In the evaluation of a 26-year-old patient with 4 months of secondary amenorrhea, you order serum prolactin and β-hCG assays. The β-hCG test is positive, and the prolactin level is 100 ng/mL (normal is < 25 ng/mL in nonpregnant women in this assay).
This patient requires which of the following?
There is a marked increase in levels of serum prolactin during pregnancy to over 10 times those values found in nonpregnant women. This woman’s pregnancy test is positive. If she were not pregnant, the prolactin value could easily explain the amenorrhea, and further evaluation of the cause of the hyperprolactinemia would be necessary. The physiologic significance of increasing prolactin in pregnancy appears to involve preparation of the breasts for lactation. As this patient is pregnant, there is no need for further evaluation of the elevated prolactin level and she should begin routine prenatal care.
You have just performed diagnostic laparoscopy on a 28-year-old patient with chronic pelvic pain and dyspareunia. At the time of the laparoscopy, there were multiple implants of endometriosis on the uterosacral ligaments and ovaries. At the time of the procedure, you ablated all of the visible lesions on the peritoneal surfaces with the CO2 laser. Because of the extent of the patient’s disease, you recommend postoperative medical treatment.
Which of the following medications is the best option for the treatment of this patient’s endometriosis?
Medical treatment of endometriosis may be recommended as suppressive therapy following ablative surgery. Combined oral contraceptives remain the mainstay of therapy; however, continuous oral progesterone is also a reasonable option. There is some data that a progesterone-containing IUD results in decreased rates of dysmenorrhea. If these therapies are not effective, aGnRH agonists may be used, although it is associated with more adverse side effects, because they produce a medically induced and reversible menopause state. Danazol has been shown to improve pain related to endometriosis, but is not used often due to significant androgenic side effects such as weight gain, hirsutism, and depression.
A 28-year-old nulligravid patient complains of bleeding between her periods and increasingly heavy menses. Over the past 9 months, a trial of oral contraceptives and NSAIDs have failed to decrease the heavy bleeding.
Which of the following options is most appropriate at this time?
In patients with abnormal bleeding who are not responding to standard therapy, hysteroscopy should be performed. Hysteroscopy can rule out the presence endometrial polyps or small fibroids by direct visualization. If these lesions are present, they can be resected or removed. In patients with heavy abnormal bleeding who no longer desire fertility, an endometrial ablation may be performed. If a patient has completed childbearing and is having significant abnormal bleeding, a hysteroscopy and possible endometrial ablation, rather than a hysterectomy, would still be the procedure of choice to rule out easily treatable disease and manage the bleeding in a minimally invasive manner. Treatment with a GnRH agonist would induce a menopausal state and only temporarily relieve symptoms.
A 26-year-old P0 presents to you for evaluation of infertility. She and her husband have been trying to get pregnant for 2 years. As part of the workup, her husband had a normal semen analysis. The patient has a history of endometriosis diagnosed by laparoscopy at the age of 17 due to severe pelvic pain and dysmenorrhea. After the surgery, the patient was told she had a few small implants of endometriosis on her ovaries and fallopian tubes and several others in the posterior cul-de-sac. She also had a left ovarian cyst, filmy adnexal adhesions, and several subcentimeter subserosal fibroids. You have recommended that she should have an HSG as part of her evaluation for infertility.
Which of the patient’s following conditions can be diagnosed with an HSG?
An HSG is a procedure in which 3 mL to 6 mL of either an oil or water-soluble contrast medium is injected through the cervix in a retrograde fashion to outline the uterine cavity and fallopian tubes. Spill of contrast medium into the peritoneal cavity proves patency of the fallopian tubes. By outlining the uterine cavity, abnormalities such as bicornuate or septate uterus, uterine polyps, or submucous myomas can be diagnosed, while tubal opacification allows identification of such conditions as salpingitis isthmica nodosum and hydrosalpinx. However, pelvic abnormalities outside the uterine cavity and fallopian tube (such as subserosal fibroids, ovarian tumors, endometriosis, or minimal pelvic adhesions) are not visible with this study. Some studies have shown a therapeutic effect resulting in an increased rate of pregnancy in the months immediately following the HSG.
During the evaluation of infertility in a 25-year-old woman, a HSG showed evidence of Asherman syndrome.
Which one of the following symptoms would you expect this patient to have?
Asherman syndrome refers to a condition where intrauterine adhesions are present. These adhesions can often cause symptoms such as amenorrhea or infertility. Because of the decreased amount of functional endometrium present in this setting, progressive hypomenorrhea (lighter menstrual flow) or amenorrhea is common. Oligomenorrhea is defined as infrequent, irregular uterine bleeding for more than 35 days apart, often attributed to anovulation. Ovulation is not affected in Asherman syndrome; therefore, ovulatory patients with Asherman syndrome may continue to have regular periods. The best diagnostic study to confirm intrauterine adhesions is an HSG under fluoroscopy. Hysteroscopy with lysis of adhesions is the treatment of choice. Prophylactic antibiotics may improve success rates.
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