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Author [[PageAuthor::Ahmed Zaghw, M.D. [1]]]
Exam Type USMLE Step 2 CK
Main Category Internal medicine, OB/GYN
Sub Category Endocrine, Head and Neck, Obstetrics & Gynecology
Prompt A 16 year old girl comes to the clinic, complaining of irregular vaginal spotting for the last 2 months. She has never had any bleeding between periods in the past. She has been taking oral contraceptive pills for the last two months and occasional pain killers for her ankle strain. She is a professional tennis player and trains daily for more than 4 hours. She reports that she has been stressed for the last month trying to catch up with her schedule for the next national championship. The pelvic examination is unremarkable. Her lab tests does not reveal any abnormality. Her pregnancy test is negative. What is the best next step?
Answer A Abdominal US
Answer A Explanation Incorrect- Abdominal ultrasound is not needed to investigate HPA disorder
Answer B Endometrial biopsy
Answer B Explanation [[AnswerBExp::Incorrect- Endometrial biopsy is only needed to assess the luteal phase and response of the endometrium to the progestrone.]]
Answer C TSH
Answer C Explanation Incorrect- TSH is not needed to assess HPA disorder.
Answer D LH
Answer D Explanation Incorrect- LH is not needed to assess HPA disorder
Answer E Reassurance
Answer E Explanation Correct-Reassurance and follow up is the best approach for HPA disorder.
Right Answer C
Explanation [[Explanation::The first step in a patient with secondary amenorrhea is to rule out common situations as pregnancy. Given her strenuous life style, competitive sport training and negative pregnancy test increase the probability of hypothalamic pituitary axis (HPA).

Reassurance and life style modification is the best approach for HPA disorder. Secondary amenorhea could be caused due stress that alter hypophthalmic pituitary axis.
Educational Objective: Secondary amenorrhea could be caused due stress that alter hypophthalmic pituitary axis.
References: First Aid USMLE 2 CK]]

Approved No
Keyword Secondary Amenorrhea, stress induced amenorrhea, Hypothalamic pituitary axis
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