A 27-year-old woman comes to the physician because of irregular menstrual periods and failure to conceive. She was on oral contraceptive pills for 4 years for irregular menstrual periods, which she discontinued 7 months ago. She has never before tried to become pregnant. There is no history of hirsutism or abdominal striae. She has no other medical problems and takes no medications. She has a sedentary desk job at a research laboratory. She does not smoke cigarettes or drink alcohol. Her partner is in good health, and his semen analysis is normal.
Her blood pressure is 126/78 mm Hg and pulse is 72/min. Her BMI is 30 kg/m². Physical examination, including bimanual pelvic examination, is unremarkable.
Laboratory investigations performed on the 2^nd day of her menstrual cycle reveal:
Mid-luteal phase progesterone is very low, indicating that she is not ovulating. Her fasting venous glucose level is 104 mg/dL.
Which of the following is the most appropriate initial treatment for her ovulatory dysfunction?

Question

A 27-year-old woman comes to the physician because of irregular menstrual periods and failure to conceive. She was on oral contraceptive pills for 4 years for irregular menstrual periods, which she discontinued 7 months ago. She has never before tried to become pregnant. There is no history of hirsutism or abdominal striae. She has no other medical problems and takes no medications. She has a sedentary desk job at a research laboratory. She does not smoke cigarettes or drink alcohol. Her partner is in good health, and his semen analysis is normal.
Her blood pressure is 126/78 mm Hg and pulse is 72/min. Her BMI is 30 kg/m². Physical examination, including bimanual pelvic examination, is unremarkable.
Laboratory investigations performed on the 2^nd day of her menstrual cycle reveal:

Mid-luteal phase progesterone is very low, indicating that she is not ovulating. Her fasting venous glucose level is 104 mg/dL.
Which of the following is the most appropriate initial treatment for her ovulatory dysfunction?

Quizplus · Accepted Answer

11ec193a_97a2_a91a_853d_c7fdcf417b22_MD0002_00 This patient has subclinical hypothyroidism, defined as elevated TSH (< 10 µU/mL) and normal T4 with nonspecific symptoms suggestive of hypothyroidism. Subclinical hypothyroidism is more common in females than males and is usually due to Hashimoto's thyroiditis, which is characterized by positive anti-thyroperoxidase antibodies (ATPA). Progression from subclinical to overt hypothyroidism is more likely in patients with positive ATPA. Ovulatory dysfunction is common in both overt and subclinical hypothyroidism and usually improves with levothyroxine treatment. Levothyroxine is recommended in all patients with TSH > 10 µU/mL. Patients with a TSH between the upper limit of normal and 10 µU/mL should be considered for treatment if they are pregnant or symptomatic, or if they have ovulatory dysfunction, cardiovascular risk factors (e.g., hypercholesterolemia), goiter, or positive ATPA. This patient has ovulatory dysfunction and would likely benefit from levothyroxine therapy. (Choice A) Subclinical hypothyroidism can cause a slight elevation of serum prolactin. Levothyroxine therapy should decrease the prolactin level in this patient, eliminating the need for bromocriptine. (Choice B) Clomiphene is a selective estrogen receptor modulator which induces ovulation by blocking the estrogen receptors in the hypothalamus. Clomiphene may be used in this patient if she fails to ovulate and conceive with levothyroxine alone. (Choices C & E) Weight loss and metformin improve ovulatory dysfunction in patients with polycystic ovarian syndrome (PCOS), which usually presents with at least 2 of the following 3 criteria: clinical or biochemical hyperandrogenization, oligoovulation, and ovarian cysts. The patient is overweight, but she does not exhibit the diagnostic criteria for PCOS. Educational objective: Subclinical hypothyroidism can be associated with ovulatory dysfunction, which may improve with levothyroxine treatment. Treatment is also considered in patients with positive anti-thyroperoxidase antibodies, goiter, pregnancy, overt symptoms, or cardiovascular risk factors. __________ References: Subclinical thyroid disease: scientific review and guidelines for diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/14722150) Infertility and thyroid disorders. (http://www.ncbi.nlm.nih.gov/pubmed/16794427)

A 27-Year-Old Woman Comes to the Physician Because of Irregular