1. A CASE OF HYPOTHYROIDISM WITH DELAYED PUBERTY AND PUBERTY MENORRHAGIA Dr. K. Sowmya PG (OB & G)

2. 25 years Old lady With Tanner – B 2 PH 1 Stage

3. Sujatha a 25 year old lady, unmarried residing at Macharla came to labor room with c/o. bleeding p/v since 15 days.

4. H/ O. PRESENT COMPLAINT Present complaint started 15 days back as heavy periods associated with clots wetting 4-5 diapers / day and continued till now. The bleeding is not associated with pain. H/o. cold intolerance H/o. constipation

5. There is h/o. 4 months amenorrhea before the starting of bleeding. No h/o. similar complaint previously. No h/o injury. No h/o fever. No h/o spontaneous or induced abortion No h/o D & C No h/o steroid therapy for any reason No h/o bleeding disorder in the past or in the family No h/o administration of anticoagulants for any reason.

6. G YNAEC H / O Attained menarchy at the age of 24 years i.e., 1 year back. Menstrual history – bleeding for 4-5 days wetting 3-4 diapers / day, heavy flow, associated with clots every 2-3 months and not associated with pain. LMP - 15 days

7. P AST H / O There is no h/o similer complaint previously No h/o bleeding disorder No h/o TB, Asthma No h/o drug allergy No previous h/o blood transfusion

8. P ERSONAL H / O She takes mixed diet Sleep & apetite – normal Intelligence - normal Studied upto – 10 th class h/o constipation - present

9. F AMILY H / O Sibling history She is the youngest girl of 4 sisters, all the other 3 girls and parents are normal. No h/o similar complaint in her siblings. No h/o genetic disorders in family. No h/o consaguinous marriage of her parents. No h/o bleeding disorders. No h/o HTN, DM

10. G ENERAL EXAMINATION She is short statured with height 123 cm & wt. 38 kg. Moderately nourished Secondary sexual characters are not well developed – Tanner B2 PH1 stage - No axillary hair Coarse facial features s/o hypothyroidism Dry mottled skin

11. Coarse facial features Broad flat nose Puffy face

14. There is no lymphadnopathy Brests – B2 tanner stag. Thyroid – No goitre Severe anaemia No jaundice No oedema feet No clubbing No cyanosis

15. V ITAL PARAMETERS Temp – Normal PR : 72/mt, regular, low volume. BP : 80 / 50 mm hg RR : 24/mt Systemic examination Cvs S1+ S2+, no added sounds Resp. system : clear Bilateral air entry normal

16. G YNECOLOGICAL EXAMINATION Abdomen : Inspection : Skin over the abdomen – normal No visible or engorged veins There are no scars Umbilicus – normal, not everted All quadrants are moving equally with respiration All hernial orifices are normal. Palpation No tenderness No rigidity, No gaurding No palpable lumps

17. Pelvic examination : External genitalia – infantile Pubic hair PH1 stage Bleeding p/v present

18. I NVESTIGATIONS Complete Haemogram HB % = 3.8 gm % TRBC = 0.50 milions / cumm TWBC = 8,600 / cumm DC = P-75%, L – 21% E – 04% ESR = 20 mm / 1 st hr Platelet count = 1,02,000 /cumm PCV = 4 ml % BT = 2’ 50” CT = 5’ 20”

19. Peripheral Smear RBC – microcytic, hypochromic RBC with anisocysosis, occasional target cells. WBC – TC, DC with in normal limits. No abnormal cells. Platelets – around lower normal range seen diserete No haemoparasites Impression : microcytic, hypochromic anaemia. Correlate clinical

20. Blood group & Rh type : A+ve RBS – 102 mg / dl Blood urea – 36 mg / dl Serum creatinine - 1.3 mg / dl HBs Ag – Negative HIV – Non reactive

21. T HYROID PROFILE T 3 - 0.29 ng / dl T 4 - 1.04 µg / dl TSH - 200 mU / Lt

22. FSH LH Oestrogen Prolactin Testosterone CT Scan MRI Scan Buccal smear Karyotyping - Not Done

23. USG Uterus : 8 cm x 4 cm x 3 cm Endometrium – Collection noted in uterus more in lower uterine segment and external os region and vagina Rt ovary not visualised Lt ovary normal

24. D IAGNOSIS Hypothroidism with delayed puberty & puberty menorrhagia

25. T REATMENT GIVEN 5 units of blood transfusion done Tab Eltroxin 100 µg / day Progesterone (Regesterone) started at 25 mg/day as 5 mg 5 times a day and tapered to 5 mg Od in 5 days and advised to continue it for 20 days. Advised review after one week - no follow up.