulfate)
– Causes: exogenous
steroid use, pituitary
cysts, hypothalamic
tumors, sarcoidosis,
cranial irradiation, drugs,
megace
Characteristic
Primary Adrenal Insufficiency
Central Adrenal Insufficiency
Symptoms
Fatgiue, nausea, anorexia,
weight loss, abdominal pain,
arthralgia, low-grade fever;
salt craving, postural dizziness,
decreased libido
Same symptoms as primary
insufficiency but no salt
craving and postural dizziness
Signs
Hyperpigmentation
Dehydration
Hypotension
Decreased pubic/axillary hair
in women
Normal pigmentation
Normal volume
Slight decrease in blood
pressure
Decreased pubic/axillary hair
in women
Major Lab Findings
Low basal serum cortisol level
(< 5.0) with a uboptimal
response to cosyntropin, low
serum CHEA and DHEA-S levels
but high plasma renin activitiy
and ACTH level
Same cortisol findings as
primary insufficency except
low or inappropriately normal
ACTH level; normal
aldosterone and plasma renin
activity
Other Lab Findings
Hyponatremia, high potassium
level, azotemia, anemia,
hypglycemia, and leukopenia
(with a high % of eosinophils
and lymphocytes)
Same findings as primary
insufficency but also normal
potassium level
A 45-year-old woman is evaluated for a 6-month history of weakness,
menstrual irregularities, hirsutism, insomnia, and emotional lability. She also
reports an 8.0-kg (17.6-lb) weight gain during this period. She was previously
healthy. She takes no medications.
On physical examination, temperature is 36.0 °C (96.8 °F), blood pressure is
172/90 mm Hg, pulse rate is 78/min, respiration rate is 16/min, and BMI is 32.
The patient has a rounded, plethoric face with increased supraclavicular and
dorsal fat pads. There are areas of unexplained ecchymoses over the upper
and lower extremities. Abdominal examination reveals purple striae. She has
proximal muscle weakness.
Results of routine laboratory studies are normal except for a serum potassium
level of 3.4 meq/L (3.4 mmol/L).
Which of the following is the most appropriate next test for this patient?
1.
2.
3.
4.
Cosynthropin stimulation test
High-dose dexamethasone suppression test
Measurement of morning serum cortisol level
Measurement of 24 hour urine free cortisol excretion
Cushing Syndrome
•
•
•
Syndrome: collection of signs and symptoms occur after prolonged exposure to
supraphysiologic doses of corticosteroids
Most commonly, exogenous corticosteroid use
First Step: Screen for hypercortisolism
– 24 hour urine free cortisol secretion
– Loss of normal diurnal variation in cortisol secretion (late night, salivary cortisol level)
– Loss of feedback inhibition (dexamethasone suppression)
•
Second Step: Confirmation when screening tests are equivocal
– 24 hour urine cortisol
– Dexamethasone +CRH
– Low dose Dexamethasone Suppression
•
Third Step: Determine the cause
– Determine ACTH dependent vs ACTH independent
– High dose dexamethasone differentiates pituitary from ectopic sources
•
Fourth Step: Imaging after biochemical confirmation
– MRI sella tursica: may be normal because often adenomas are too small to be picked up
•
Consider petrosal sinus catheterization with measurements of ACTH levels after CRH
– CT of adrenal glands if ACTH indepednent: adenoma vs. carcinoma
Step 1 and 2
Step 3
A 25-year-old man is evaluated for a 2-year history of infertility. He and his
wife have been unable to conceive since marrying 2 years ago. Analysis of a
semen sample provided 3 weeks ago during an infertility evaluation showed
azoospermia. The patient has a strong libido and no history of erectile
dysfunction. He has no other medical problems and exercises regularly. There
is no family history of delayed puberty or endocrine tumors.
On physical examination, the patient appears very muscular. Temperature is
normal, blood pressure is 142/85 mm Hg, pulse rate is 55/min, respiration
rate is 14/min, and BMI is 22. Visual fields are full to confrontation. There is
extensive acne but no gynecomastia or galactorrhea. Testes volume is 4 mL
(normal, 18-25 mL) bilaterally. The penis appears normal.
Labs
FSH: < 0.1, LH: <0.1, Prolactin: 12, Total Test: < 50
MRI of the pituitary gland shows normal findings.
Which is the most likely diagnosis?
1.
2.
3.
4.
Anabolic Steroid Abuse
Nonfunctioning Pituitary macroadenoma
Primary Testicular Failure
Prolactinoma
Male Reproductive Disorders
Primary
Hypogonadism
• Almost always causes infertility
• Chromosomal, congenital, toxic/traumatic, infiltrative
• Toxic exposures such as alkylating agents
• Suggested by high serum FSH level and confirmed by inhibin B level < 100
Secondary
Hypogonadism
• Hypothalamic and/or pituitary dysfunction
• Careful work up in younger men
• Prolactin suppresses gonadotropins directly
• Drugs, malnutrition, obesity, aging, anabolic steroids
Androgen
deficiency in aging
male
• Testosterone production declines at 1%/year after age 25
• ADAM (adrogen deficiency in the aging male)
• Fatigue, muscular loss, poor libido, hot flushes, sexual dysfunction,depression
• Normal prolactin, normal LH, low testonerone, men >60 y/o
Best screening test: total serum testosterone before 10:00AM (ideally, three
pooled specimens drawn at 20-30 minute intervals)
Random Testosterone> 350ng/dL excludes hypogonadism, <200ng/dL confirms
hypogonadism
If low testosterone, will need to check bioavailable testosterone
A 23-year-old woman is evaluated after having no menses for 6 months. She
began menstruating at age 12 years, and menses have always been regular.
The patient reports no recent weight gain, voice change, or facial hair growth;
she says she may even have lost some weight recently and tends to feel
warm. She is not sexually active. There is no family history of infertility or
premature menopause.
On physical examination, temperature is normal, blood pressure is 115/72
mm Hg, pulse rate is 66/min, respiration rate is 14/min, and BMI is 22. She
has no acne, hirsutism, or galactorrhea. Her thyroid gland is slightly enlarged.
Visual field testing yields normal results.
Results of standard laboratory studies are normal, including thyroidstimulating hormone and free thyroxine (T4) levels; a human chorionic
gonadotropin level is negative for pregnancy.
Which of the following is the most appropriate first step in evaluation?
1.
2.
3.
4.
Hysterosalpingography
Measurement of serum follicle-stimulating hormone and prolactin levels
Measurement of total serum testosterone level
Pelvic Ultrasound
Female Reproductive Disorders
Primary
Amenorrhea
Secondary and
Hypothalamic
Amenorrhea
Hirsutism and
PCOS
•Absence of spontaneous menses by 16 or age 14 in the absence of secondary sexual characteristics
•Anatomic defects, ovarian failure, chronic anovulation with normal estrogen, chronic anovulation with low estrogen
•Turners, mullerian duct agenesis, congenital hypopituitarism, anorexia nervosa, systemic illness
•Requires thorough evaluation by gynecologist
•Absence of menses for 3 or more consecutive months in woman who previously menstruated
•Oligomenorrhea (irregular and infrequent) is more common than complete amenorrhea
•Women who do not resume their menstrual cycle after OCPs should be evaluated as spontaneous amenorrhea
•Causes: PCOS,Asherman Syndrome, Elevated prolactin, mosaic Turners, autoimmune oophoritis, hypothalamic amenorrhea
•PCOS: chronic anovulation with normal estrogen levels
•Ovulator dysfunction, laboratory evidence of hyperandrogenism, ultrasound evidence of polycystic ovaries
•Most common cause of secondary amenorrhea or oligomenorrhea
•Serum total testosterone level > 150 suggests an androgen-producing ovarian or adrenal tumor (requires further work up)
•Treatment: spironolactone + OCP or metformin or clomiphene
Check pregnancy test first
Reproductive axis is particularly vulnerable to disruption by systemic illness and weight
loss
First Step: Test: FSH, prolactin, TSH, free thyroxine levels
Second Step: progestin withdrawla challenge with medroxyprogesterone acetate for 10
days. Menstruation= normal estrogen levels, absense= low estrogen or anatomic
defect review pelvic anatomy with US, MRI or hysteroslpingography
A 72-year-old man is evaluated for a 2-week history of low back pain. The patient has
a history of alcoholism but stopped drinking alcohol 10 years ago. He also has stage 3
chronic kidney disease and a 50-pack-year smoking history. Current medications are
hydrochlorothiazide, ramipril, and a multivitamin.
On physical examination, vital signs are normal. Lumbar lordosis, decreased mobility
and spasm of the paravertebral muscles, and tenderness to palpation at L4-L5 are
noted. Neurologic screening examination findings are normal.
Labs: Calcium: 9.0, creatinine: 2.1, Phos: 2.1, PTH: 50, Testosterone: 400, 25 hydroxy
vitamin D: 34, eGFR: 40
A radiograph of the lumbosacral spine shows a compression fracture of L4. A dualenergy x-ray absorptiometry scan shows a T-score of –3.0 in the lumbosacral spine and
–3.2 in the left hip.
Which of the following is the best treatment for this patient?
1.
2.
3.
4.
Alendronate
Calcitonin
Teriparatide
Testosterone
Metabolic Bone Disease
• Osteoporosis
– T score of 2.5 SDs below the peak
values
– Severe: if < -2.5 with history of
fragility fracture
– Osteopenia: -1.0- -2.5
– Normal: >-1.0
– Treatment: (anyone with <-1.0)
• Vit D: >50 years old 800-1000U/d
• Vit D: <50 years old 400-800 U/d
• Severe Vit D deficiency: 50K U three
times weekly for 5 weeks
• Calcium: age related dose
• Ca: < 50 years old 1000mg/day
• >50 years old 1200-1500mg/day
• Bisphosphanates
• Raloxifene (SERM)
• Teriparatide (recombinant human
parathryoid hormone)
• Paget Disease of Bone
– Localized disorder of osteoclast
overactivitiy
– Leads to formation of mechanically
ineffective woven or repaired,
rather than lamellar, bone.
– Results in bending and periosteal
expansion and cortical thickening
– Progressive
– Treatment if symtpoms are present
or if lytic involvement of the
vertebrae, skull, weight-bearing
bones, or areas adjacent to major
joints occur
– bisophosphanates
Diabetes
Diabetic Complications
• Acute:
– DKA
– Hyperglycemic Hyperosmolar Syndrome
– Hypoglycemia
• Chronic:
– Microvascular
• Diabetic nephropathy
• Diabetic neuropathy
• Diabetic retinopathy
– Macrovascular
• CAD
• Carotid artery disease
• CVA