Step threeassess estrogen status

1. The progesterone challenge test is used to determine estrogen status and determine the competence of the uterine outflow tract.

2. Medroxyprogesterone (Provera) 10 mg is given PO qd for 10 consecutive days. Uterine bleeding within 2-7 days after completion is considered a positive test. A positive result suggests chronic anovulation, rather than hypothalamic-pituitary insufficiency or ovarian failure, and a positive test also confirms the presence of a competent outflow tract.

3. A negative test indicates either an incompetent outflow tract, nonreactive endometrium, or inadequate estrogen stimulation.

a. To rule out an abnormality of the outflow tract, a regimen of conjugated estrogens (Premarin), 1.25 mg daily on days 1 through 21 of the cycle, is prescribed. Medroxyprogesterone (Provera) 10 mg is given on the last 5 days of the 21-day cycle. (A combination oral contraceptive agent can also be used.)

b. Withdrawal bleeding within 2-7 days of the last dose of progesterone confirms the presence of an unobstructed outflow tract and a normal endometrium, and the problem is localized to the hypothalamic-pituitary axis or ovaries.

4. In patients who have had prolonged amenorrhea, an endometrial biopsy should be considered before withdrawal bleeding is induced. Biopsy can reveal endometrial hyperplasia.

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