Oligomenorrhoea –what hormone to test?? Oligomenorrhoea heralds heart attack & endometrial cancer

Oligomenorrhoea –what hormone to test??Endocrine evaluation of which women??  Ans:- Endocrine evaluation is a must for 1) PCOS, 2) secondary amenorrhoea(Non-PCOS) 3)  all anovulation women,4)  woman suffering from galactorrhea(now termed as inappropriate  lactation) , 5) those women with clinical cutaneous features of androgen excess disorders like  acne, alopecia, hirsutism, & 6)  Insulin resistance likely( Acanthosis nigricans ) , 7) all obese women-warrant detailed endocrine evaluation to arrive at a definitive diagnosis. These seven groups of women and 8)  women heading for induction of ovulation and 9) unexplained infertility mandate detailed but selective endocrine evaluation-though most cannot afford. An experienced astute clinician can select which hormone to test –and other endocrine test at a later date.

  Which hormones yto tests for PCOS?? Ans:- PCOS  is a syndrome . Many nonPCOS  diseases can therefore  mimic/present as PCOS which again may I remind U iy asyndrome and cluster of several diseases,. However PCO women may be ovulatory and can have early  pregancy without any agent. These cases are ovulatory PCO . Fertile or not fertile –this criteria onec usxed for PCO classification do not hold good now, Infertility alone is  not sufficient to simply stamp a woman as PCOS. Neither all PCOS are endocrinologically alike,

We have to find the exact endocrine abnormality in a given PCOS and select most suitable treatment for her. In fact adolescent PCOS also mandate diagnosis of exact endocrine disorder for the origin of PCOS and then select appropriate treatment protocol. In such adolescents- it is more due to cardio-metabolic aberration induced by “Adiponectin-Leptin-Ghrelin-insulin disorder “backed up tyrosine kinase activity disorders. In fact we formulate the treatment plan to treat a PCOS on the bases of her hormonal aberration which are not alike in all PCOS. Some exhibit high insulin or high androgen levels, some exhibit hyperprolactinaemia, high DHEASO4 or rarely cortisol. The clinician cannot ask for testing all the six hormones. Then what is the way out?? At first one can clinically classify in which group she falls and then select the exact hormones she have to be investigated. Phenotypic analysis helps us to select which hormones to test- test by exclusion.

 Tail of snake is oligomenorrhoea à It heralds Heartattack ny 15 yrs time in most cases !! To remember oligomeno or infrequent M periods preceds endometraiol Ca  or Heart  attack or Brain  stroke  by about  10-16 yrs . As such Oligomenorrhea iks not ato be viewed as reproductive tracgt diosrdeers only, cardio metabolic risk outstrips reproductive desirs .   Which hormone to test in cases of oligomenorrheic teenage girl?? Opinion varies. The problem is there are many causes of oligo which are almost always of endocrine origin. Only few oligo are  stress related. If she does not want fertility (imagine someone has completed family and had tubectomy  and she has reported to U with solo complaint of oligoà>–her only concern is delayed periods )   then too one has to establish the cause of oligo for two reasons A) Risk of endo hyperplasia B) Metabolic aberrations, abnormal Lipid profile  in particular, including  premature atheroma formation , The order of or sequence of hormones tets well opinion varies . However the final diag of etiology of oligo  diagnosis is by exclusion . We know that subfertile oligomenorrhoic women may be due to following  uncommon clinical syndromes in addition to three common causes of oligo like insulin resistance, hyperandrgenaemia, Leptin & LH pulse disorders. Such uncommon diseases which can cause menstrual  disorders are) NC-CAH (Nonclassic adrenal hyperplasia), 2) Cushing syndrome, 3) Virilizing ovarian tumour-all presenting with evidence of hyperandrogenism. The other four conditions which usually present as PCOS 4) hypothyroid, 5) hyperprolactinaemia, 6) acromegaly, and 7) premature ovarian failure (Oligomenorrhoea, weight gain, ovarian enlargement) are. Sometimes 8) drug-related hyperandrogenism may report to us.   clinical conditions And each disease mandate different treatment protocol for their primary disease and also for treatment of subfertility. Continuum of symptoms:    To whom to consider that it is classical PCOS? The problem is that all the four features of PCO are not present in all cases of PCO and even if present do not express in equal severity. The problem is that symptoms appear as spectrum of symptoms and signs the occurrence which is dissimilar. It is a continuum and we have to add more endocrine tests as new symp and fresh clinical signs appear. The usual sequence is menst irregularity à wt gain marked at waist Acne/slight hair growthàslight aberrations in M. cyclesàWt gainà Unnecessary hormone testing It is true that selections of endocrine tests is guided by the personal and then present history. We often miss this and do unnecessary hormone testing like androgen levels and PRL, Cortisol, DHEASO4 in all cases of PCOS who do not need it.

But if a girl was born in mother who had PCOS, hyperandrogenism, dyslipidaemia, & now that mother are diabetic then there is a resin to believe that this adolescent girl is suffering from adolescent Classical PCOS.A low birth weight, premature puberache (appearance of pubic hairs befor the age of 8 years.)-need much vigilance for onward development of PCOS. Puberache is an expression of premature activation of Hypothalamo-Pituitary-Adrenal axis

Hirsutism: Such clinical conditions which mimic PCOS (oligomenorrheic/ eumenorrhoic) and with without hirsutism mandate endocrine evaluation to arrive at a definitive clinical diagnosis. Such condition are 1) NC-CAH (Nonclassic adrenal hyperplasia), 2) Cushing syndrome, 3) Virilizing ovarian tumour-all presenting with evidence of hyperandrogenism. The other four conditions which usually present as PCOS 4) hypothyroid, 5) hyperprolactinaemia, 6) acromegaly, and 7) premature ovarian failure (Oligomenorrhoea, weight gain, ovarian enlargement) are. Sometimes 8) drug-related hyperandrogenism may report to us. Elicit detailed drug history before much money is spent on hormone testing with an erroneous diagnosis of PCOS of endocrine disorder.

In cases of dysthyroidism both TSH and T4 measurements are essential.

Premature Ovarian Failure: - One should insist on endocrine confirmation.

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The issue of Hyperprolactinaemia.

If two fold raise that will speak of hyperprolactinaemia. In 20-40% of clinically diagnosed PCOS PRL will be slightly raised but to diagnose that PRL is the primary cause of PCOS (no other endocrine disorder) - then there should be at least two fold rise of PRL. This is due to hyperoestrinismà activation of Lactotrophsà more release of PRLà mastodynia, tenderness of breasts and bloating. If less than double level-do not treat by dopamine agonist. Better treat by Insulin sensitizers if unmarried and by OCP if married and does not seek for restoration of fertility Role of estimating 17 hydroxyl progesterone.

This is a screening test for CAH (adult onset type) which is also called as NCAH-non classic Adrenal Hyperplasia.

 The sample should be drawn in early follicular phase and the result should be normally

Stress and Female Subfertility...

Causes of elevated DHEASO4 1) attenuated adrenal enzyme deficiency- proved by ACTH stimulation test; 2) Cushing syndrome & Adrenal Tumours are uncommon causes of raised DHEASO4,

In cases of documented NC-CAH & also in cases where there has been repeated anovulation inspite of CC- then administration of dexamethasone will increase the adrenal pool of androgens.

In some cases it will improve the ovulation rate. 

But after one month of initiation of dexa- morning cortisol should be done to assess the degree of suppression of endogenous cortisol by exogenous Dexa. If cortisol is< 3 mcg./mlàthen the dose of Dexa should be decreased. It is not used in pregnancy,