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NBME 22 Answers

nbme22/Block 4/Question#46

A 39-year-old woman comes to the physician because ...


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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. +2  
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 +  
meningitis  I guess that's another reason for steroids and doping up. +2  

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submitted by oznefu(7),

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.

hysitron  I guessed this one cause men have a higher hemoglobin than women. +1  
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. +3  
meningitis  It kinda makes sense knowing testosterone causes catabolism so I was in between Alkaline phosphatase and hemoglobin... +1  
enbeemee  isn't testosterone anabolic? +  

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submitted by alexb(15),

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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submitted by nwinkelmann(109),

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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submitted by sup(4),

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 :)

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

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.


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submitted by yobo13(1),

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