Step 5 Followup laboratory evaluation

1. High serum prolactin concentration. Prolactin secretion can be transiently increased by stress or eating. Therefore, serum prolactin should be measured at least twice before cranial imaging is obtained, particularly in those women with small elevations (<50 ng/mL). These women should be screened for thyroid disease with a TSH and free T4 because hypothyroidism can cause hyperprolactinemia.

2. Women with verified high serum prolactin values should have a cranial MRI unless a very clear explanation is found for the elevation (eg, antipsychotics). Imaging should rule out a hypothalamic or pituitary tumor.

3. High serum FSH concentration. A high serum FSH concentration indicates the presence of ovarian failure. This test should be repeated monthly on three occasions to confirm. A karyotype should be considered in most women with secondary amenorrhea age 30 years or younger.

4. High serum androgen concentrations. A high serum androgen value may suggest the diagnosis of polycystic ovary syndrome or may suggest an androgen-secreting tumor of the ovary or adrenal gland. Further testing for a tumor might include a 24-hour urine collection for cortisol and 17-ketosteroids, determination of serum 17-hydroxyprogesterone after intravenous injection of corticotropin (ACTH), and a dexamethasone suppression test. Elevation of 17-ketosteroids, DHEA-S, or 17-hydroxyprogesterone is more consistent with an adrenal, rather than ovarian, source of excess androgen.

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