WBR0655

{{WBRQuestion |QuestionAuthor={{SSK}, Ayokunle Olubaniyi, M.B,B.S [1] (Reviewed by Serge Korjian) |ExamType=USMLE Step 1 |MainCategory=Physiology |SubCategory=Reproductive |MainCategory=Physiology |SubCategory=Reproductive |MainCategory=Physiology |SubCategory=Reproductive |MainCategory=Physiology |MainCategory=Physiology |MainCategory=Physiology |SubCategory=Reproductive |MainCategory=Physiology |SubCategory=Reproductive |MainCategory=Physiology |SubCategory=Reproductive |MainCategory=Physiology |SubCategory=Reproductive |MainCategory=Physiology |MainCategory=Physiology |SubCategory=Reproductive |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?

|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. |AnswerA=A |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 |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 |AnswerCExp=This profile is classically seen in patients with menopause menopause. |AnswerD=D |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 |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. |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. |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. |RightAnswer=E |WBRKeyword=Perimenopause, Menopause, Irregular cycles, Estrogen, LH, FSH, Follicle stimulating hormone, Gonadotropins, |Approved=Yes }}