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Transitions: Menopause and Puberty Kevin Kuan and Renee ChanTable of Contents 1. What is puberty? 2. Adrenarche and Gonadarche (and other terms) 3. Tanner Stages 4. Initiation of Puberty 5. Disorders of Puberty 6. Menarche 7. Menstruation 8. Menopause (physiology, symptoms, management)Defining puberty What is puberty? - Puberty is a well-defined sequence of physical and physiological changes which result in full physical and sexual maturity - From the 1st appearance of secondary sexual characteristics until full sexual development When does puberty begin? - Onset for females = 8-13 years - Onset for males = 9-14 yearsAdrenarche and Gonadarche Adrenarche = “awakening of the adrenal gland” = production of androgens, precedes gonadarche by about 2 years (6-8 years old) Gonadarche = activation of the HPG axis, production of sex steroids (F = progesterone, estrogen, M = testosterone) Thelarche = onset of female breast development (usually the first sign of puberty in girls) Pubarche = the development of pubic hair Menarche = onset of menstruationWhat scale do we use to quantify puberty? hint: it was mentioned earlier :)Tanner Stages of puberty in males What device is used to measure testicle size?OrchidometerTanner Stages of puberty in femalesTanner Stages of puberty in females Tanner MCQ 1 A 13 year old girl presents with her mum for a check-up. On examination she has started to develop breast buds and has minimal straight, fine pubic hair. What Tanner Stages is she at? A. B1, P2 B. B2, P3 C. B3, P3 D. B3, P2 E. B2, P2Tanner MCQ 1 - answer A 13 year old girl presents with her mum for a check-up. On examination she has started to develop breast buds and has minimal straight, fine pubic hair. What Tanner Stages is she at? B2, P2 Tanner MCQ 2 A 12.5 year old boy presents as his dad his concerned about the growth of his pubic hair. On examination, he has dark, coarse, curly hair. There are too many hairs to count but growth is sparse. What Tanner Stage is he at? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Stage 5Tanner MCQ 2 A 12.5 year old boy presents as his dad his concerned about the growth of his pubic hair. On examination, he has dark, coarse, curly hair. There are too many hairs to count but growth is sparse. What Tanner Stage is he at? Stage 3 = too many to countOther changes in puberty girls boys breast development testicle growth pubic hair pubic hair hair on arms and legs growth of penis/testicles/scrotum underarm hair and sweating underarm hair menstruation sweating acne “wet dreams” vaginal discharge acne and voice changes growth spurt and weight gain growth spurt and muscle MOOD CHANGES!Initiation of Puberty (1) - The initiating event of puberty is the increase in GnRH secretion - Secreted from the arcuate nucleus in the hypothalamus - This is occurs when: - Kisseptin neurons in the arcuate nucleus release neurokinin B and dynorphin (peptides) - Neurokinin B and dynorphin cause the secretion of GnRHInitiation of Puberty (2) - GnRH causes release of LH and FSH - from the anterior pituitary gland - LH and FSH act on: - in males, the Leydig and Sertoli cells in the testes - in females, the theca and granulosa cells of the ovary - In females: - FSH and LH stimulate the ovaries to produce estrogen and progesterone - In males: - LH acts on Leydig cells to convert cholesterol into testosteroneHas the age of puberty increased or decreased over the last 150 years?Initiation of Puberty - Earlier Onset - Genetic factors - Family history, timing correlates to parents/siblings - Social factors - Lower social class linked to earlier menarche - Metabolic factors - Obese children/higher leptin levels = earlier puberty - Geographical factors - Earlier puberty seen in those closer to equator, lower altitudes, urban settings - Environmental factors - Endocrine-disrupting chemicals (ex: plastics, agriculture, fuels) - Race - Onset is earlier for those of Afro-Caribbean descent when compared to white childrenDisorders of Male PubertyDisorders of Puberty (male) Classifications of Causes 1. Temporary delay a. Constitutional (familial/sporadic), malabsorption/malnutrition, hormonal deficiency (i.e. GH/hypothyroid) 2. Hypogonadotrophic hypogonadism a. Kallman’s syndrome, tumour, trauma 3. Hypergonadotrophic hypogonadism a. Klinefelters (XXY), anorchia, orchitis Outcomes: - Secondary sexual characteristics - Osteoporosis - Fatigue - Sexual dysfunctionMale infertility: hypogonadotrophic hypogonadism due to hyperprolactinaemia Hyperprolactinaemia is an underdiagnosed cause of infertility in males because of its subtle clinical manifestations. Prolactin suppresses the pulsatile GnRH secretion. Hypothalamic dopamine inhibits prolactin. Investigations: Causes: ▶ High prolactin ▶ Prolactinomas ▶ Low FSH and LH ▶ Medication (dopamine antagonists): ▶ Low testosterone anti-emetics (e.g. metoclopramide), anti-psychotics (e.g. haloperidol) ▶ Exercise, stress, herbal remedies Treatment: ▶ Avoid stress ▶ Avoid causative medications ▶ Dopamine agonist: bromocriptine or cabergoline ▶ Surgery: if medical treatment not effective and patient symptomatic (e.g. compression of the optic chiasm) Male Infertility If following endocrine investigations for infertility, the male reproductive axis appears normal, the infertility is classified as obstructive and generally comes from one of the following component of the reproductive system: A. Epididymis (e.g. epididymitis, cystic fibrosis) B. Vas deferens (e.g. previous surgery like hernia repair) C. Ejaculatory duct (e.g. trauma, infection, surgery) Male reproduction MCQ: Case 1 A 31 year old man with a BMI of 30 is referred to the endocrinology clinic with a history of poor libido and erectile dysfunction. Blood tests reveal total testosterone 5.6 nmol/L (low), SHBG 42.1 nmol/L (normal), FSH 2.1 IU/L (borderline low) and LH 1.76 IU/L (low). He has no other past medical history of note and has not fathered any children. On examination visual fields are normal, testes are 5 mL volume and soft on palpation. He has little in the way of pubic or axillary hair. He has not noticed any problem with his sense of smell. Which of the following is the most likely underlying diagnosis? A. Kallmann’s syndrome B. Klinefelter syndrome C. Previous trauma to the testes D. Reduced testosterone secondary to obesity E. Reduced testosterone with age Male reproduction MCQ: Case 1 A 31 year old man is referred to the endocrinology clinic with a history of poor libido and erectile dysfunction. Blood tests reveal total testosterone 5.6 nmol/L (low), SHBG 42.1 nmol/L (normal), FSH 2.1 IU/L (borderline low) and LH 1.76 IU/L (low). He has no other past medical history of note and has not fathered any children. On examination visual fields are normal, testes are 5 mL volume and soft on palpation. He has little in the way of pubic or axillary hair. He has not noticed any problem with his sense of smell. Which of the following is the most likely underlying diagnosis? A. Kallmann’s syndrome 🡪hypogonadotropic hypogonadism, small testes, underdeveloped secondary sexual characteristics, anosmia not in all cases B. Klinefelter syndrome 🡪 HYPERgonadotropic hypogonadism C. Previous trauma to the testes 🡪 HYPERgonadotropic hypogonadism D. Reduced testosterone secondary to obesity 🡪 testicular volumes not reduced to this extent E. Reduced testosterone with ageMale reproductive MCQ: Case 2 A new-born is noted to have ambiguous genitalia at birth. Pregnancy was normal and the new-born’s weight was 3.3kg at birth. Genetic testing shows that the baby is XY. Ultrasound scan shows abdominal gonads and biochemical investigations show raised testosterone. What is the most likely underlying cause for the ambiguous genitalia? A. Klinefelter Syndrome B. Androgen insensitivity syndrome C. Kallmann’s syndrome D. This is normal, genitalia will grow in the first month of life E. Abnormal adrenal androgen secretionMale reproductive MCQ: Case 2 A new-born is noted to have ambiguous genitalia at birth. Pregnancy was normal and the new-born’s weight was 3.3kg at birth. Genetic testing shows that the baby is XY. Ultrasound scan shows abdominal gonads and biochemical investigations show raised testosterone. What is the most likely underlying cause for the ambiguous genitalia? A. Klinefelter Syndrome 🡪 testosterone elevated so no B. Androgen Insensitivity syndrome 🡪 the baby is secreting testosterone but not responding (or partially) to it due to abnormal androgen receptors C. Kallmann’s syndrome 🡪 testosterone elevated so no D. This is normal, genitalia will grow in first 3 months of life 🡪 False, the penis and testes should be formed at birth E. Abnormal adrenal androgen secretion Male reproductive MCQ: Case 3 A 22 year old patient with a past medical history of cystic fibrosis comes to your infertility clinic. He has been unsuccessfully trying to conceive for more than 12 months of regular unprotected sex with his wife. His wife has had a full fertility check and everything is normal with her. On examination the patient has normal secondary sexual characteristics, normal testes and penis. You decide to do some investigations: LH, FSH and testosterone levels normal, prolactin not elevated. Semen analysis: azoospermia. What are the fertility options for this patient? A. Oestrogen antagonist B. Dopamine agonist C. Microscopic testicular sperm extraction D. Testosterone injections E. Pulsatile GnRH injections Male reproductive MCQ: Case 3 A 22 year old patient with a past medical history of cystic fibrosis comes to your infertility clinic. He has been unsuccessfuly trying to conceive for more than 12 months of regulated unprotected sex with his wife. His wife has had a full fertility check and everything is normal with her. On examination the patient has normal secondary sexual characteristics, normal testes and penis. You decide to do some investigations: LH, FSH and testosterone levels normal, prolactin not elevated. Semen analysis: azoospermia. What are the fertility options for this patient? A. Oestrogen antagonist 🡪 why? B. Dopamine agonist 🡪 hyperprolactinaemia treatment C. Microscopic testicular sperm extraction 🡪 cystic fibrosis often develop obstructive infertility. Sperm production is normal but does not reach the semen. Extraction with microsurgery can allow cystic fibrosis to conceive without needing sperm donation. D. Testosterone injections 🡪 his biochemical profile is totally normal E. Pulsatile GnRH injections 🡪 his biochemical profile is totally normalDisorders of Female PubertyDisorders of Puberty (female) Causes of infertility: 1. Endocrinological -> hypothalamus/pituitary + ovaries 2. Obstructive -> vagina/cervix/uterus/fallopian tubesDisorders of Puberty (female) Investigations: ▯ Low FSH & LH ▯ Low oestrogen Causes: ▯ Low body fat is a common cause: anorexia, over exercise (athletes) ▯ Stress, illness ▯ Radiotherapy, brain tumour ▯ Hyperprolactinaemia Treatment: ▯ Lifestyle management may be enough ▯ If patient wants to conceive 🡪 gonadotrophins (FSH/LH) ▯ Dopamine agonists/surgery for hyperprolactinaemia (see slide in male infertility for mechanisms) ▯ Oestrogen + progesterone (CCP): It is important that all females of conceiving age have regular periods 🡪 low oestrogen for 2+ years puts the patient at risk of osteoporosisFemale infertility: Ovarian Causes Investigation: biochemical profile of menopause ▯ High LH & FSH Presentation: in addition of amenorrhea, patients may present with menopause symptoms: hot flushes, vaginal dryness etc Other non-physiological causes of ovarian failure: ▯ Genetic: Turner Syndrome (45 X, short stature), Fragile X syndrome, Congenital Adrenal Hyperplasia ▯ Premature ovarian failure (POF) ▯ Polycystic ovarian syndrome (PCOS): biochemical profile slightly different (see specific slide on PCOS) ▯ Chemotherapy/radiotherapy/surgery Treatment: ▯ POF and chemotherapy etc causes need to be addressed by egg donation and patients will need oestrogen therapy to protect against osteoporosis ▯ PCOS: oestrogen antagonist at start of the cycle (clomiphene citrate) Polycystic ovarian syndrome (PCOS): PCOS is an heterogenous disorder sometimes called hyperandrogenic anovulation, is characterised by increased LH compared to FSH and an increased testosterone. This prevents the maturation of eggs 🡪 irregular periods. Presentation: ▶ Menstrual irregularity +/- infertility Complications: ▶ Hirsutism ▶ Cardiovascular disease ▶ Acne ▶ Type 2 diabetes mellitus ▶ Obesity +/- insulin resistance ▶ Endometrial cancer 🡪 Diagnosis: requires two of the following anovulatory cycles means ▶ Menstrual irregularity that there is no progesterone secretion and ▶ Clinical or biochemical androgen excess 🡪 elevated testosterone endometrial growth is ▶ Multiple cysts in the ovaries 🡪 transvaginal ultrasound unopposed Treatment: ▶ Patients who do want to conceive: combined contraceptive pill suppresses gonadotrophins ▶ Patients who want to conceive: ▶ Metformin may restore ovulatory cycles in obese women ▶ Oestrogen antagonist at start of cycle (e.g. clomifene citrate) 🡪 explanation in notes belowFemale reproduction MCQ: Case 1 A 42 year old woman is referred with galactorrhoea. Her periods have become irregular. She has two children who are 16 and 21 years old and she has been more stressed at work than previously. She is not on any regular medication. Blood tests reveal a prolactin level of 570 ng/mL (elevated) with no evidence of macroprolactinoma on MRI. What is the most appropriate treatment? A. Monitor prolactin levels every year B. Reassure and discharge C. Refer for pituitary surgery D. Start on cabergoline 0.25mg twice weekly E. Start on carbimazole 40mg once dailyFemale reproduction MCQ: Case 6 A 42 year old woman is referred with galactorrhoea. Her periods have become irregular. She has two children who are 16 and 21 years old and she has been more stressed at work than previously. She is not on any regular medication. Blood tests reveal a prolactin level of 570 ng/mL (elevated) with no evidence of macroprolactinoma on MRI. What is the most appropriate treatment? A. Monitor prolactin levels every year B. Reassure and discharge 🡪 not really nice for the patient… C. Refer for pituitary surgery 🡪 No evidence of macroprolactinoma so surgery is not 1 option D. Start on cabergoline 0.25mg twice weekly 🡪 dopamine agonists inhibit prolactin secretion. E. Start on carbimazole 40mg once daily 🡪 hyperthyroidism medicationFemale reproduction MCQ: Case 2 A 26 year old female presents with irregular periods, acne, hirsutism. A transvaginal ultrasound scan reveals ovarian cysts. She is diagnosed with Polycystic ovarian syndrome (PCOS). She does not want to conceive. What treatment will you offer her? A. None, PCOS is usually transient B. Cysts aspiration C. Clomiphene citrate D. Progesterone antagonist E. Combined oral contraceptive pillFemale reproduction MCQ: A 26 year old female presents with irregular periods, acne, hirsutism. Her BMI is 32 kg/m2. A transvaginal ultrasound scan reveals ovarian cysts. She is diagnosed with Polycystic ovarian syndrome (PCOS). She does not want to conceive. What pharmacological treatment will you offer her? A. None, PCOS is usually transient 🡪 false, but remember that lifestyle measures to promote weight loss can really help with the condition B. Cysts aspiration 🡪 that’s not a thing for PCOS C. Clomiphene citrate 🡪 oestrogen antagonists used to balance FSH and LH ratio and promote egg growth if a PCOS patient wants to conceive. Given only for a few days at the start of the cycle. D. Progesterone antagonist 🡪 that won’t help to balance her gonadotrophins and reduce androgens. Used in pregnancy termination or post-coital contraception. E. Combined oral contraceptive pill (CCP) 🡪 yes the oestrogens will inhibit the LH and FSH release which will in turn lower androgen production and attenuate symptoms. Progesterone protects endometrium from overgrowing. The mini-pill (progesterone only) would not inhibit gonadotrophins, or at least not to the extent of how oestrogens do. As the patient does not want to conceive CCP is appropriate.MenstruationMenarche - Onset of menstruation (around age 13) Causes of delayed menarche: 1. Malnutrition (malabsorption or ….) 2. Over exercise 3. Long term illnesses (CF, diabetes, etc…) 4. Problems with ovaries, thyroid gland, pituitary gland -> hormone dysregulation Amenorrhea classification: 1. Primary = haven’t gotten first one (up to age 15) 2. Secondary = missed periods The menstrual cycle: ▶ Follicular phase: oestrogens grow the endometrium ▶ Around 14 days positive feedback of oestrogens on the HPG axis leads to ovulation ▶ Luteal phase: Progesterone production by the corpus luteum prepares uterus for implantation ▶ If there is no implantation, corpus luteum regresses and stops producing progesterone 🡪 menstruation Menopause: A woman last spontaneous menstrual period. Natural phenomenon that occurs between 45 and 55 years old. Causes: HRT risks and side effec:s ▯ Vast majority: natural depletion and aging of the finite amount of oocytes ▯ Autoimmune: Addison’s disease, thyroid disease ▯ Small extra risk of ▯ Surgery/chemotherapy/radiotherapy breast cancer ▯ Small risk of venous thromboembolism Presentation: many more symptoms that just the ones mentioned below ▯ Small risk of stroke ▯ Hot flushes ▯ Breast tenderness, ▯ Night sweats 🡪 these leads to very poor sleep bloatedness, breast ▯ Palpitations ▯ Vaginal dryness and dyspareunia (painful intercourse) pain The clinician and the ▯ Low libido patient must discuss of Investigations: the risks vs benefits of HRT. Patients with minimal symptoms and ▯ Low oestrogen (no more follicles to produce it) ▯ High FSH and LH as there is no negative feedback who present older are Complications: Osteoporosis is the most common unlikely to need it. Young patients (Premature ovarian deficiency) always Treatment: Hormone replacement therapy (HRT)🡪 oestrogen + progesterone get treatment. (oestrogen only therapy would lead to uncontrolled endometrial growth)Female reproduction MCQ: Case 3 A 28 year old woman present with secondary amenorrhea and galactorrhea. An MRI of her brain is likely to show a lesion in which area? A. Anterior pituitary B. Hypothalamus C. Lactiferous ducts D. Pars intermedia E. Posterior pituitaryFemale reproduction MCQ: A 28 year old woman present with secondary amenorrhea and galactorrhea. An MRI of her brain is likely to show a lesion in which area? A. Anterior pituitary B. Hypothalamus C. Lactiferous ducts D. Pars intermedia E. Posterior pituitary Hyperprolactinaemia (often due to a microprolactinoma) is a common cause of secondary amenorrhoea in this age group. Prolactin is synthesised by lactotrophs in the anterior pituitary gland. Synthesis and release of prolactin is under the tonic inhibition of dopamine, which is released from the hypothalamus and passes down capillaries surrounding the pituitary stalk to the anterior pituitary.Female reproduction MCQ: Case 4 A 32 year old woman attends her family physician with a 12-month history of inability to conceive. She has been having regular periods every 28 days. Ovulation can be confirmed by which of the following tests? A. Day 10 rise in follicle stimulating hormone B. Day 13 surge in oestradiol C. Day 14 surge in progesterone D. Day 14 surge in luteinising hormone (LH) E. Regular mensesFemale reproduction MCQ: case 4 A 32 year old woman attends her family physician with a 12-month history of inability to conceive. She has been having regular periods every 28 days. Ovulation can be confirmed by which of the following tests? A. Day 10 rise in follicle stimulating hormone B. Day 13 surge in oestradiol C. Day 14 surge in progesterone 🡪 yes but at 21 days! D. Day 14 surge in luteinising hormone (LH) E. Regular menses Regular menses imply, but do not confirm, ovulation. During a 28-day cycle, ovulation can be predicted by a surge in LH on day 14 and by measuring the responding increase in progesterone on day 21 (mid-luteal phase). Timings have to be adjusted depending on the length of the woman’s menstrual cycle. Alternatively, ultrasound scanning can be used to track the growth and development of follicles, thus predicting ovulation.Female reproduction MCQ: case 5 You review a 21 year old woman in the reproductive endocrinology clinic. She has a history of secondary amenorrhoea and anorexia since she was 18 years old. She is keen to know why she has stopped having periods. Functional hypothalamic amenorrhoea is underpinned by which process? A. A high LH to FSH ratio B. Gonadotrophin releasing hormone (GnRH) resistance C. High circulating leptin D. Hyperprolactinaemia E. Reduced pulsatility and secretion of GnRH Female reproduction MCQ: case 5 You review a 21 year old woman in the reproductive endocrinology clinic. She has a history of secondary amenorrhoea and anorexia since she was 18 years old. She is keen to know why she has stopped having periods. Functional hypothalamic amenorrhoea is underpinned by which process? A. A high LH to FSH ratio 🡪 that’s characteristic of PCOS, here we are likely to see the opposite: High FSH to LH ratio B. Gonadotrophin releasing hormone (GnRH) resistance 🡪 rare genetic condition that would present in a similar manner but it would be detected on genetic testing C. High circulating leptin 🡪 anorexia points towards low body fat and therefore low leptin levels D. Hyperprolactinaemia 🡪 High level of prolactin or galactorrhoea not mentioned, no visual field defect E. Reduced pulsatility and secretion of GnRH 🡪 Functional hypothalamic amenorrhoea is characterised by abnormal hypothalamic GnRH secretion with resultant reduction in pulsation of gonadotrophins. Functional hypothalamic amenorrhoea can be caused by eating disorders, mental or physical stress or over-exercising.Female reproduction MCQ: Case 6 A 16 year old girl presents to her family physician having never had a period. She is noted to be of short stature. Blood tests reveal FSH 26.2 IU/L (normal/elevated), LH 18.5 IU/L (normal/elevated) and oestradiol < 50 pmol/L (very low). What is the next most appropriate investigation? A. CT scan ovary and adrenal glands B. Karyotype C. MRI pituitary D. Synacthen test E. Ultrasound ovariesFemale reproduction MCQ: Case 6 A 16 year old girl presents to her family physician having never had a period. She is noted to be of short stature. Blood tests reveal FSH 26.2 IU/L (normal/elevated), LH 18.5 IU/L (normal/elevated) and oestradiol < 50 pmol/L (very low). What is the most appropriate investigation to establish a diagnosis? A. CT scan ovary and adrenal glands B. Karyotype 🡪 short stature and primary amenorrhea with low oestrogen and normal gonadotrophins think Turner Syndrome (45, X) C. MRI pituitary 🡪 more relevant in hypogonadotrophic cases D. Synacthen test E. Ultrasound ovaries 🡪 PCOS not very likely here (no high LH/FSH ratio, no androgen related symptoms, no obesity)Female reproduction MCQ: Case 7 A 26 year old female presents with irregular periods, acne, hirsutism. A transvaginal ultrasound scan reveals ovarian cysts. She is diagnosed with Polycystic ovarian syndrome (PCOS). She does not want to conceive. What treatment will you offer her? A. None, PCOS is usually transient B. Cysts aspiration C. Clomiphene citrate D. Progesterone antagonist E. Combined oral contraceptive pillFemale reproduction MCQ: Case 7 A 26 year old female presents with irregular periods, acne, hirsutism. Her BMI is 32 kg/m2. A transvaginal ultrasound scan reveals ovarian cysts. She is diagnosed with Polycystic ovarian syndrome (PCOS). She does not want to conceive. What pharmacological treatment will you offer her? A. None, PCOS is usually transient 🡪 false, but remember that lifestyle measures to promote weight loss can really help with the condition B. Cysts aspiration 🡪 that’s not a thing for PCOS C. Clomiphene citrate 🡪 oestrogen antagonists used to balance FSH and LH ratio and promote egg growth if a PCOS patient wants to conceive. Given only for a few days at the start of the cycle. D. Progesterone antagonist 🡪 that won’t help to balance her gonadotrophins and reduce androgens. Used in pregnancy termination or post-coital contraception. E. Combined oral contraceptive pill (CCP) 🡪 yes the oestrogens will inhibit the LH and FSH release which will in turn lower androgen production and attenuate symptoms. Progesterone protects endometrium from overgrowing. The mini-pill (progesterone only) would not inhibit gonadotrophins, or at least not to the extent of how oestrogens do. As the patient does not want to conceive CCP is appropriate.Female reproduction MCQ: Case 8 A 42 year old woman is referred with galactorrhoea. Her periods have become irregular. She has two children who are 16 and 21 years old and she has been more stressed at work than previously. She is not on any regular medication. Blood tests reveal a prolactin level of 570 ng/mL (elevated) with no evidence of macroprolactinoma on MRI. What is the most appropriate treatment? A. Monitor prolactin levels every year B. Reassure and discharge C. Refer for pituitary surgery D. Start on cabergoline 0.25mg twice weekly E. Start on carbimazole 40mg once dailyFemale reproduction MCQ: Case 8 A 42 year old woman is referred with galactorrhoea. Her periods have become irregular. She has two children who are 16 and 21 years old and she has been more stressed at work than previously. She is not on any regular medication. Blood tests reveal a prolactin level of 570 ng/mL (elevated) with no evidence of macroprolactinoma on MRI. What is the most appropriate treatment? A. Monitor prolactin levels every year B. Reassure and discharge 🡪 not really nice for the patient… C. Refer for pituitary surgery 🡪 No evidence of macroprolactinoma so surgery is not 1 option D. Start on cabergoline 0.25mg twice weekly 🡪 dopamine agonists inhibit prolactin secretion. E. Start on carbimazole 40mg once daily 🡪 hyperthyroidism medicationFeedback Please take a minute now before you leave to fill in a quick feedback form: https://app.medall.org/training/feedback/anonymou s?organisation=accessibility-in-medicine&keyword=90 9c3e40db04dbcaf06077e5 AIM Facebook Page ▶ Give our Facebook page a like for updates and opportunities,just search @AIMEdinburgh Thank you for coming! ▶ If you have any more questions, feel free to email me at ▶ s2271119@ed.ac.uk ▶ s2134683@ed.ac.uk or email, accessibilityinmedicine@gmail.com