Case Scenarios and Questions
Case 1
A 30-year-old G2P2002, with last menstrual period (LMP) 8 weeks ago complains of no menses for the past 2 months. She usually has menses regularly every 28 days, lasting for 5 days. She denies any medical or surgical history. She has had two term spontaneous vaginal deliveries. She uses combination oral contraceptive pills (OCPs) regularly, and has not missed any pills recently.
What is the next step in management of this patient?
Answer: Obtain a pregnancy test (urine beta-hCG; confirm with serum beta-hCG if needed).
Case 2
A 35-year-old G2P2002 with LMP one year ago presents with hot flashes and vaginal dryness. Her serum FSH is very high and in the menopausal range. What is the most likely diagnosis?
Most likely diagnosis: premature ovarian insufficiency (premature menopause).
Rationale: Amenorrhea β₯12 months with menopausal-range FSH in a woman <40 years indicates premature ovarian failure/insufficiency, causing vasomotor and genitourinary symptoms.
AMH <3 | >30 FSH - Indicates Insufficiency
Case 3
A 35-year-old G3P3003 complains of absence of menses for 8 months. She reports menarche at age 12 with menses every 40β50 days until recently. She complains of an β of 20 lb in her weight over the last year. She denies any family history or use of medications or drugs. She used clomiphene to become pregnant with her last two pregnancies. Her weight 106 kg, BP 120/80. She has hair on her upper lip and chin. She has acne and oily skin on her face.
What is the most likely diagnosis?
- Most likely diagnosis: secondary dysmonherea due to Polycystic ovary syndrome (PCOS) presenting with chronic anovulation (oligomenorrhea/amenorrhea), obesity, hirsutism and acne.
If left untreated, what is this patient at β risk for?
- If left untreated, she is at increased risk for:
- Endometrial hyperplasia and endometrial carcinoma (from chronic anovulation and unopposed estrogen)
- Insulin resistance β type 2 diabetes mellitus
- Dyslipidemia and increased cardiovascular disease risk
- Infertility / persistent ovulatory dysfunction
- Obstructive sleep apnea and metabolic syndrome-related complications
Case 4
A 40 year old patient, G3P3, with no significant medical or surgical history, was admitted to the intensive care unit with hemorrhagic shock due to postpartum hemorrhage following a normal delivery at home. The clinical examination on arrival confirmed the state of shock: an undetectable blood pressure, a tachycardia of 120 beats/min, cold peripheries, pale conjunctivae
Immediate care involved vascular expansion with colloids via a central venous catheter, followed by a transfusion of 5 units of cross matched packed red cells since the haemoglobin level was 5g/dl. The short-term evolution was marked by lactational failure, The medium-term evolution was marked by prolonaed amenorrhea, fatigue and apathy.
Diagnosis
- Sheehan syndrome (postpartum hypopituitarism due to pituitary ischemic necrosis after massive postpartum hemorrhage). Clinical clues: severe PPH with shock, failure to lactate (low prolactin), prolonged amenorrhea, fatigue, apathy (secondary hypothyroidism and/or adrenal insufficiency).
Workup
- Immediate/basic labs
- Serum sodium, potassium, glucose (to assess for adrenal insufficiency and electrolyte abnormalities).
- Morning (08:00) cortisol and plasma ACTH.
- TSH and free T4.
- Prolactin.
- LH, FSH and estradiol (to document gonadotropin deficiency).
- Consider serum IGF-1 (screen for GH deficiency).
- Dynamic/endocrine testing (as indicated)
- Short ACTH (cosyntropin) stimulation test or insulin tolerance test (if safe) to assess adrenal reserve when baseline cortisol equivocal.
- If diagnosis unclear, formal pituitary stimulation tests per endocrinology.
- Imaging
- MRI pituitary with contrast (may show an empty sella or infarction/atrophy).
- Other
- Bone mineral density (baseline if chronic hypogonadism).
- Assessment for diabetes insipidus if polyuria/polydipsia (serum sodium, plasma/urine osmolality, consider water deprivation test or trial of desmopressin).
Management
- History
- Acute management (if adrenal insufficiency suspected or patient unstable)
- Give empiric IV glucocorticoids (e.g., hydrocortisone 100 mg IV bolus then 50β100 mg IV q6β8h or equivalent) before initiating thyroid hormone replacement.
- Correct hypovolemia, electrolytes, and hypoglycemia as required.
- Hormone replacement (long-term)
- Glucocorticoids: oral hydrocortisone replacement (typical maintenance 15β25 mg/day in divided doses) once diagnosis confirmed and tapered to physiologic dose. Patient education about stress dosing and emergency steroid card.
- Levothyroxine: start only after adequate glucocorticoid coverage; dose individualized (lower starting dose in older/comorbid patients).
- Sex steroid replacement: estrogen with cyclic progestin in women who need symptom control or bone protection; consider combined oral or transdermal preparations. For fertility desires, refer to reproductive endocrinology for ovulation induction (gonadotropins) or IVF.
- Growth hormone: consider in selected symptomatic adults after other deficiencies treated and per endocrinology.
- Desmopressin (DDAVP) if central diabetes insipidus present.
- Monitoring and follow-up
- Regular endocrine follow-up to titrate replacement (clinical and laboratory assessment).
- Educate on sick-day rules, carry steroid emergency card/kit.
- Bone density monitoring and address osteoporosis risk (calcium, vitamin D, bisphosphonates if indicated).
- Repeat pituitary MRI if needed.
- Multidisciplinary care
- Endocrinology referral for confirmation, dynamic testing, and long-term management.
- Gynecology/reproductive medicine for fertility counseling.
- Psychological support as needed.
Question 1
A 36-year-old female, who is not pregnant comes in with chief complaint of galactorrhea. Which of the following would be an appropriate lab test to order to investigate the cause?
a) MRI b) Urinalysis c) CT of head d) T3/FT4 e) Prolactin level
Multiple Choice Questions
Question 2
A 17-Year-old female, no menstruation, high testosterone, Normal breast development, coarse pubic hair?
A. Mayer Rokitansky Kuster Hauser syndrome (or Mullerian agenesis) B. Complete androgen insensitivity C. Congenital hypothyroidism D. Turner syndrome
Question 3
A 17-Year-old female, no menstruation, normal testosterone, Normal breast development, normal pubic hair?
A. Mayer Rokitansky Kuster Hauser syndrome (or Mullerian agenesis)
B. Complete androgen insensitivity
C. Congenital hypothyroidism
D. Kalmanβs syndrome
Question 4
A 17-year-old female, medically free, (athlete) gymnast in her class, breasts later and never menstruated, on developed examination she is tanner stage 5, but no menstruation, diagnosis?
A. Hypothalamic hypogonadism
B. Transverse vaginal septum
C. Gonadal agenesis
D. Testicular feminization (Athlete)
Question 5
A 35-Year-old female complaining of secondary amenorrhea for 8 months, what to do next?
A. Pregnancy test
B. US
C. Full history taking
D. Physical exam
Question 6
A 36-year-old lady with secondary amenorrhea (elevated FSH & LH) which of risk or complication she might probably develop in the future?
A. Risk of endometrial cancer
B. Risk of ovarian cancer
C. Risk of osteoporosis
D. Risk of DM