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Re: Gyn: AmenorrheaFrom: Terrence.Jones@kp.orgWed Sep 27 20:26:54 2006
This is a multipart message in MIME format. --=_alternative 0007EB84882571F7_ Content-Type: text/plain; charset="us-ascii" Think the knee jerk rxn to this is add TZD (thiazolidinedione: Actos or Avandia). But Her F Ins was only borderline elevated (12), and FBS/Ins ratio was 7.1 (looking for ratio lower than 4.5). Strange that She failed to withdraw bleed from initial progestin with an EEC of 16 mm. Was that just recently? (Sometimes the progestin triggers ovulation, and the bleed is delayed 2 weeks?) If prior F Ins was more elevated, would've rechk'd while on the Biguanide, and added Actos if persistent elevation. Given the marginal elevation, would leave the glitazone option up to the Internist. One recently identified additional benefit of the TZD's is correction of the transaminase in Patients who's Metabolic Syndrome includes NASH (non-alcoholic steato-hepatitis). As mentioned WRT your prior patient with PE and menomet, the lower systemic progestin levels with Mirena can accomplish endometrial protection with less adverse effects (insulin resistance, and weight gain). If the complexion worsens, consider checking androgens. Think some Internists/Endocrinologists might also check either 2 hr GTT or A1C (the FBS alone, sometimes leaves out a part of the story). The homework You are doing will be rewarded, as You will be seeing ever increasing numbers of Patients with this scenario. Haven't had a chance to review it yet, but have a great article waiting on my desk on the TZD's (PPARa's) and direct ovarian effects (Froment et al, Jnl of Endocrinol (2006) 189:199-209). /tj NOTICE TO RECIPIENT: If you are not the intended recipient of this e-mail, you are prohibited from sharing, copying, or otherwise using or disclosing its contents. If you have received this e-mail in error, please notify the sender immediately by reply e-mail and permanently delete this e-mail and any attachments without reading, forwarding or saving them. Thank you. 46 YO P2002 amenorrhea 4 years heavy-set, facial hair, oily skin FSH less than 10. fasting insulin 12, glucose 85, elevated lipids on Metformin still hasn't menstruated failed a Provera challenge scan showing a 16 mm endometrium I am repeating the Provera now. I will do some homework, but any thoughts are welcome. Garry --=_alternative 0007EB84882571F7_ Content-Type: text/html; charset="us-ascii" <br><font size=2 face="sans-serif"> Think the knee jerk rxn to this is add TZD (thiazolidinedione: Actos or Avandia). But Her F Ins was only borderline elevated (12), and FBS/Ins ratio was 7.1 (looking for ratio lower than 4.5). Strange that She failed to withdraw bleed from initial progestin with an EEC of 16 mm. Was that just recently? (Sometimes the progestin triggers ovulation, and the bleed is delayed 2 weeks?) If prior F Ins was more elevated, would've rechk'd while on the Biguanide, and added Actos if persistent elevation. Given the marginal elevation, would leave the glitazone option up to the Internist. One recently identified additional benefit of the TZD's is correction of the transaminase in Patients who's Metabolic Syndrome includes NASH (non-alcoholic steato-hepatitis). As mentioned WRT your prior patient with PE and menomet, the lower systemic progestin levels with Mirena can accomplish endometrial protection with less adverse ! effects (insulin resistance, and weight gain). If the complexion worsens, consider checking androgens. Think some Internists/Endocrinologists might also check either 2 hr GTT or A1C (the FBS alone, sometimes leaves out a part of the story). The homework You are doing will be rewarded, as You will be seeing ever increasing numbers of Patients with this scenario. Haven't had a chance to review it yet, but have a great article waiting on my desk on the TZD's (PPARa's) and direct ovarian effects (Froment et al, Jnl of Endocrinol (2006) 189:199-209). /tj<br> </font> <br> <br><font size=2 face="sans-serif"><br> </font><font size=1 color=blue face="Arial"><b>NOTICE TO RECIPIENT:</b></font><font size=1 face="Arial"> If you are not the intended recipient of this e-mail, you are prohibited from sharing, copying, or otherwise using or disclosing its contents. If you have received this e-mail in error, please notify the sender immediately by reply e-mail and permanently delete this e-mail and any attachments without reading, forwarding or saving them. Thank you.<br> </font> <br> <br><font size=2 face="Courier New">46 YO P2002 amenorrhea 4 years<br> <br> heavy-set, facial hair, oily skin<br> <br> FSH less than 10.<br> <br> fasting insulin 12, glucose 85, elevated lipids</font> <br><font size=2 face="Courier New">on Metformin still hasn't menstruated</font> <br><font size=2 face="Courier New">failed a Provera challenge<br> scan showing a 16 mm endometrium<br> <br> I am repeating the Provera now.<br> <br> I will do some homework, but any thoughts are welcome.<br> <br> Garry<br> <br> </font> <br>
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