Presentation made in December 2018. Some interesting cases pertaining to Endocrine disorders in Women

1. Interesting Endocrine
cases in women
DR. OM J LAKHANI
CONSULTANT ENDOCRINOLOGIST
ZYDUS HOSPITAL, AHMEDABAD & ANAND

2. Case 1

3. A 29 year old married woman comes
with history of Oligo-amenorrhea
and whitish discharge from the
nipple

4. She has past history of Dyspepsia
for which she is taking multiple
medications

5. Prolactin value is 60 ng/dl
Repeat value is also 70 ng/dl

6. What would you do next
?
A) Start Cabergoline
B) Ask for an MRI Pituitary
C) Both A and B
D) Neither A nor B

7. What would you do next
?
A) Start Cabergoline
B) Ask for an MRI Pituitary
C) Both A and C
D) Neither A nor C

8. A MRI was ordered by her physician
which was Normal

9. We reviewed her drug history and we
found she was taking

10. We stopped the medication,
reviewed the patient again after 2
months and found that Prolactin to
be 18 ng/dl and nipple discharge had
stopped

11. Case 1 - Lessons to learn

12. PROLACTIN VALUE
AND DIAGNOSIS
Value of Prolactin often gives hint of the diagnosis
Value of 30-40 ng/dl - typically can be seen in PCOS
Again, 30-40 ng/dl- may be typically associated with Drugs
like Metoclopromide or Domperidone
Values of 70-80 ng/dl- May be drug induced due to
Levosulpiride
Values of >100 ng/dl- Thing of Pituitary tumors and ask for
an MRI

13. Antagonists against the Dopamigeric
D2 receptors often produce
hyperprolactinemia

14. Domperidone, Metoclopromide and
Levosulpiride are common culprits

15. Anti-Psychotic drugs like
Risperiodone can cause SEVERE
hyperprolactinemia- often values in
100s

16. If Drug induced hyperprolactinemia
is suspected- it is not a bad idea to
review the patient again after
stopping the offending drug.

17. Case 2

18. This is a case of a 61 year old female.
She was complaining of weakness and fatigue for a
long time.
Someone ordered a TSH, which was 6.3 ng/dl

19. What would you do next
?
a) Get a complete thyroid function- T3, T4 and TSH
b) Ask for Anti-TPO antibody
c) Both A and B
d) Neither A nor B

20. What would you do next
?
a) Get a complete thyroid function- T3, T4 and TSH
b) Ask for Anti-TPO antibody
c) Both A and B
d) Neither A nor B

21. We ordered a thyroid function which
shows
T3 and T4- Reduced
TSH- 6.3
Anti-TPO- negative

22. What does this suggest ?
a) Subclinical hypothyroidism
b) Overt Primary hypothyroidism
c) Possible central hypothyroidism
d) Normal thyroid function

23. What does this suggest ?
a) Subclinical hypothyroidism
b) Overt Primary hypothyroidism
c) Possible central hypothyroidism
d) Normal thyroid function

24. T3 and T4- Normal
TSH - elevated
Subclinical Hypothyroidism

25. T3 and T4- Low
TSH - Elevated- value >20 mIU/ml
Overt Primary hypothyroidism

26. T3 and T4- Low
TSH - Elevated- value <20 mIU/ml
(some use 10 as cut-off)
Think of Central hypothyroidism

27. T3 and T4- Low
TSH - Normal
Think of Central hypothyroidism

28. T3 and T4- Low
TSH - low
Think of Central hypothyroidism

29. We ordered test for anterior pituitary
function
S. Cortisol- low
FSH and LH - low
Prolactin - also low

30. Q. What happens to FSH and LH in a
post-menopausal woman ?

31. On taking a detailed history, the patient revealed she
had a history of post-partum hemorrhage 23 years
back in her last delivery.
Following this she had amenorrhea and lactational
failure.

32. We ordered an MRI which showed
the following :

34. Q. What is the Diagnosis ?

35. Q. What is the Diagnosis ?
Sheehan’s syndrome

36. Lessons from case 2-
When to suspect
Sheehan’s ?

37. Low T4, Low T3 with Normal, High or Low TSH

38. History of severe Post-Postpartum haemorrhage

39. History of Lactational failure after delivery

40. History of Secondary amenorrhea persistent after
delivery

41. Unexplained Hyponatremia and Hypoglycemia

42. Characteristic pale, listless face.

43. Empty sella on an MRI

44. Case 3

45. This is a case of a 28 year old
Primigravida
10 weeks of pregnancy

46. Presents with Hyperemesis
gravidarum

47. A thyroid function test is ordered
which shows elevated T3 and T4 with
low TSH

48. What would you do next
?
a) Start Carbimazole
b) Start PTU
c) Evaluate further

49. What would you do next
?
a) Start Carbimazole
b) Start PTU
c) Evaluate further

50. A TSH Receptor antibody was
ordered - which was negative

51. Our Diagnosis - Gestational
thyrotoxicosis

52. Patient was closely followed-up
during pregnancy- thyroid function
remained normal subsequently

53. Q. Which hormone is responsible for
Gestational thyrotoxicosis ?

54. Q. Which hormone is responsible for
Gestational thyrotoxicosis ?
Answer- HCG

55. Gestational thyrotoxicosis can be
differentiated from Graves’ disease
by
a) TSH Receptor antibody
b) Thyroid ultrasound and Doppler

56. Gestational thyrotoxicosis can be
differentiated from Graves’ disease
by
a) TSH Receptor antibody
b) Thyroid ultrasound and Doppler

57. Gestational thyrotoxicosis does not
require any treatment
While Graves’ disease needs to be
treated

58. Case 4

59. A 30 year old primigravida is referred
to me with following results on OGTT
Fasting- 81 (>92)
1 hr – 207 (>180)
2 hr- 186 (>153)

60. She has a strong family history of
Diabetes mellitus
Diagnosed to have GDM in last
pregnancy

61. She had previously undergone only
Fasting plasma glucose twice both
of which were normal.

62. Gestational diabetes is often missed
out when diagnosed using fasting
plasma glucose- OGTT is the
diagnostic test for GDM

63. We started her on Metformin + 1800
Kcal meal plan- followed her up with
CGMS

65. Target values of Gestational
diabetes in pregnancy
Fasting <95 mg/dl
1 hr post meal <140 mg/dl
2 hr post meal <120 mg/dl

67. Results 1
Metformin compared to insulin lowered the risk of neonatal
hypoglycaemia [risk ratio (RR) = 0.63; 95% confidence
interval (95% CI), 0.45 to 0.87]
large for gestational age babies (RR = 0.80; 95% CI, 0.64 to
0.99)
pregnancy-induced hypertension (RR = 0.56; 95% CI, 0.37
to 0.85)
total maternal pregnancy weight gain [mean difference (MD)
-2.07; 95% CI -2.88 to -1.27].

68. Results 2
Metformin compared to insulin did not increase
preterm delivery (RR = 1.18; 95% CI 0.67 to 2.07)
small for gestational age babies (RR = 1.20; 95% CI,
0.67 to 2.14)
perinatal mortality (RR = 0.82; 95% CI, 0.17 to 3.92)
Caesarean section (RR = 0.97; 95% CI, 0.80 to 1.19).

69. Lessons from Case 4

70. Screen all Indian women for GDM-
using OGTT

71. CGMS is useful for monitoring such
women

72. Metformin is useful and safe in GDM

73. Case 5

74. A 28 year old Primigravida
Routine thyroid function test was
done in First trimester

75. Total T3- Normal
Total T4- Normal
TSH - 3.8 mIU/ml

76. Anti-TPO antibody - negative

77. Anti-TPO antibody - negative

78. What would you do next
?
a) Start Levothyroxine
b) Wait and watch - repeat thyroid function after an
interval.

79. What would you do next
?
a) Start Levothyroxine
b) Wait and watch - repeat thyroid function after
an interval.

81. Lesson from Case 5

82. Newer ATA recommendation for
Hypothyroidism in Pregnancy do not
recommend the use of LT4 in when
with Subclinical hypothyroidism
having TSH 2.5-4.0 with anti-anti-TPO
negative.

84. Join our WhatsApp Group
Endocrine Disorders in Women
+91 9871009021 for being added to the
group

85. Thank you !