During the evaluation of secondary amenorrhea in a 24-year-old woman, hyperprolactinemia is diagnosed.
Which of the following conditions could cause increased circulating prolactin concentration and amenorrhea in this patient?
Physical or psychological stress may result in an increase in prolactin. Prolactin is under the control of prolactin-inhibiting factor (PIF), which is produced in the hypothalamus. Many drugs (eg, the phenothiazines), stress, hypothalamic lesions, stalk lesions, and stalk compression decrease PIF. In anorexia nervosa, prolactin, TSH, and thyroxine levels are normal, FSH and LH levels are low, and cortisol levels are elevated. In hypothyroidism, elevated TRH acts as a prolactin-releasing hormone to cause release of prolactin from the pituitary; hyperthyroidism is not associated with hyperprolactinemia. There are many other conditions, such as acromegaly and pregnancy, that are associated with elevated prolactin levels. Hyperandrogenic conditions such as congenital adrenal hyperplasia or polycystic ovarian disease are not typically associated with hyperprolactinemia.
A 36-year-old morbidly obese woman presents to your office for evaluation of irregular, heavy menses occurring every 3 to 6 months. An office endometrial biopsy shows complex hyperplasia of the endometrium without atypia.
The hyperplasia is most likely related to the excess formation in the patient’s adipose tissue of which of the following hormones?
In premenopausal adult women, most of the estrogen in the body is derived from ovarian secretion of estradiol, but a significant portion also comes from the peripheral conversion of androstenedione to estrone in adipose tissue. When there is an increase in fat cells, as in obese persons, estrogen levels—particularly estrone—will be higher, provoking anovulation and endometrial hyperplasia.
A couple presents for evaluation of primary infertility. The evaluation of the woman is completely normal. The husband is found to have a left varicocele. If the husband’s varicocele is the cause of the couple’s infertility,
what would you expect to see when evaluating the husband’s semen analysis?
A varicocele is an abnormal tortuosity and dilation of the veins of the pampiniform plexus within the spermatic cord. The incidence of varicoceles in the general population is about 15%, but 40% of males with infertility are found to have varicoceles. Varicoceles are more likely to occur on the left side due to the direct insertion of the spermatic vein into the renal vein. There is no correlation between the size of the varicocele and the prognosis for fertility. The characteristic semen analysis seen with varicoceles shows a decrease in the number of spermatozoa with decreased motility and increased abnormal forms. How the varicocele causes abnormal semen quality, and the relationship between varicocele, semen abnormalities, and male infertility (especially when semen quality appears normal) is unclear.
Your patient delivers a 7-lb male infant at term. On physical examination, the baby has normal-appearing male external genitalia. However, the scrotum is empty, and no testes are palpable in the inguinal canals. At 6 months of age, the boy’s testes still have not descended. A pelvic ultrasound shows the testes in the pelvis, and there appears to be a uterus present as well.
The presence of a uterus in an otherwise phenotypically normal male is caused by which of the following?
Bilateral nonpalpable testes in a phenotypically normal male newborn require prompt evaluation due to the possibility of a disorder of sexual development. Müllerian structures appear during embryonic development in both males and females. Female gonads do not secrete Müllerian-inhibiting substance (MIS), and therefore the Müllerian structures persist. Male testes secrete MIF, which causes regression of Müllerian structures. Anything that prevents MIF secretion in genetic males will result in persistence of Müllerian structures into the postnatal period. Persons who appear to be normal males but who possess a uterus and fallopian tubes have such a failure of MIF. Their karyotype is 46, XY, testes are present, and testosterone production is normal.
A 45-year-old G2P2 presents for management of heavy menses. She reports her periods occur once a month, last 6 days, and are very heavy and painful. She has tried oral contraceptives, but she does not like having to take a pill every day. She had a levonorgestrel-containing intrauterine device (IUD) in the past, but did not like it due to symptoms of cramping. Her medical history is unremarkable, and her only surgery is a postpartum tubal ligation. Her evaluation has included a normal Pap smear, normal endometrial biopsy, and normal pelvic ultrasound.
What is the best next step in management of this patient’s bleeding?
This patient has had a normal workup, and has failed conservative treatment. She had adverse symptoms with an IUD in the past, so this is not the best option. Daily oral progesterone is a very reasonable option to manage her bleeding, but she does not want to take a pill every day. UAE is a reasonable treatment option for women with fibroids, but this patient had a normal ultrasound. Hysterectomy will certainly manage her bleeding, but there is another option that is more conservative and minimally invasive. Endometrial ablation has a high success rate, with roughly a 50% amenorrhea rate at 1 year, and over a 90% patient satisfaction rate based on normalization of menstrual flow. It is an outpatient procedure that requires very little time for recovery.
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