Quiz feedback: Men’s & Women’s health
This quiz feedback provides an opportunity to revisit the September 2010 “Best Tests” document and accompanying quiz which focused on appropriate use of laboratory tests in the primary care setting, for men’s and women’s health. All general practitioners who responded to this quiz will receive personalised online feedback and CME points.
There are now in excess of 25 interactive quizzes available which provide an ongoing opportunity for accumulating CME points. These are available from www.bpac.org.nz.
|1. When investigating erectile dysfunction in a patient, which of the following tests are recommended?|
Evidence suggests that up to 80% of erectile dysfunction (ED) cases have an organic cause. Organic causes include vasculogenic, neurogenic and hormonal aetiologies, of which vasculogenic aetiologies represent the largest group. Hormonal aetiologies are by contrast a rare cause.
There is a lack of consensus regarding the best choice of laboratory tests for the evaluation of patients with ED. However given the association of ED with vascular disease and diabetes, it is recommended that a cardiovascular risk assessment is performed and screening for diabetes is undertaken. In terms of hormonal tests, the American College of Physicians has been unable to recommend either for or against routine use of hormonal blood tests or hormonal treatment in the management of patients with ED.
|2. When investigating a patient with gynaecomastia, when is laboratory testing most useful?|
|Long standing gynaecomastia||6%|
|Bilateral or tender gynaecomastia||71%|
|Acute onset gynaecomastia||95%|
Gynaecomastia (GM), a benign enlargement of male breast tissue, is a common condition which indicates an imbalance between free oestrogen and androgen action in the breast tissue.
Although laboratory evaluation may be appropriate, abnormalities are not detected in the majority of patients with GM. Endocrine evaluation in adolescent patients, and in adult patients with longstanding fibrotic GM, is contentious.
If an adult male presents with unilateral or bilateral GM that is of acute onset, particularly if tender, and if the patient’s history and physical examination do not reveal the cause, then serum testosterone, LH, oestradiol and hCG are usually sufficient.
|3. Why is the role of testosterone testing limited?|
|Lack of clarity around reference ranges||60%|
|Levels drop as people age||74%|
|Lack of clear recommendations around appropriate use of the test||78%|
|It is not widely available||11%|
The association between ageing-related testosterone reduction and late-onset hypogonadism in men remains a controversial concept due to the high prevalence of hypogonadal symptoms in the aging male population and the non-specific nature of these symptoms.
The issue is further complicated by the impact of a variety of medical conditions on the male gonadal axis, the diurnal variation in testosterone levels (more than one pre-9 am sample is essential) and the limitations of available total and free testosterone assays.
As healthy men age, the serum concentration of testosterone, particularly free testosterone but also total testosterone, declines by 0.4 – 2.6% per year after the age of 40 years. This results in a total testosterone level that is below the normal laboratory range in approximately 25% of men aged over 70 years and 50% aged over 80 years.
|4. What is the most common cause of delayed puberty in boys?|
|Constitutional delay in growth and puberty||99%|
Delayed puberty in males is defined by the absence or incomplete development of secondary sexual characteristics by age 14 years, i.e. the age at which 95% of males have initiated sexual maturation.
The most common cause of delayed puberty is constitutional delay in growth and puberty. These patients will eventually spontaneously progress through puberty. For boys aged under 16 years, watchful waiting should reliably distinguish those with constitutional delay from those with other causes of delayed puberty. A positive family history for constitutional delay of puberty, especially in the father, can be useful for helping to confirm this. Reassessment of the patient may be considered after six months.
|5. Which of the following define primary amenorrhoea?|
|Absence of menses by age 16 years with development of secondary sexual characteristics||97%|
|Absence of menses by age 13 years with no development of secondary sexual characteristics||81%|
|Absence of menses by age 16 years with no development of secondary sexual characteristics||5%|
|Absence of menses by age 13 years with development of secondary sexual characteristics||2%|
Amenorrhoea is the absence of menstruation flow. It can be classified as either primary or secondary, relative to menarche. Primary amenorrhoea is the absence of menses by age 16 years in a female with appropriate development of secondary sexual characteristics or absence of menses by age 13 years and no other pubertal maturation.
Although only a small number of respondents correctly selected this option, absence of menses in a 16 year old girl with no secondary sexual characteristics is also considered as primary amenorrhoea.
|6. What is the most common cause of secondary amenorrhoea?|
Secondary amenorrhoea is the lack of menses in a previously menstruating, non-pregnant female, for greater than six months. Pregnancy is the most common cause of secondary amenorrhoea, followed by:
- Ovarian disease (40%) – ovarian failure due to normal or early menopause, hyperandrogenism, e.g. PCOS, testosterone supplementation
- Functional hypothalamic anovulation (35%) – due to excessive exercise, eating disorders, stress or some medicines, e.g. oral contraceptives, depot medroxyprogesterone
- Pituitary disease (19%) – has a similar presentation to functional hypothalamic amenorrhoea except for the occasional additional finding of galactorrhoea in some women. Rare causes are sellar masses, other diseases of the pituitary and primary hypothyroidism.
- Uterine disease (5%) – Asherman’s syndrome is the only uterine cause of secondary amenorrhoea
|7. Which of the following tests is usually helpful when investigating loss of libido in a woman?|
|None of the above||96%|
A full history and clinical examination, including sexual history and relationship factors is important. A key requirement for the evaluation of female sexual dysfunction is to determine whether sexual issues are associated with personal stress. Laboratory testing should be performed only if indicated by history or examination. The correlation between androgen levels and sexual dysfunction is considered weak, apart from a few well defined situations such as proven pituitary or adrenal insufficiency or past bilateral oophorectomy. Similarly, testing oestradiol or other hormones e.g. FSH and prolactin, has limited utility in evaluating sexual dysfunction.
|8. Which of the following is true for a women presenting with secondary amenorrhoea?|
|It is important to exclude pregnancy||99%|
|The history will seldom be helpful||2%|
|Laboratory results can be difficult to interpret||59%|
|FSH, LH and prolactin levels may be helpful||78%|
Pregnancy should be first excluded by testing rather than relying solely on history. The history, physical examination and measurement of FSH, TSH and prolactin will often be helpful to identify the most common causes of amenorrhoea. In addition, for women with evidence of hyperandrogenism, the measurement of testosterone would also be indicated.
|9. Which of the following is true for a women presenting with dysfunctional uterine bleeding?|
|It is important to exclude pregnancy||93%|
|Coagulation tests should always be requested||2%|
|Trauma will frequently be the cause||1%|
|It is important to exclude cervical and uterine cancer||98%|
A pregnancy test is indicated for women of reproductive age with dysfunctional uterine bleeding, to exclude intrauterine or ectopic pregnancy, or gestational trophoblastic disease (hydatiform mole).
Any malignancy of the genital tract can cause dysfunctional bleeding. It can be difficult to determine whether bleeding is from an endocervical or endometrial source, so cervical cancer must be excluded. Any visible cervical lesion should be biopsied, even if cervical cytology is negative for malignancy.
Depending upon the history, clinical examination and initial evaluations, a second tier of laboratory testing may be appropriate. Coagulation tests are only useful in women with a history suggestive of haemostatic defect, e.g. frequent nosebleeds, easy bruising.