I am an endocrinology intern form india,this my second case to the ask the expert section.firstly i would thank u for the advice given for the last case.
The case is 18/F, h/o primary amenorrhoea, Fourth child of a nonconsanguinus marriage,family history- Elder sister had periods at 16 yrs, normal pernatal events,normal developmental milestones,normal intelligence.No history of growth spurt but was growing normally. Thelarche at 12 yrs and pubarche at 14 yrs.No history of virilization at pubertal age.Normal prenatal events.Normal developmental milestones.Normal intelligence. No history of growth spurt but was growing nornally.Thelarche at 12 yrs and pubarche at 14 yrs.No history of virilization at pubertal age.No history of inguinal hernia.H/O infertility in paternal aunt. No history of acne,hirsutism.No history of maternal abortions or neonatal deaths.No history of short stature.
H/o attempted withdrawal to progesterone : no bleeding,. Mother's height: 158 cm. Father is short. Height : 153cm Weight : 48.5kg Height is at 5 th centile.Upper segment : 74 cm Lower segment: 78 cm. Arm span : 153 cm
Thyroid:Normal. Other findings:Smell normal. Pubic hair stage 4, Breast stage 4 Axillary hair has been shaved off.
Local Examination : Labia Majora - normal, labia minora - fused together. Small blind vagianal opening / pouch. P/R - could not get Uterus. Systems :Normal
Investigations: TSH/FT4,PROLACTIN,-NORMAL LEVELS. Testosterone; total 0.097 (ng/ml)(F-< 0.1). FSH-2.43 (mIU/ml)(1-8). LH-<0.1(mIU/ml). Estradiol 154.8 pg/ml. Sonogram of pelvis: Uterus Measures 32.6x8.2mm (CC x AP). Endometrium not visualised. Bilateral ovaries :Not visualised. No obvious pelvic mass seen. : Hypoplastic uterus.No obvious pelvic mass
The question is how to further proceed about the case? any further investigations? management? Arun Kannan:, India < mailto:email@example.com >
This 18 year old has genital outflow tract obstruction and perhaps uterine abnormalities and probably represents a variant of Rokitansky-Kuster-Hauser Syndrome. The workup of this patients indicates:
1. Normal progression of pubertal events including thelarche and adrenarche.
2. Adequate growth given the history of short stature in the father.
3. Normal thyroid and prolactin function.
4. Low or normal FSH with ovulatory levels of estradiol.
5. Failure to withdraw bleed with progesterone due to no endometrial compartment.
Thus, this individual has proceeded through puberty, has adequate secondary sex characteristics that are estrogen driven, has a normal XX karyotype but is unable to respond to estrogens due to inadequate development of the Mullerian system and the upper parts of the vagina with a blind vaginal pouch.
To complete her workup, I would probably perform a transrectal ultrasound which may provide further anatomic details such as an absence of a cervix and no endometrium and the presence of ovaries (I disagree that there are absent ovaries since the estradiol levels are too high for peripheral conversion of estradiol).
She can be treated with vaginal dilators to achieve a functional vagina using the approach proposed by Frank.
James H. Liu, M.D. Case School of Medicine, Cleveland, OH