EMQs

1. Pakistan Society Of Chemical PathologistsDistance Learning Programme In Chemical PathologyLesson No 16Female Reproductive Endocrinology(Short Name: FRE)By Surg Commodore AamirIjazMCPS, FCPS, FRCP (Edin)Professor of Pathology / Consultant Chemical PathologistBahria University Medical &Dental College / PNS SHIFA Karachi

2. EMQs

3. Options Anovulatory cycle Idiopathic HypogonadotropicHypogonadism Hyperprolactinaemia Normal Profile in Non-Pregnant Normal Profile in Pregnant Polycystic Ovaries Polycystic Ovary Syndrome Post-menopausal levels Primary Ovarian Insufficiency Turner`s Syndrome

4. b. Idiopathic HypogonadotropicHypogonadism Q 1. A 19 y old girl is having Primary Amenorrhea. Her hormonal profile is as following:• FSH: 2.0 mIU/mL• LH: 1.2 mIU/mL• Oestradiole: 20 pmol/L• Progesterone: 0.31 ng/mlWhat is the most probable diagnosis in this patient?

5. Normal Hypothalamo-Pituitary-Gonadal Axis HYPOTHALAMUS GnRH PITUITARY FSH LH GONAD Steroids Gametes

6. Normal Menstrual Cycle

7. Females: Males: Breasts: age 9-11 Pubic hair: 8-9 Growth spurt: 12 Menses: age 12 Testes: age 10-11 Pubic hair: 10-11 Penile growth: 13 Growth spurt: 14 Normal Pubertal Milestones

8. Delayed Puberty Females: No breast development: age 13 No menses: age 15 Males: No testes development: age 14

9. HypogonadotrophicHypogonadism Hypogonadotrophic hypogonadism (HH) is characterized by absent or decreased function of the female hypothalamus, pituitary and ovarian hormone . Inappropriately low serum concentrations of LH and FSH, which is an effect of GnRH deficiency. HH is caused by number of pathological processes, But it can occur as a part of various congenital syndromes. Idiopathic HH in which secondary causes of HH had been excluded.

10. Congenitalhh • Idiopathic Hypogonadotropic Hypogonadism (IHH)Kallmann syndrome          Adult onset IHH          Fertile eunuch syndrome          Adrenal Hypoplasia Congenita • Genetic defects of the gonadotropin subunitsHH associated with other pituitary hormone deficiencies • HH associated with obesityPrader-Willi syndrome          Laurence- Moon-Biedl syndrome

11. Acquired HH Structural          TumorsCraniopharyngiomas                    Pituitary adenomas (e.g. prolactinoma, non functioning tumor)Germinoma, glioma, meningioma          Infiltrative disorders                    Sarcoidosis, hemochromatosis, histiocytosis X          Head trauma          Radiation therapy          Pituitary apoplexyFunctional          Exercise          Dieting          Anabolic steroidsGlucocorticoid therapy          Narcotics          Critical illness

12. Idiopathic HH (IHH) IHH also called isolated GnRH deficiency, caused by selective impairments of the hypothalamic-pituitary axis resulting in inappropriately low gonadotropin secretion with otherwise normal pituitary function. is characterized by a failure of initiation of puberty due to insufficient gonadotropin release, thus resulting in failure to develop secondary sexual characteristics and a mature reproductive system. 30% of IHH cause by genetic defects Estimated Prevalence of IHH 1 in 4,000 to 1 in 10,000 male Female effect 2-5 times < than male (male: female ratio is 4:1).

13. Kallman Syndrome • IHH was first reported with insomia called Kallman syndrome (KS) • When embryonic migration of GnRH neurons from the nasal placode to their final destination in the hypothalamus is disturbed, resulting phenotype is Kallman syndrome (KS) characterized by HH and insomia. • Normosmic IHH (nIHH) has been observed • Both chromosomal and single gene mutation have been identified in patient with IHH, KS

14. Diagnosis of IHH / KS Presence of both suggestive clinical findings and laboratory findings and absence of secondary causes of HH. Detail history and physical examination with the assessment of secondary sexual characteristics, and family history Assessment of olfaction to detect hyposmia, examination of outer ear and hearing to rule out mild CHARGE syndrome In nIHH can be revealed by isolated chronic an ovulation, whereas oestradiol secretion is almost normal. Ultrasound pelvis for uterus and ovaries development MRI brain Olfactory bulb Renal ultrasound for Kallman syndrome

15. LABORATORY DIAGNOSIS Serum oestradiol < 40 pg/ml (110 pmol/L) Serum LH <10 IU/L Serum FSH <10 IU/L GnRH stimulation test

16. i. Primary Ovarian Insufficiency Q 2. A 35 years old female complains of Menstrual Irregularity. Her hormonal profile is as following (LMP not known):• FSH: 87 mIU/mL• LH: 22 mIU/mL• Prolactin: 15 ng/ml (Upper Reference Value: 20 ng/ml)• Testosterone: 0.65 nmol/L (0.53 -2.43 nmol/L)What is the most probable diagnosis in this patient?

17. Primary Ovarian Insufficiency (POI)

18. Synonyms Premature Menopause Premature Ovarian Failure Primary Ovarian Failure Primary Ovarian Insufficiency

19. Salient Features Affects 1% of women Age < 40 years May not be permanent Spontaneous recurrence of ovarian function and even pregnancy are possible

20. Amenorrhoea Climacteric Symptoms Raised FSH - Reduced Oestradiol Biopsy unhelpful Diagnosis

21. Idiopathic Chromosomal abnormalities Turner’s syndr., X chromosome deletions Autoimmune Galactosaemia Radiotherapy / Chemotherapy Surgery – TAH, BSO, Ovarian Cystectomy Infection - Mumps, TB. Causes of Premature Menopause

22. Representative Syndromes with Which Spontaneous 46,XX POI Has Been Associated Nelson L. N Engl J Med 2009;360:606-614

23. Mechanisms and Causes of Spontaneous POI Nelson L. N Engl J Med 2009;360:606-614

24. Clinical States Included in the Spectrum of POI Nelson L. N Engl J Med 2009;360:606-614

25. A Typical Patient with POI • A 30-year-old woman presents with a history of no menses since she stopped taking oral contraceptives 6 months ago in order to conceive. • She had undergone puberty that was normal in both timing and development, with menarche at 12 years of age. • At 18 years of age, she started taking oral contraceptives for irregular menses. • She reports stress at work. • Her weight is 59 kg, and her height 1.66 m; her body-mass index is 21.3. • There is no galactorrhea, hirsutism, or acne.

26. A Typical Patient with POI (cont) • The pelvic examination is normal. • A pregnancy test is negative. • The prolactin level is normal • FSH level is in the menopausal range. • May lead to emotional problems • There is 5-10% chances of conception

27. d. Normal Profile in a Non-pregnant Q 3. A 28 years old female with Secondary Infertility (two live babies). Her Follicular Phase hormonal profile is as following:• FSH: 7.2 mIU/mL• LH: 8.6 mIU/mL• Prolactin: 10.2 ng/ml (Upper Reference Value: 20 ng/ml)• Testosterone: 1.7 nmol/L (0.53 -2.43 nmol/L)What is the most probable diagnosis in this patient?

28. h. Post-menopausal levels Q 4. A 52 years old female complains of Secondary Amenorrhoea. Her Hormonal profile is as following:• FSH: 104 mIU/mL• LH: 47 mIU/mL• Prolactin: 5 ng/mlWhat is the most probable diagnosis?

29. g. Polycystic Ovary Syndrome Q 5. A 25 years old female with Primary Infertility. Her hormonal profile is as following (LMP not known):• FSH: 6 mIU/mL• LH: 5 mIU/mL• Prolactin: 16 ng/ml (Upper Reference Value: 20 ng/ml)• Testosterone: 5.4 nmol/L (0.53 -2.43 nmol/L)Her Biochemical Profile is indicative of which disorder?

30. i. Primary Ovarian Insufficiency Q 6. A 38 years old female complains of Menstrual Irregularity. Her hormonal profile is as following (LMP not known):• FSH: 69 mIU/mL• LH: 14 mIU/mL• Prolactin: 14 ng/ml (Upper Reference Value: 20 ng/ml)What is the most probable diagnosis in this patient?

31. e. Normal Profile in Pregnant Q 7. A 29 years old female complains of Secondary Amenorrhoea. Her hormonal profile is as following:• FSH: 1 mIU/mL• LH: 1.5 mIU/mL• Estradiole: 3.4 ng/ml

32. The hormones during pregnancy: • Estradiole is increased thousands of folds (in ng/ml rather than in pg/ml in non-pregnancy) • FSH and LH are markedly reduced • Placental hormones like HCG, HPL, Relaxin, Inhibin are increased

33. BCQs

34. e. Pituitary hCG. Q 8. A 49 years female is being investigated for Secondary Amenorrhoea. Her urine pregnancy test is negative but Serum Beta hCG is 7.2 mIU/ml. There is no previous history of any disorder of Obstetrics or Gynaecology. Consultant Gynaecologist seeks your opinion about this hCG result. What could be the most probable cause of this mild rise of hCG:a. Foetal abnormalityb. Gastric Trophoblastic Diseasec. Normal Pregnancyd. Ovarian Malignancye. Pituitary hCG

35. b. Detection of ectopic pregnancy Q 9. Clinical situation when result of Beta HCG is urgently required:a. Antenatal detection of trisomy 21b. Detection of ectopic pregnancyc. Diagnosis choriocarcinomad. Diagnosis of hydatidiform molee. Pregnancy Test in urine

36. Detection of pregnancy Diagnosis of Ectopic Pregnancy (as an emergency test) Diagnosis and monitoring of Abortion (may be an emergency test) Tumor marker for Hyditifom Mole and Choriocarcinoma Tumour marker for testicular tumours Part of the maternal triple test. Indications of Beta HCG estimation

37. a. Choriocarcinoma Q 10. A 36 years female is suspected of Gestational Trophoblastic Disease (GTD). Her total hCG is 22,344 mIU/ml while HyperglycosylatedhCG (hCG-H) is 72% of the total hCG. What is the most probable diagnosis in this patient?a. Choriocarcinomab. Complete hydatidiform molec. Invasive moled. Partial hydatidiform molee. Placental site trophoblastic tumour

38. HyperglycosylatedhCG (hCG-H) It is an emerging marker related to HCG More useful in the diagnosis of pregnancy and Gastric Trophoblastic Disease (GTD). Higher Percentage of hCG-H indicates more invasive nature of GTD. (for details plz see article posted by Dr HumairaAsif in PSCP Facebook group)

40. a. High FSH at Day 3 of the menstrual cycle . Q 11. A 28 y old woman is to undergo an IVF procedure. She has been referred to you for assessment of ovarian reserves. Which of the following results will be an indicator of Poor Ovarian Reserve:a. High FSH at Day 3 of the menstrual cycle .b. Low estradiole at Day 3 of the menstrual cyclec. Low Progesterone at Day 20 of the menstrual cycled. Low Prolactin e. Low Testosterone

41. c. Serum estriol (E3) Q 12. The test included in the Triple Screening carried out in the maternal serum to rule out various abnormalities is: a. Serum androsteindioneb. Serum estradiole (E2) c. Serum estriol (E3) d. Serum estrione (E1) e. Serum progesterone

42. Triple Test (B-HCG, a-fetoprotein and estriol) is an example of maternal screening used in developed world. Triple test is carried out in maternal serum of all expectants to diagnose fetal abnormalities and placental well-being. Maternal Screening

43. SAQs

44. Q:13: You are a newly posted Consultant Chemical Pathologist in a Teaching Hospital. Dr Huma is your class-mates and is working as Consultant in Gynaecology and Obstetrics in the same hospital. On her first visit to your office she discusses the use of Luteal Phase Serum Progesterone as a diagnostic test for ovulation. She requests to make this test useful for her patients by solving following queries: Which is the exact day of the menstrual cycle when Serum Progesterone should be tested for assessment of ovulation? In a patient with irregular cycles how the day of sample collection should be determined? What cut-off value of Serum Progesterone is indicator of ovulatory cycles? .

45. Suggested Answer to Q.13a Which is the exact day of the menstrual cycle when Serum Progesterone should be tested for assessment of ovulation?  Day 21 of the Menstrual Cycle

46. Suggested Answer to Q.13b In a patient with irregular cycles how the day of sample collection should be determined? It should really be taken 7 days post ovulation If bleeding does NOT start 6-8 days after the test-repeat the test Excellent replacement of D&C

47. Suggested Answer to Q.13c What cut-off value of Serum Progesterone is indicator of ovulatory cycles? If > 10 ng/ml -ovulatory On a medicated cycle >15ng/ml Should be repeated in women > 30 y

48. Q:14:Hyperprolactinaemia is a common Endocrinal finding in females. While interpreting its reports a Consultant Chemical Pathologist can face various diagnostic dilemmas. Please give your opinion in following varied situations of hyperprolactinaemiain females: Serum Prolactin level in a 24 years female is 245ng/ml (Upper Reference Value: 20 ng/ml). Name Two Physiological causes which can cause this much high Prolactin level. A neurosurgeon has called you to complain about a Serum Prolactin Report of 34 y female, generated from your lab. Your result was 122 ng/ml (Upper Reference Value: 20 ng/ml) while imaging clearly showed a macroadenoma which is usually associated with very high prolactin in the range of 4000-5000 ng/ml.   What could be the technical reason of this result and how will you solve this issue? Serum Prolactin level: 82 ng/ml (Upper Reference Value: 20 ng/ml). She has no significant gynaecological problem. No physiological causes or associated pathological conditions could be found. All her imaging investigations are normal.   Can you delineate an important cause of this Hyperprolactinaemia and how will you confirm this cause by using some lab technique?

49. Suggested Answer to Q.14a Serum Prolactin level in a 24 years female is 245ng/ml (Upper Reference Value: 20 ng/ml). Name Two Physiological causes which can cause this much high Prolactin level.  Pregnancy (35 to 600 ng/ml) : It is due to very high Oestradiole. First 4-6 weeks of suckling: The level can be as high as in pregnancy. It is again due to high (but dwindling) Oestradiole in post-partum period. With decreasing Oestradiole Prolactin decreases and in major part of lactation it remains only mildly increased (Plz see next slide) In all Physiological and Associated Pathological causes (e.g. Hypothyroidism) there is mild hyperprolactinaemia.