Thanks to Avril Owen for suggesting this Case.
A 34-year old lady (herself a Family Doctor) presented to her own Family
Doctor with secondary amenorrhoea. A range of serum endocrine tests were
requested. Results were:
Testosterone: 6.3 nmol/L (0.3-2.9)
Sex Hormone Binding Globulin: 109 nmol/L (25-100)
DHEA Sulphate: 3.1 umol/L (1.4 - 14.7)
Androstenedione: 22.4 nmo/L (3.0-9.6)
Progesterone: 54.3 nmol/L (luteal phase, 24 - 71)
Prolactin: 268 mIU/L (83 - 622)
FSH: <0.1 U/L (luteal phase 1- 8)
LH: <0.1 U/L (luteal phase 1 - 11)
Thyroid function tests were within reference limits.
This Case attracted 26 participants, who fell into two neat groups.
7 would contact the Family Doctor to ask about previous history and
medication; [1.0]
3 would ask if the patient was hirsute; [0.3]
3 would not telephone the Family Doctor. [-0.6]
4 suggested the patient should be referred to an Endocrinologist. [1.5]
8 participants queried ovarian androgen excess/ androgen secreting tumour;
[1.7]
6 queried pregnancy;[1.0]
4 queried synthetic oestrogen/ androgen use;[1.0]
3 queried late onset congenital adrenal hyperplasia;[0.7]
1 each queried
treatment for polycystic ovaries;[0]
a chromosomal abnormality.[0.3]
8 participants would measure HCG;[1.3]
7 would measure oestradiol;[0.7]
6 would suggest referral for scanning;[1.0]
3 each would measure
cortisol;[0.3]
17-OH progesterone;[0.7]
2 would suggest repeating the assays;[0.7]
1 each would suggest
17-OH progesterone after ACTH stimulation;[1.0]
a dexamethasone suppression test;[0.3]
LFTs.[0.3]
This patient was referred to the Consultant Gynaecologist, who after
clinical examination referred her for an ultrasound scan, suspecting an
androgen-secreting tumour. The scan showed that the patient was around 20
weeks' pregnant. A urine pregnancy test carried out around 10 weeks
previously (after the second missed period) had proved negative (!).
Neither the patient's doctor nor the Gynaecologist had thought that the
patient showed clinical signs of pregnancy.
Best wishes
Gordon Challand
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