A 39-year-old female presents to the office, also - abrahem

[ArchivalUser]

A 39-year-old female presents to the office, also complaining of amenorrhea. She has had normal menses until 8 months ago, when they became infrequent, then stopped. She insists she cannot be pregnant, because she denies sexual activity œin years. She believes she is going through œthe change but wants to know why she is reaching menopause at a much earlier age than other women she knows. On review of systems, she complains of headaches œfor years and recent onset of weakness and fatigue. She also complains of arthritis in the hip and knees, something she attributes to œgetting old. She denies other complaints.
Physical exam results show that her vitals are normal. The patient is an adult female of average height, with a noticeably large jaw and hands. She is not wearing rings on her fingers (she reports that now that she is fat, they don™t fit any more). Her hair is thick and coarse, and hirsutism is present. Her thyroid gland is slightly enlarged, but regular in shape. No bruit or tenderness is present. The point of maximal impulse is displaced laterally, but the heart is regular with no murmurs. The rest of the exam is normal.

What is the most appropriate next step?

A) Reassure the patient that menopause is a normal process and offer estrogen replacement therapy for symptomatic relief (but warn the patient about risks of long-term use).
B) Tell the patient you suspect depression and offer a regimen of counseling combined with serotonin reuptake inhibitor (SSRI) therapy.
C) Although she is likely depressed, tell the patient she may have a thyroid disorder at least contributing to the problem and recommend measuring her TSH level.
D) Although she is likely depressed, tell the patient she may suffer from growth hormone (GH) excess, and recommend obtaining a serum insulin-like growth factor (IGF-I) level.
E) Tell the patient to get a life (you know of one for sale cheap on eBay).

[ArchivalUser]

D?? symptoms of pituaitary tumors..

[ArchivalUser]

d.

[ArchivalUser]

The correct answer is D. This patient represents a classic presentation of acromegaly due to GH excess, and the best single test for this is the IGF-I level. Although GH levels will often be elevated, the IGF-I does not vary from hour to hour and is not dependent on food intake, as is the case with GH. An elevated GH after a glucose load is also very suggestive of GH excess. Acromegaly of adult onset (after fusion of the long bones) does NOT result in increased height, but does cause coarsening of facial features, prognathism, and thickening of the feet and hands. This change is very subtle, and occurs over an average of 12 years before diagnosis. Comparing older photographs of the patient to her current appearance may be a clue (a driver™s license photograph may be a convenient source). Patients with acromegaly also develop hypertrophy of certain organs (such as the thyroid and heart) and may present with congestive heart failure due to cardiomyopathy. Eighty-five percent of females with acromegaly have at least some menstrual dysfunction, and 60% are amenorrheic.

Helpful Tip: Premature ovarian failure is defined as menopause at age 40 or younger (2 standard deviations below the mean).


2-The patient™s IGF-I is elevated, and her TSH is normal. An MRI is performed, which reveals a pituitary mass slightly < 1 cm in diameter.
What is the most effective therapy for this condition?


A) Weekly anti-IGF-I antibody infusions.


B) Bromocriptine therapy.


C) Transsphenoidal surgery.


D) Somatostatin analogs (such as octreotide).


E) Pegvisomant (growth hormone receptor antagonist).

[ArchivalUser]

C) Transsphenoidal surgery?

[ArchivalUser]

The correct answer is C. Acromegaly is caused by a GH-secreting pituitary tumor. Surgery is the treatment of choice for patients with a microadenoma (1 cm or less in diameter), or for patients with a macroadenoma that appears to be fully resectable. Somatostatin analogs and pegvisomant may be useful adjuncts to surgery, and are an option for patients who are not surgical candidates. Bromocriptine is not very effective, and only about 10% of acromegaly patients will achieve normal IGF-I levels with bromocriptine. But cabergoline (a similar medication) seems to work in about half of patients. Cabergoline has an advantage over somatostatin analogs in that it can be taken orally. Radiation is also an option for therapy, especially for those patients who are not surgical candidates and do not tolerate or do not respond to medical therapy. Anti-IGF-I antibody (if it existed as a medication) would not have an effect on a GH-secreting tumor. But it does not exist. It™s a made-up answer, so it™s wrong.