A 29 year old female patient, visiting her Community Physician. Clinical
information is 'On methadone. Erratic periods. Polycycstic ovaries?'
Serum FSH: <0.1 U/L (follicular phase 2 - 11)
LH: 1.7 U/L (follicular phase 1 - 10)
Prolactin: 3025 mU/L (80 - 530)
Oestradiol: 13200 pmol/L (follicular phase 75 - 260)
This Case attracted 28 participants, with a major concensus on
interpretation. Comment components are scored on the usual +2 (highly
appropriate) to -2 (highly inappropriate) basis. The mean scores given by
the assessors are included beside each comment component. The Assessors had
major disagreement on only one comment component (indicated by an asterisk
below).
8 would contact the Community Physician directly [+1.5].
17 said the results were likely to indicate pregnancy [+1.6],
4 said that they were not suggestive of polycystic ovaries [+1.6].
16 would measure HCG or suggest a pregnancy test [+1.8],
1 each would measure
TSH [-0.4]
testosterone [-0.2]
a urine drug screen [-0.4].
1 would suggest repeating the assays [-0.2];
3 would suggest ultrasound [0.2];
1 would suggest a pituitary scan [-1.2].
3 would not have measured oestradiol on this patient [0.2];
2 commented 'higher prolactin than expected' -0.2];
3 commented 'drug effect on prolactin' [0.0];
2 commented 'methadone effect on prolactin [0.2]';
1 commented 'prolactin probably too high to be a methadone effect' [0.8]
3 commented 'some LH assays suffer from cross-reaction with HCG' [0.6];
1 queried slight HCG cross-reaction with LH [-0.4].
2 commented that the (apparent) very high oestradiol was odd [0.6*];
4 queried the use of synthetic oestrogens [1.0];
1 queried whether the oestradiol was related to alcohol or illicit drugs
[0.2];
1 queried cross reaction of cannabinoids in the oestradiol assay [0.2].
1 each queried
suppressed pituitary function [0.2];
a prolactinoma [0.0];
an oestrogen producing tumour [0.4];
ovarian hyperfunction [-0.4].
This was a case in which I initially went in the wrong direction. My
excuses for this are
1. Our previous LH assay had considerable HCG cross-reaction, and in
pregnancy, LH values greater than 100 were usual. Apparently our current LH
assay does not suffer the same problem.
2. I thought the high prolactin could be ascribed to methadone and/or other
psychoactive drugs; and
3. I had not realised that oestradiol could go as high as this in early
pregnancy (I still don't know if it does). Interestingly, Tietz's admirable
'Clinical Guide to LaboratoryTests' does not even mention pregnancy as a
cause of a raised oestradiol.
So I 'phoned the Community Physician to ask about the possibility of this
patient abusing steroids - the CP thought this unlikely, so I suggested a
repeat sample and said one had to think about the possibility of an
oestrogen-secreting tumour. Thirty minutes' later, after discussion, I
somewhat shamefacedly 'phoned back and enquired about the possibility of
pregnancy. On this sample, the HCG was 28 000 U/L (average for around day
47 - see Case for Comment No 11, January 1998).
For this Case, the mean comment score for CME participants was 3.1 (range
-0.4 to 5.5).
Best wishes
Gordon Challand
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