The reason germ-cell tumors are less common in females is because a female germ-cell system only produces one egg per month (approximately 300-400 in a female’s life), whereas a male germ-cell system produces about 525 billion sperm cells over a lifetime. Less active cell multiplication means smaller chance of abnormal cell division.
Oral contraceptive pills (OCPs) with estrogen and progesterone are first-choice agents. (In ovulatory dysfunction, it is important to decrease the risk of endometrial hyperplasia and cancer, by counteracting the effect of unopposed estrogen.)
For hemodynamically unstable patient, NSIM is intrauterine tamponade (balloon or gauze packing), then uterine curettage. For persistent bleeding, start IV estrogen. Emergency hysterectomy might be needed in refractory cases.
• If there is no obvious etiology, NSIDx is MRI to look for pituitary disorders. Sheehan’s syndrome (postpartum pituitary necrosis) is a potential cause, if there is a history of pregnancy-related hemorrhage.
eThe idea behind progestin challenge is that a woman with sufficient estrogen level will have withdrawal bleeding after a dose of progesterone, indicating that amenorrhea is likely due to progesterone deficiency, e.g., chronic anovulation in conditions such as PCOS.
Hypergonadotropic hypogonadism (menopause or premature ovarian failure) a
Normal or slightly highb
PCOS is a diagnosis of exclusion: rule out conditions that present similarly to PCOS (i.e., other causes of late-onset virilization and hyperandrogenism). Check 17-OH progesterone level, TSH, prolactin, IGF-1, cortisol, and testosterone levels.
Ovarian hyperthecosis (idiopathic hyperplastic increase of luteinized thecal cells that overproduce androgen)a
aThis is thought to be due to genetic mutation. Similar in pathophysiology, luteoma (which can occur with normal pregnancy) and hyperreactio luteinalis (associated with abnormally high β-hCG, which occurs with multiple gestation, molar pregnancy, ovulation induction, etc.) can result in transient hyperandrogenism.
Metformin is used as an adjunctive treatment in patients with obesity, diabetes mellitus (DM), or impaired fasting glucose.c
Formulary: A 28-pill OCP pack has 21 hormone pills (known as active pills). The additional seven pills are placebo pills (containing sugar or iron) to help the user stay in the habit of taking a pill every day.
Mechanism of action: Combination of estrogen and progesterone prevents mid-cycle LH surge and follicular maturation. Progesterone also works by making endometrium less suitable for implantation, and by making cervical mucus thick (this might be the reason for the decreased risk of PID).
Rx: Exercise and heat application is 1st line. If not responding, 2nd line is NSAIDs like ibuprofen or hormonal therapy (combination OCPs or progestin-only pills). If 1st line NSAIDs fail, 2nd line NSAIDs is mefenamic acid (a specific type of NSAIDs for menstrual pain). For patients who desire contraception, use combination OCPs or progestin-only pills.
NSIDx: Cervical specimens for microscopy, nucleic acid amplification tests (NAATs) for C. trachomatis and gonorrhoea (+/-Mycoplasma genitalium). Do not forget pregnancy test and screening for other STDs (HIV, HBV, HCV).