Female Reproductive System and Breast 1 out of 220
A 19-year-old woman comes to the physician because of recent weight gain. She started a combined oral contraceptive for dysmenorrhea and acne six months ago. She has been taking the medication consistently and experiences withdrawal bleeding on the 4th week of each pill pack. Her acne and dysmenorrhea have improved significantly. The patient increased her daily exercise regimen to 60 minutes of running and weight training three months ago. She started college six months ago. She has not had any changes in her sleep or energy levels. She is 162 cm (5 ft 4 in) tall and weighs 62 kg (137 lbs); six months ago she weighed 57 kg (126 lbs). Examination shows clear skin and no other abnormalities. A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?
Switch contraceptive to a nonhormonal contraceptive methodSwitching from hormonal contraceptive methods to nonhormonal contraceptive methods is indicated in women who experience side effects or have contraindications to combined hormonal contraception (e.g., development of hepatic adenoma, increased risk of thromboembolism, estrogen-dependent tumor). Since this woman's dysmenorrhea and acne have improved since starting treatment with combined oral contraceptives (COCs) and there is no evidence that weight gain is a side effect of COCs, there is no indication to change her treatment regimen. Measure serum thyroid-stimulating hormone concentrationSerum thyroid-stimulating hormone (TSH) levels are measured to diagnose thyroid disorders, such as hypothyroidism. Individuals with hypothyroidism often present with symptoms of decreased metabolic rate, including fatigue, weight gain, cold intolerance, constipation, and secondary amenorrhea. In the absence of any other typical features of hypothyroidism, this woman's weight gain is more likely due to other causes. Perform a low-dose dexamethasone suppression testA low-dose dexamethasone suppression test is used to diagnose elevated cortisol levels in individuals with Cushing's syndrome. Common clinical features include hypertension, central obesity, moon facies, easily bruisable skin and acne, muscle atrophy, and features of virilization in women (hirsutism, menstrual cycle irregularities). Since this woman's weight gain did not occur simultaneously with her other symptoms and she does not have hypertension, Cushing's syndrome is unlikely. Switch contraceptive to a progestin-only pill
Progestin-only contraceptive pills are indicated in women who have contraindications to treatment with estrogen-containing combined oral contraceptives. Contraindications include estrogen-dependent and hepatic tumors, an increased risk for thromboembolic events and cardiovascular disease, cigarette smoking, acute pancreatitis, and systemic lupus erythematosus. Since this patient has no known contraindications to estrogen-containing treatment and is tolerating her current medication well, a change in treatment is not indicated. Measure serum testosterone concentrationSerum testosterone levels are measured in women with suspected polycystic ovary syndrome (PCOS), a disorder characterized by hyperandrogenism, anovulation, and polycystic ovaries. Typical clinical features include menstrual irregularities (e.g., amenorrhea), infertility, hirsutism, obesity, and acne. Although PCOS causes acne, and the condition may also improve with combined oral contraceptive treatment, she had no other features suggestive of PCOS and only started gaining weight after treatment, which makes this diagnosis unlikely. Perform a pelvic ultrasoundA pelvic ultrasound is performed to confirm pregnancy. Although weight gain is a symptom of pregnancy, pregnancy is unlikely since she consistently takes oral contraceptives, menstruates regularly, and her urine pregnancy test is negative.
Reassure the patientThis woman started gaining weight around the time she started treatment with combined oral contraceptives (COC) but, despite popular belief, weight gain has not been proven to be a side effect of COC. Since the patient also started college 6 months ago and has recently intensified her training routine, her weight gain is most likely attributable to changes in eating habits and an increase in muscle mass. As the current treatment has also proven to be beneficial for her previous dysmenorrhea and acne, reassurance and advice on maintaining a healthy weight are the most appropriate steps in management.
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