Re: Help with a case please

[Guest guest]

Looks like she has reversal of FSH/LH ratio and LH is a little high and she is probably a mild variant of PCO. I would do a 3-4 mo trial of Clomid. Les From: [mailto: ] On Behalf Of BameSent: Thursday, August 02, 2012 2:46 PM Subject: Help with a case please Dear friends, would you please help me with your opinion about a wonderful young patient who gives me permission to use her name and information. Her name is Jacinta and she is 20 and comes from a wonderful Catholic family. She initially came to me for NFP counselling. Upon questioning, i found out that her periods had always been irregular since age 15. She has never had a workup for this. She has always been healthy, has had no past medical problems, no surgeries, is on no medications, doesnt drink or smoke or use drugs. Her mother is very regular, and fertile, having had 6 children. Her siblings are all healthy. Upon physical exam, She is 5 foot 5 and 145 pounds. Her exam was completely normal. Upon lab testing, all labs were normal, LH 13.0 and FSH 7.5, DHEA-S 380.4, testosterone 45, tsh 1.6, androstenedione 179, free testosterone 0.9, progesterone 0.9 (follicular phase), cholesterol normal, insulin level normal, fasting glucose normal (89), vitamin levels, including b12, folate, and D are all normal. I had ordered a prolactin level, but the lab did not draw it. Her ultrasound was read as normal, but upon reviewing it she does have multiple tiny follicles both ovaries and the ovaries are normal size and endometrial stripe is 4.0 mm. I taught her NFP, and she only got shiny, scant mucus on Days 10-13, never stretchy or egg white, and she did not get temperature elevations. To confirm, I taught her Marquette method and she was getting basically all lows (low urine estradiol). She was using the monitor properly, and we had her collect concentrated urine. She wants to get pregnant, but moreover wants to know her diagnosis. She was given a trial of metformin, which did not help the cycles at all and a trial of oral progesterone which produced a period approximately 7 days after taking it. This patient is not ovulating and what would the group's next steps or advice be with the caveat that the patient is a practicing Catholic. Thanks in advance and Blessings, Dr. Peck, MD, CCD, ABFM, Marquette NFP InstructorPecks Family Practice, PLC1688 W Granada Blvd, Ste 2AOrmond Beach, FL 32174(386) 677-2018 fax: (386) 676-0737 cell: (386) 212-9777 " I have chosen you from the world, says the Lord, and have appointed you to go out and bear fruit, fruit that will last, alleluia " (Cf. Jn 15:16,19)

[Guest guest]

Why not draw progesterone levels after Peak day?And replace bioidentical progesterone or HCG?On Fri, Aug 3, 2012 at 10:25 PM, Les Ruppersberger <lruppersberger@...> wrote:

 

Looks like she has reversal of FSH/LH ratio and LH is a little high and she is probably a mild variant of PCO.  I would do a 3-4 mo trial of Clomid.

Les 

From: [mailto: ] On Behalf Of Bame

Sent: Thursday, August 02, 2012 2:46 PM Subject: Help with a case please

   Dear friends, would you please help me with your opinion about a wonderful young patient who gives me permission to use her name and information. Her name is Jacinta and she is 20 and comes from a wonderful Catholic family. She initially came to me for NFP counselling.  Upon questioning, i found out that her periods had always been irregular since age 15. She has never had a workup for this. She has always been healthy, has had no past medical problems, no surgeries, is on no medications, doesnt drink or smoke or use drugs. Her mother is very regular, and fertile, having had 6 children. Her siblings are all healthy.  

 Upon physical exam, She is 5 foot 5 and 145 pounds. Her exam was completely normal.

 Upon lab testing, all labs were normal,  LH 13.0 and FSH 7.5, DHEA-S 380.4, testosterone 45, tsh 1.6, androstenedione 179, free testosterone 0.9, progesterone 0.9 (follicular phase),  cholesterol normal, insulin level normal,  fasting glucose normal (89),  vitamin levels, including b12, folate, and D are all normal.  I had ordered a prolactin level, but the lab did not draw it. 

 Her ultrasound was read as normal, but upon reviewing it she does have multiple tiny follicles both ovaries and the ovaries are normal size and endometrial stripe is 4.0 mm.

 I taught her NFP, and she only got shiny, scant mucus on Days 10-13, never stretchy or egg white,  and she did not get temperature elevations.  To confirm, I taught her Marquette method and she was getting basically all lows (low urine estradiol). She was using the monitor properly, and we had her collect concentrated urine.  

 She wants to get pregnant, but moreover wants to know her diagnosis.

 She was given a trial of metformin, which did not help the cycles at all and a trial of oral progesterone which produced a period approximately 7 days after taking it.  

 This patient is not ovulating and what would the group's next steps or advice be with the caveat that the patient is a practicing Catholic.  Thanks in advance and Blessings, 

 Dr. Peck, MD, CCD, ABFM, Marquette NFP Instructor

Pecks Family Practice, PLC1688 W Granada Blvd, Ste 2A

Ormond Beach, FL  32174(386) 677-2018  fax: (386) 676-0737 cell: (386) 212-9777

  " I have chosen you from the world, says the Lord, and have appointed you to go out and bear fruit, fruit that will last, alleluia " (Cf. Jn 15:16,19)

-- Therese , RN, FCP*

*FertilityCare Practitionerwww.fertilitycare.org/maryland

" your cycles, your fertility, in your hands "

[Guest guest]

Good suggestion, Therese.I'd be interested to see a periovulatory estradiol profile (however, may not be practical given her irregular cycles) and post-peak progesterone/estradiol profile, as well.

Good luck, ! Trumble, ARNP, FCPI, NFPMCI

[Guest guest]

With the Creighton Model, I've been able to find very hard to find Peak days with clients.  Just fyi, finding progesterone drawn after peak day is a standard practice with Naprotechnology.    consult with Dr. Hilgers or his staff at the Pope VI Institute.

www.popepaulvi.com   peace in Christ,I've had clients given progesterone in pill form with minimal results but.......... absolutely dynamic results, we still cry for joy over when we see each other , for shots of progesterone prescribed by her Naprotechnology ob/gyn, given after Peak day.

On Fri, Aug 3, 2012 at 11:12 PM, Trumble <kellymtrumble@...> wrote:

 

Good suggestion, Therese.I'd be interested to see a periovulatory estradiol profile (however, may not be practical given her irregular cycles) and post-peak progesterone/estradiol profile, as well.

Good luck, ! Trumble, ARNP, FCPI, NFPMCI

-- Therese , RN, FCP*

*FertilityCare Practitionerwww.fertilitycare.org/maryland

" your cycles, your fertility, in your hands "

[Guest guest]

Dear Les, Therese, ,thank you all for responding. Les, yes, i was thinking of that, but dont' usually use clomid in my practice as a FP but know someone i can send her to for that. and Therese, please bear with me, as I am not trained in FertilityCare or Naprotech (but will someday take the course). If she is not displaying either mucus, temp or urinary hormonal evidence of "peak", how do i obtain the post-peak progesterone level? And, could you explain, what threshold progesterone value would indicate treatment, and could you further elucidate what other kinds of progesterone (other than proverra) you use? Also, in my mind, while she doesnt have premature ovarian failure -

she is still producing some estrogen and her FSH is not high, it doesnt seem to me that she is producing enough estrogen on her own to perhaps mature the follicles and then stimulate the LH surge. Are there other treatments you use for low estrogen states? I know i have learned about the Harvard Fertility Diet, do you find that works? I will tell her to start the B6 and guaifenecin in the meantime. Thanks in advance for your thoughts. Blessings, Dr. Peck, MD, CCD, ABFM, Marquette NFP Instructor

Pecks Family Practice, PLC

1688 W Granada Blvd, Ste 2A

Ormond Beach, FL 32174

(386) 677-2018 fax: (386) 676-0737 cell: (386) 212-9777

"I have chosen you from the world, says the Lord, and have appointed you to go out and bear fruit, fruit that will last, alleluia" (Cf. Jn 15:16,19) From: Trumble <kellymtrumble@...>

Sent: Friday, August 3, 2012 11:12 PM Subject: Re: Help with a case please

Good suggestion, Therese.I'd be interested to see a periovulatory estradiol profile (however, may not be practical given her irregular cycles) and post-peak progesterone/estradiol profile, as well.

Good luck, ! Trumble, ARNP, FCPI, NFPMCI

[Guest guest]

Hi ,

If you get a pelvic sono and the ovarian volume with at least one ovary is high

(>10ml), and the ovulation induction with clomid or letrazole doesn't work then

she may be a good candidate for an ovarian wedge resection. The pregnancy

success rates are very high in PCOS after this procedure.

Also they end up with regular cycles. Ovarian drilling doesn't work that well.

>

> Dear friends, would you please help me with your opinion about a wonderful

young patient who gives me permission to use her name and information. Her name

is Jacinta and she is 20 and comes from a wonderful Catholic family. She

initially came to me for NFP counselling.  Upon questioning, i found out that

her periods had always been irregular since age 15. She has never had a workup

for this. She has always been healthy, has had no past medical problems, no

surgeries, is on no medications, doesnt drink or smoke or use drugs. Her mother

is very regular, and fertile, having had 6 children. Her siblings are all

healthy.  

>  

> Upon physical exam, She is 5 foot 5 and 145 pounds. Her exam was completely

normal.

>  

> Upon lab testing, all labs were normal,  LH 13.0 and FSH 7.5, DHEA-S 380.4,

testosterone 45, tsh 1.6, androstenedione 179, free testosterone 0.9,

progesterone 0.9 (follicular phase),  cholesterol normal, insulin level normal, 

fasting glucose normal (89),  vitamin levels, including b12, folate, and D are

all normal.  I had ordered a prolactin level, but the lab did not draw it. 

>  

> Her ultrasound was read as normal, but upon reviewing it she does have

multiple tiny follicles both ovaries and the ovaries are normal size and

endometrial stripe is 4.0 mm.

>  

> I taught her NFP, and she only got shiny, scant mucus on Days 10-13, never

stretchy or egg white,  and she did not get temperature elevations.  To confirm,

I taught her Marquette method and she was getting basically all lows (low urine

estradiol). She was using the monitor properly, and we had her collect

concentrated urine.  

>  

> She wants to get pregnant, but moreover wants to know her diagnosis.

>  

> She was given a trial of metformin, which did not help the cycles at all and a

trial of oral progesterone which produced a period approximately 7 days after

taking it.  

>  

> This patient is not ovulating and what would the group's next steps or advice

be with the caveat that the patient is a practicing Catholic.  Thanks in advance

and Blessings, 

>

> Dr. Peck, MD, CCD, ABFM, Marquette NFP Instructor

> Pecks Family Practice, PLC

> 1688 W Granada Blvd, Ste 2A

> Ormond Beach, FL  32174

> (386) 677-2018  fax: (386) 676-0737 cell: (386) 212-9777

>  

> " I have chosen you from the world, says the Lord, and have appointed you to go

out and bear fruit, fruit that will last, alleluia " (Cf. Jn 15:16,19)

>