Assignment
Case Study
Amanda is a 23-year-old person who went to a gynecologist because their menstrual periods had been irregular and sparse for over a year. They stated that they had their menarche at the usual age. The physician noted that Amanda was obese and had mild hirsutism-excessive hairiness. The vaginal smear and cervical mucus were consistent with the presence of adequate amounts of estrogen, and the physician asked Amanda to take a progesterone preparation orally for 5 days and then to see if they get a period a week to ten days later. The physician also asked them to chart their basal body temperature over the course of the month following the test. Amanda provided blood for various measurements, including those for total testosterone, 17-hydroxyprogesterone, TSH, and prolactin, and was scheduled for an ultrasound to examine their ovaries. The physician encouraged Amanda to begin a weight loss program and scheduled them for a follow-up visit once all these tests had been performed.
Amanda apparently had adequate amounts of estrogen and did have a menstrual flow a week after taking the progesterone preparation. The following month, however, they did not have a menstrual period and their basal body temperature failed to show any changes during the month. The blood tests for TSH and prolactin were normal, as was the test for 17-hydroxyprogesterone (ruling out adrenal hyperplasia as a cause of their hirsutism). The ultrasound revealed enlarged ovaries with many small follicles but no Graafian follicle. The physician said that oral contraceptives could help restore normal menstrual cycles and reduce Amanda's hirsutism. A drug called clomiphene (a selective estrogen receptor modulator or SERM), could also be used to promote FSH and LH secretion by reducing negative feedback from estrogen, thereby promoting ovulation. The physician also said that metformin could be used; this drug enhances insulin action and improves the stimulation of ovulation while it reduces insulin resistance and the risk of type 2 diabetes. Amanda is at risk of developing diabetes, and the physician again urged them to lose weight.
Task
A. Describe the normal hormonal fluctuations that occur in FSH, LH, estradiol, and progesterone during the ovarian menstrual cycle.
B. Why was progesterone administration followed by progesterone withdrawal effective in causing a menses?
C. How can basal body temperature be used to track patterns in the menstrual cycle, and what does the absence of a temperature changes indicate?
D. What is the likely pathophysiological cause for Amanda's hirsutism?
E. What are the possible sources of Amanda's estrogen?