Answer a) discuss the most likely cause of her complaint
commonest cause is pregnancy .Premature ovarian failure to be considered.Polycystic ovarian diasease is a cause.In case of any recent delivery in the last 10 to 11 months lactational amenorrhoea likely cause.Incase no such history of delivery hyperprolactinemia is a cause for sec.amenorrhoea.Hyperandrogenism too could manifest as secondry amenorrhoea.If she had a dand c in the past -Ashermans syndrome as a complication of that dand c could lead to secondry amenorrhoea.
b)clinical assessment Any obstetric history -time of last delivery she could be breast feeding-hence sec. amenorrhoea.
pregnancy ,any nausea and vomiting afew months ago.If she feels any foetal movements.Any increase in weight gain,,acne,hirsuitism,,may suggest polycystic ovarian syndrome,or,if viriliuzation-clitoromegaly,or rapid virilization,breast atrophy,masculinization ,in case of hirsuitism use ferriman galliwey score.This may indicate androgen producing tumours..To enquire if she has hot flushes,cold intolerence,could be premature ovarian failure or hypothyroidism.To check for galactorrhoea for hyperprolactinoma as part of clinical assessment..To do an abdominal and pelvic examination.
c)justify the investigations to establish diagnosis..
Firstly pregancy test preferrably s. beta hcg.For premature ovarian failure (POF)do serum fsh and lh.High FSH indicatesPOF.Thyroid stimulating hormone and s. prolactin shows primary endocrine disorder.Serum Testosterone ,sex hormone binding globulin shows the free androgen index.High s.testosterone levels indicate pcos,but very high levels of testosterone mean an androgen tumour.DHEA and DHEAS identify adrenal hyperandrogenemia.Late onset CAH diagnosed by 17-OH progesterone levels.Usg pelvis to check for polycystic ovaries,as well as any mass in pelvis.
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