Endocrine-related things Flashcards
What is primary amenorrhea?
no menses by age 13 with no breast development
or no menses by age 15 WITH breast development
What are Tanner stages for breast development?
Stage 1: pre-pubertal
Stage 2: breast budding
Stage 3: breast + areola enlarging
Stage 4: areola elevates and form secondary mounts
Stage 5: adult presentation
How do you evaluate for primary amenorrhea?
History (medical problems-endocrine disorders, other signs of puberty, meds, prior chemotherapy leading to ovarian failure)
physical exam (weight to assess for low BMI, breast exam, pelvic exam assessing for tanner stages, evaluating for signs of Turners)
What is initial workup of primary amenorrhea?
pelvic US (assess for presence of uterus), b-hcg, TSH, prolactin, FSH, estradiol (will show streak gonads/low estrogen)
What are structural causes of primary amenorrhea?
Mullerian agensis, imperforate hymen, transverse vaginal septum
If you have breasts, you have ovaries! Except in androgen insensitivity
If FSH elevated, how would it change your differential for primary amenorrhea
Primary ovarian failure: think Fragile X or Turner syndrome. Get genetic testing, karyotype, exam (streak ovaries, widely spaced nipples, short stature).
What is SLE?
chronic multisystem inflammatory autoimmune disease.
- dsDNA is most specific, ANA not as specific.
- flare: decr complement and elevated dsDNA. RF for flare: active disease within 6 mo priorto pregnancy, active nephritis, discontinuation of hydroxychloroquine.
sx: fatigue, fever, arthralgia, myalgias, weight loss, rash.
Lupus nephritis: HTN, proteinuria. distinguish btw this and PEC w/ renal biopsy.
Recs: LDA, hydroxychloroquine, stop methotrexate and MMF prior to conception. If APS and no prior VTE, prophylactic anticoagulation. If APS + VTE, therapeutic!
What are adverse pregnancy outcomes w/ SLE?
PEC, FGR, neonatal lupus, incr risk pregnancy loss.
- anti-SSA and anti-SSB incr risk complete heart block (develops btw 18-22 weeks) - need weekly US to eval for hydros.
- delivery at 39wks.
What is galactorrhea?
What are causes?
What is workup?
milky discharge, bilateral unrelated to pregnancy or breastfeeding
- Prolactin is inhibited by dopamine and stimulated by TRH and nipple stim.
- causes: pregnancy/breastfeeding, excessive breast stimulation, meds, hyperprolactinemia.
- workup: med hx (antipsychotics, metoclopramide/reglan, SSRI, TCA, oral estrogen)
- breast exam
- prolactin (<25 nanograms/mL is normal), TSH, renal function, HCG (CKD can cause incr PRL)
- prolactin testing (early AM, fasting, no intercourse/nipple stim)
- visual field test
- MRI of pituitary fossa.
Treat if macroadenoma >1cm or hypogonadism/bothersome galactorrhea.
What is treatment of galactorrhea?
Dopamine agonists (bc inhibits prolactin)
- Cabergoline: long-acting/preferred. less severe SE. 0.25mg twice a week.
- Bromocriptine: SE=postural hypotension, N/HA. 2.5mg BID.
What are hormone units?
PAP= ng/mL
Progesterones (ng/ml)
Androgens (ng/ml)
Prolactin (ng/ml)
Estrogens pg/mL
FSH+LH, HCG mIU/ml - milli international units
TSH mIU/ml
What is hypothyroidism?
What are causes?
high TSH, low T4.
- sx: fatigue, cold intolerance, weight gain, constipation, dry skin, meals.
-exam: goiter, bradycardia.
- if Hashimoto’s (chronic autoimmune thyroiditis): elevated TPO Ab.
PRIMARY:
- autoimmune (Hashimoto’s) - most common. Has +TPO Ab but don’t need to order.
- infiltrative
- impaired thyroid synthesis (iodine deficiency, congenital)
- RAI ablation for prior hyperthyroid
- meds
SECONDARY (central) - inadequate thyroid stimulation by TSH (pituitary) or TRH (hypothalamus). TSH doesn’t increase as T4 falls so TSH can be normal/low or high.
- Tumors of pituitary or hypothalamus
- Radiation effect
- Sheehan’s hypopituitarism
- infiltative (sarcoid).
When do you use TPO Ab
indicated in patients with goiter, subclinical hypothyroid or PP thyroiditis to predict likelihood to progression to permanent overt hypothyroidism.
- If +TPO Ab but normal TFTs, has chronic autoimmune thyroiditis but NOT hypothyroidism. Check TSH yearly.
What is hyperthyroidism?
What is the workup and treatment?
Grave’s disease=most common disorder. Benign neoplasm=2nd most common.
-sx: anxiety, weakness, tremor, palpitations, heat intolerance, weight loss, perspiration, diarrhea, oligo/amenorrhea.
- exam: exophthalmos and pretrial myxedema, tachycardia, hyperreflexia, HTN.
Workup:
- measure TRAb (thyrotropin-R Ab)
- determine RAI uptake (determines toxic multi nodular goiter vs toxic adenoma 2/2 Grave’s) - AVOID IN PREGNANCY/BF
- thyroid US to measure blood low.
Tx: thioamides, RAI (requires thyroxine supplementation afterwards), or surgery. - start beta blocker.
What are the effects of inadequately treated hyperthyroidism in pregnancy?
Incr risk PEC, maternal heart failure and thyroid storm
Medically indicated PTD, LBW, miscarriage, stillbirth
What are effects of inadequately treated hypothyroidism in pregnancy?
Adverse perinatal: SAB, PEC, PTB, abruption, stillbirth
How do you diagnose and manage subclinical hyperthyroidism?
Low TSH, normal Free T4. not assoc w/ adverse prreg outcomes. Treatment not recommended bc no benefit.