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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{AO}} (Reviewed by Serge Korjian)
|QuestionAuthor= {{SSK}},  {{AO}} (Reviewed by Serge Korjian)
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Physiology
|MainCategory=Physiology
Line 21: Line 21:
|MainCategory=Physiology
|MainCategory=Physiology
|SubCategory=Reproductive
|SubCategory=Reproductive
|Prompt=A 50-year-old woman with past history significant for hypothyroidism presents to the outpatient clinic with complaints of emotional lability.  She reports excessive crying and irritable for the past 2 months.  She denies any history of hot flashes or night sweats.  She also reports that her menstrual cycles have seemed irregular for the past year, and have gotten longer than usual recently. Which of the following laboratory studies most likely belong to this patient?
|Prompt=A 48-year-old woman with past history significant for hypothyroidism presents to the outpatient clinic with complaints of emotional lability.  She reports excessive crying and irritable for the past 2 months.  She denies any history of hot flashes or night sweats.  She also reports that her menstrual cycles have seemed irregular for the past year, and have gotten longer than usual recently. Which of the following laboratory studies most likely belong to this patient?


[[File:WBR question 0655.JPG]]
[[File:WBR0655b.png|600px]]
|Explanation=This woman is experiencing symptoms of menopause which include mood swings, irritability.  Other symptoms may include: depression, fatigue, memory loss, hot flushes, night sweats, vaginal dryness, e.t.c.  Menopause, whose average age of onset is 50 years, is a cessation of estrogen production due to a decreased number of ovarian follicles. Menopause can also be described as the permanent cessation of the primary functions of the ovaries - the ripening and release of ova and the release of hormones that cause both the creation of the uterine lining, and the subsequent shedding of the uterine lining.  Postmenopausal women have low estrogen levels but high levels of LH, FSH, and GnRH due to the lack of negative feedback on the anterior pituitary and hypothalamus. The ovaries produce estrogens; anterior pituitary gland produce LH and FSH while the hypothalamus releases GnRH. Menopause can be managed with hormone replacement therapy.
|Explanation=This patient in this scenario is experiencing classical symptoms of perimenopause including mood swings, irritability, and irregular and lengthy cycles.  Other typical symptoms are similar to those seen during menopause and may include: depression, fatigue, hot flashes, night sweats, and vaginal dryness.  The main defining factor that distinguishes the perimenopausal period from menopause is the cessation of menstruation for a period of 12 months, as well as a significant drop in estrogen levels. In premenopause, estrogen levels are mildly greater than in premenopausal women. Initially, the reduced quantity and quality of ovarian follicles leads to lower baseline estrogen levels that trigger a positive feedback increase in GnRH, FSH and LH. This rise causes increased estrogen secretion by the still functional ovaries. During menopause, this increase in gonadotropins does not affect estrogen levels due to the inability of the ovaries to produce estrogens.
 
Educational objective: Menopause is the permanent cessation of estrogen production due to a decreased number of ovarian follicles. Symptoms of menopause may be as subtle as having only mood swings and emotional lability.  Postmenopausal women have low estrogen levels but high levels of LH, FSH, and GnRH due to the lack of negative feedback on the anterior pituitary and hypothalamus
|AnswerA=A
|AnswerA=A
|AnswerAExp=This profile suggests a disease in the anterior pituitary which is unable to stimulate the ovaries to produce LH and FSH despite adequate hypothalamic input. In menopause, the primary dysfunction is the inability of the ovaries to produce estrogen
|AnswerAExp=This profile suggests hypogonadotropic hypogonadism due to a disease in the anterior pituitary, given the low levels of FSH and LH despite an increase in GnRH.
|AnswerB=B
|AnswerB=B
|AnswerBExp=This profile suggests a disease involving the hypothalamus, causing a lack or inadequate release of GnRH to optimally stimulate the anterior pituitary and ovaries
|AnswerBExp=This profile suggests hypogonadotropic hypogonadism involving the hypothalamus. This is due to an inadequate release of GnRH to optimally stimulate the anterior pituitary to release FSH and LH.
|AnswerC=C
|AnswerC=C
|AnswerCExp=This profile suggests menopause. This is a primary dysfunction of the ovaries to produce estrogen
|AnswerCExp=This profile is classically seen in patients with menopause menopause.
|AnswerD=D
|AnswerD=D
|AnswerDExp=In menopause, levels of estrogen should be low and not high.  Estrogen levels may be high in cases of estrogen-producing tumors of the ovaries, but in that case, the levels of LH, FSH and GnRH would be low due to the negative feedback effect
|AnswerDExp=The profile may be seen early in a normal menstrual cycle, when levels of FSH are high and and LH response has not yet mounted.
|AnswerE=E
|AnswerE=E
|AnswerEExp=In menopause, levels of estrogen should be low and not high
|AnswerEExp=This profile is commonly seen in patients with perimenopause. What differentiates it from menopause is the slight increase in estrogen levels, even compared to premenopausal women.
|RightAnswer=C
|EducationalObjectives=Perimenopause defines the time frame preceding menopause that may be characterized by irregular cycles, and certain symptoms of menopause. Classically gonadotropins are increased and estrogens are higher than normal levels in premenopausal women. The main defining factor that distinguishes the perimenopausal period from menopause is the cessation of menstruation for a period of 12 months, as well as a significant drop in estrogen levels.
|WBRKeyword=Menopause
|References=Santoro N, Brown JR, Adel T, Skurnick JH. Characterization of reproductive hormonal dynamics in the perimenopause. J Clin Endocrinol Metab. 1996;81(4):1495-501.
|Approved=No
|RightAnswer=E
|WBRKeyword=Perimenopause, Menopause, Irregular cycles, Estrogen, LH, FSH, Follicle stimulating hormone, Gonadotropins,
|Approved=Yes
}}
}}

Latest revision as of 01:20, 28 October 2020
Author [[PageAuthor::Serge Korjian M.D., Ayokunle Olubaniyi, M.B,B.S [1] (Reviewed by Serge Korjian)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Physiology
Sub Category SubCategory::Reproductive
Prompt [[Prompt::A 48-year-old woman with past history significant for hypothyroidism presents to the outpatient clinic with complaints of emotional lability. She reports excessive crying and irritable for the past 2 months. She denies any history of hot flashes or night sweats. She also reports that her menstrual cycles have seemed irregular for the past year, and have gotten longer than usual recently. Which of the following laboratory studies most likely belong to this patient?

]]

Answer A AnswerA::A
Answer A Explanation AnswerAExp::This profile suggests hypogonadotropic hypogonadism due to a disease in the anterior pituitary, given the low levels of FSH and LH despite an increase in GnRH.
Answer B AnswerB::B
Answer B Explanation AnswerBExp::This profile suggests hypogonadotropic hypogonadism involving the hypothalamus. This is due to an inadequate release of GnRH to optimally stimulate the anterior pituitary to release FSH and LH.
Answer C AnswerC::C
Answer C Explanation AnswerCExp::This profile is classically seen in patients with menopause menopause.
Answer D AnswerD::D
Answer D Explanation AnswerDExp::The profile may be seen early in a normal menstrual cycle, when levels of FSH are high and and LH response has not yet mounted.
Answer E AnswerE::E
Answer E Explanation AnswerEExp::This profile is commonly seen in patients with perimenopause. What differentiates it from menopause is the slight increase in estrogen levels, even compared to premenopausal women.
Right Answer RightAnswer::E
Explanation [[Explanation::This patient in this scenario is experiencing classical symptoms of perimenopause including mood swings, irritability, and irregular and lengthy cycles. Other typical symptoms are similar to those seen during menopause and may include: depression, fatigue, hot flashes, night sweats, and vaginal dryness. The main defining factor that distinguishes the perimenopausal period from menopause is the cessation of menstruation for a period of 12 months, as well as a significant drop in estrogen levels. In premenopause, estrogen levels are mildly greater than in premenopausal women. Initially, the reduced quantity and quality of ovarian follicles leads to lower baseline estrogen levels that trigger a positive feedback increase in GnRH, FSH and LH. This rise causes increased estrogen secretion by the still functional ovaries. During menopause, this increase in gonadotropins does not affect estrogen levels due to the inability of the ovaries to produce estrogens.

Educational Objective: Perimenopause defines the time frame preceding menopause that may be characterized by irregular cycles, and certain symptoms of menopause. Classically gonadotropins are increased and estrogens are higher than normal levels in premenopausal women. The main defining factor that distinguishes the perimenopausal period from menopause is the cessation of menstruation for a period of 12 months, as well as a significant drop in estrogen levels.
References: Santoro N, Brown JR, Adel T, Skurnick JH. Characterization of reproductive hormonal dynamics in the perimenopause. J Clin Endocrinol Metab. 1996;81(4):1495-501.]]

Approved Approved::Yes
Keyword WBRKeyword::Perimenopause, WBRKeyword::Menopause, WBRKeyword::Irregular cycles, WBRKeyword::Estrogen, WBRKeyword::LH, WBRKeyword::FSH, WBRKeyword::Follicle stimulating hormone, WBRKeyword::Gonadotropins
Linked Question Linked::
Order in Linked Questions LinkedOrder::
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