NBME 22 Hemoglobin (NBME Answers)

Retired NBME 22 Answers

nbme22/Block 4/Question#46 (reveal difficulty score)
A 39-year-old woman comes to the physician ...
Hemoglobin 🔍 / 📺 / 🌳 / 📖
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submitted by ∗johnthurtjr(168)

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here's a google

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johnthurtjr FTR I had no idea this was a thing, and was pretty disappointed in myself when the google search had it in big bold letters right in my face. +3

drdoom via @johnthurtjr link: "Testosterone and other androgens have an erythropoietic stimulating effect that can cause polycythemia, which manifests as an increase in hemoglobin, hematocrit, or red blood cell count." https://www.medscape.com/viewarticle/773465 +3

meningitis I guess that's another reason for steroids and doping up. +8

drschmoctor For once I feel like I've been led astray by Pathoma. My instinct was to go with hemoglobin, but I talked myself out of it after remembering Dr. Sattar saying that the reason why women have lower hemoglobin is due to menstruation. +2

fexx F U testosterone! and F U NBME 22 question +1

schep I only knew this because there are three (at least three, maybe more that I don't know) contraindications to giving testosterone replacement therapy: +OSA +prostate cancer +hematocrit >50% +2

drdoom ^ linkify @drdoom https://www.medscape.com/viewarticle/773465 +

kayla @drschmoctor; I still think it lines up with the correct reasoning; during the menstrual phase ( in addition to loosing hemoglobin in the blood) there are also very low levels of the androgen hormones that usually serve as a stimulating effect on hemoglobin... +

abhishek021196 Fortunately, we were taught this in med school - testosterone stimulates erythropoiesis by stimulating EPO and recalibrating the set point of EPO in relation to hemoglobin and by increasing iron utilization for erythropoiesis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4022090/ +

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submitted by ∗oznefu(22)

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how do you narrow down that testosterone increased hemoglobin concentration? just a random fact to know? i put alkaline phosphatase because i figured increased testosterone will increase bone growth and ruled out prostate-specific antigen bc it’s a woman.

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hysitron I guessed this one cause men have a higher hemoglobin than women. +11

notadoctor High levels of testosterone will result in amenorrhea. I guessed that since she's not menstruating she will not be losing blood and therefore hemoglobin. Therefore her hemoglobin levels will be higher than expected. +5

meningitis It kinda makes sense knowing testosterone causes catabolism so I was in between Alkaline phosphatase and hemoglobin... +1

enbeemee isn't testosterone anabolic? +4

syoung07 ALK phosph is indicative of osteoclast activity. Testosterone keeps male bones strong just like estrogen does for women. Testosterone builds bone (osteoblast activity) therefore we would not see a rise in ALK phos +1

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submitted by ∗adong(144)

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uworld says somewhere that testosterone increases hematocrit, increases LDL, and decreases HDL

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passplease Estrogen increases HDL. Testosterone is converted into estrogen. Why doesnt testosterone increase HDL. Why is my logic wrong? +

avocadotoast The woman in this vignette has an increased androgen:estrogen ratio, so the effects of testosterone on lipid levels will be greater than those of estrogen on lipid levels. Boards and beyond also states that testosterone causes an increase LDL, decreased HDL, and increase in hematocrit, which is why males with primary hypogonadism can present with anemia and the use of anabolic steroids can present with erythrocytosis. +

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submitted by ∗alexb(53)

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First Aid 2019 page 622 stimulatory growth effects of testosterone include red blood cells. I think they expect us to know this.

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medstudent FA 2020 p. 636 +

specialist_jello Growth spurt: RBCs (fa2020 p 636) +

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submitted by rogeliogs(12)

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My mind went this way: in Men Andropause = less testosterone = less bone density in Women more testosterone = more bone density = more alkaline phosphatase. Hemoglobin was my second option because I don't hear too much about anemia in post menopause or post andropause, but bonds density is a big deal there.

blah.

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submitted by ∗sup(31)

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Somehow I was able to convince myself that increased testosterone --> decreased estrogen --> decreased negative feedback on LH/FSH secretion --> increased FSH. Does anyone care to explain why this logic is wrong? Thanks :)

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btl_nyc The increased testosterone is metabolized by granulosa cells to estrogen and by adipose tissue into estrone. Both feed back on the hypothalamus to inhibit FSH & LH secretion, but FSH is much more sensitive to feedback inhibition than LH, causing an increased LH/FSH ratio. +1

impostersyndromel1000 @sup, i did the same thing. Had no idea testosterone and androgens can increase epo +

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submitted by ∗johnthurtjr(168)

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here's what I found

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submitted by ∗asharm10(37)

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It's an anabolic hormone, muscle mass, RBC mass will increase.

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submitted by gokings2021(9)

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Men generally have a higher RBC mass (hematocrit, hemoglobin, etc) and it is thought to be attributed to higher testosterone levels. She has high testosterone so you can assume the same for her. This is in Zanki, so it must be in FA or Pathoma.

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submitted by ∗medstudent(18)

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For all wondering why testosterone doesn’t cause an increase in alk phos, I found this article that basically says men with low testosterone have high alkaline phosphatase and weak bones.

https://news.weill.cornell.edu/news/2015/03/alkaline-phosphatase-determined-to-show-success-of-testosterone-therapy-on-bone-mineral-density

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submitted by ∗medguru2295(64)

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TBH I only got this bc of the controversy with Lance Armstrong blood doping. IDk the mechanism at all. But, it will help you all remember this question/answer.

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submitted by yobo13(5)

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Easy way: Lab values. The only one that made sense/was different for men vs women = Hb

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submitted by ∗nwinkelmann(366)

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I interpreted the patient to have PCOS (hirsutism, amenorrhea, ovarian mass) though the super elevated testosterone is more concerning for ncer (per this article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1069067/). If the patient has PCOS, she is likely obese and at higher risk for NAFLD which can be associated with elevated alkaline phosphatase, lipid accumulation, and elevated testosterone, but not DUE to androgenic effects ("serum androgen levels were not associated with the presence of NALFD. This is indirectly confirmed with our result on phenotypes. Namely, there is no difference in NAFLD prevalence between hyperandrogenic, and non-hyperandrogenic or reproductive PCOS phenotypes. NAFLD is considered a hepatic component of metabolic syndrome with a central pathogenic role of insulin resistance that also affects the hypothalamo-pituitary-ovarian axis in subjects with PCOS... Hyperandrogenic state may be due to insulin resistance." http://bit.ly/2FWKGjy).

Then, as said by @btl-nyc, elevated testosterone in a female is converted to estrogen and estrone and feedback inhibits the hypothalamus leading to decreased FHS and LH levels, but FSH is inhibited more, so there is an increased LH:FSH ratio.

Finally, regarding PSA (which does occur in women, who knew? lol), the correlation between testosterone and PSA in men is still pretty week (in this study, there was only a correlation and a weak one at that, after multivariate analysis adjusting for several things https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5436005/) so there is definitely not a correlation in women. However, per this study (https://www.ncbi.nlm.nih.gov/pubmed/9062481/) there may be an association between certain androgens (not testosterone) and PSA in women.

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