A 25-year-old woman reports that from menarche until age 19 years, she menstruated only once a year. At the age of 19, a gynecologist’s workup was negative, and the patient was prescribed oral contraceptives (OCs). Since then, her periods have been regular. Now she wants to get pregnant. Blood work ordered by another gynecologist included normal levels of thyroid hormone, luteinizing hormone, and follicle-stimulating hormone; only the estradiol level was low at 18 pg/mL (normal: 19-528). A physical examination was unremarkable. The patient, who is 5 ft 7 in tall and weighs 123 lb, was advised to gain weight. Despite what she describes as continuous eating, she has gained just 1 lb. What would you advise?—NISHITH M. GAMI, MD, Marlton, N.J.
This woman has oligomenorrhea and anovulation that have been masked by the ingestion of exogenous hormones. Her estradiol level is low, but follicular development could have been suppressed by use of OCs. A repeat estradiol determination should be done after OCs have been discontinued temporarily. If the level is >30 pg/mL, clomiphene citrate should induce ovulation. If the level is <30, she should be given gonadotropins under the supervision of a gynecologic endocrinologist to induce ovulation.—Daniel R. Mishell Jr, MD (147-8)