XY Chromosome in a Female With Secondary Amenorrhea

XY Chromosome in a Female With Secondary Amenorrhea Dania Al-Jaroudi, M.D Capsule A 17-year-old girl presented to our gynecology clinic with secondary amenorrhea. She had been diagnosed with ALL at the age of 5 years, she received chemotherapy and radiotherapy over the following years. Her chromosomal analysis showed a karyotype of 46, XY. Introduction Primary ovarian insufficiency is a disorder that is emotionally traumatic and bears lifelong consequences on fertility, bone and cardiovascular health (1,2), making it more challenging is its occurrence in adolescents. Previously the term premature menopause had been used and found to be incorrect; as about 50 % of women have intermittent ovarian function and may ovulate and conceive after this diagnosis (1,2,3). The diagnosis is made when women younger than 40 years, have four or more months of amenorrhea and two serum FSH levels taken one month apart in the menopausal range (2). Causes of primary ovarian insufficiency in adolescents include chromosomal abnormalities, premutation in the FMR1 gene for fragile X, or iatrogenic from chemotherapy or radiation therapy (1). Infiltrative, infectious processes and pelvic surgery are less common causes (1). Autoimmune disease is another cause, as around 4% of women will have adrenal or ovarian antibodies. Still the etiology remains unknown in many cases (3). Although advances in oncology treatments have improved survival of childhood cancer, this came at the expense of ovarian function, increasing the risk of ovarian insufficiency and infertility (4). Morse et. al showed in a prospective observational study of ovarian function during cancer treatment of females aged 0 to 18 years that ovarian insufficiency occurred in chemotherapy treated prepubertal and pubertal patients regardless of menarche, age, diagnosis or chemotherapy given (5). Furthermore, females receiving radiotherapy below the diaphragm and/or stem cell transplant (SCT) had no recovery in their ovarian function followed for one and a half years from the end of their treatment (5). Clinicians need to be sensitive in delivering the diagnosis of primary ovarian insufficiency to their patients (6). This diagnosis can be emotionally traumatic and emotional needs of the patient need to be addressed as should further support be available (6). Adequate information regarding the diagnosis should be given as according to Groff AA et al (6); most patients feel that inadequate information decreased their sense of control (6). Case Report Our patient is a17-year old single girl who presented to our clinic with secondary amenorrhea. She had been diagnosed with acute lymphocytic leukemia (ALL) in 2002 at 5 years of age. Therapy began with hyperfractionated chemotherapy with two courses; course A: cyclophosphamide, vincristine, doxorubicin, and dexamethasone and Course B: methotrexate and cytarabine (HCVAD). She relapsed in 2007 and 2012 and was treated with methotrexate (MTX), dexamethasone (DEXA), vincristine, and L-asparagine. She then had total body radiation in 2012. In July 2012, patient was referred to King AbdulAziz medical city at 15 years of age with pancytopenia, she was again given hyperfractionated chemotherapy with two courses; course A: cyclophosphamide, vincristine, doxorubicin, and dexamethasone and Course B: methotrexate and cytarabine (HCVAD). After remission she was given busulfan/cyclophosphamide then she had stem cell transplant (SCT) from her full HLA matched sibling. Patient had menarche at 11 years, after which she had regular menstruations for 4 years before she developed secondary amenorrhea. Progesterone challenge test was done with no response. Hormonal profile showed hypergonadotropic hypogonadism, normal thyroid function test and prolactin levels. Pelvic ultrasound showed normal, but small sized uterus and ovaries. Chromosomal analysis showed 46, XY, this confused her primary physician was unsure about the best plan of management. On further review of her previous investigations, her chromosomal analysis one-year back had been a normal female genotype. So with the stem cell transplant (SCT) from her HLA matched sibling her genotype and her whole cell line had changed. With the impression of premature ovarian insufficiency as her primary diagnosis, patient was started on cyclical hormonal therapy; estradiol valerate 2 mg, norgestrel 500 mcg (progyluton ®, Bayer Health, Germany) for 6 months. On follow up after 2 months, she didn’t start progyluton because she thought she needs to start 5th day of cycle; proper counseling was done and patient was seen 2 months afterwards on hormonal therapy, calcium and vitamin D with withdrawal bleeds. Objective: To report a case of primary ovarian insufficiency in 17 year old, single girl, who had ALL and was treated with chemo and radiotherapy, followed by bone marrow transplant. Design: Case report. Setting: King Abdulaziz Medical City Patient(s): A patient diagnosed with primary ovarian insufficiency, after receiving chemo and radiotherapy for ALL. She later received bone marrow transplant from her HLA matched brother. Intervention(s): Hormone replacement therapy. Main Outcome Measure(s): After ruling out other causes, counseling and emotional support where given to the patient. She was then started on hormonal replacement therapy, calcium and vitamin D. Result(s): Patient started hormonal therapy and was followed in the clinic. Conclusion(s): This case describes a primary ovarian insufficiency in a girl post chemo and radiotherapy; it also describes a change in cell line following bone marrow transplant from her HLA matched brother. Key Words: Secondary amenorrhea, primary ovarian insufficiency, Hormonal replacement therapy, stem cell transplant. Acknowledgments: We would like to express our thanks to Dr. Hanan Dahlawi for providing care to the patient. Discussion: Conditioning with chemotherapy and radiotherapy prior to stem cell transplant (SCT) particularly with cyclophosphamide and total body irradiation will inevitably lead to primary ovarian insufficiency and infertility (7). The risk of primary ovarian insufficiency when patients receive busulfan and cyclophosphamide is about 100%, similar to what our patient has received (7). We report this case as this patient’s karyotype changed to a male karyotype following stem cell transplant (SCT) from her full HLA matched sibling. This led to a diagnostic confusion at first, and was later understood after her karyotype one year earlier was reviewed and genetist was consulted. There was no similar cases reported in the literature, although numerous cases where reported on primary ovarian insufficiency in adolescents, and successful pregnancy thereafter. Therefore, we recommend to educate physician on changes occurring after stem cell transplant. Unfortunately, this patient was not offered fertility preservation options prior to her treatment; this again is another area of awareness that needs to be raised in physicians. Nonetheless, this patient was offered counseling and hormonal therapy after she was referred to our out patient clinics. The aim of hormonal therapy in adolescents with primary ovarian insufficiency includes the relief of hypoestrogenic symptoms in addition to bone support, cardiovascular, and sexual health (8). Adolescents may need higher doses of estrogen than menopausal women to ensure adequate replacement and optimal bone health (8).

The Arctic National Wildlife Refuge (ANWR) in Alaska

The world is filled with many natural wonders, and one of these marvels is the Arctic National Wildlife Refuge (ANWR) in Alaska. Its 19. 6 million acres comprise some of the last truly undisturbed wilderness, and the area has even been called the crown jewel of America's refuge system. This refuge is composed of a far-reaching stretch of tundra covered with marshes and lagoons and intertwined with rivers spectacularly positioned among the foothills of the snowcapped Brooks Mountain Range and the sparkling waters of the Beaufort Sea, presenting an awe-inspiring spectacle (Defenders of Wildlife, 2001a). It was because of this beauty that ANWR was set-aside as government land. Originally, the North Slope of Alaska was only used for military purposes, and the public was not allowed on any of its 48. 8 million acres during World War II. But in 1952-1953, some government scientists decided that this area of Alaska should become a conservation area. So, Fred Seaton, the Secretary of the Interior, made 8. 9 million acres of the North Slope into the â€Å"Arctic National Wildlife Range† to protect it. A lot of oil was found throughout the North Slope in the following years, so many wanted to drill for oil in the Arctic National Wildlife Range. In the Alaska National Interest Lands Conservation Act (ANILCA – 1980), most of the Range plus more of the North Slope was designated as Wilderness and called the Arctic National Wildlife Refuge. However, Section 1002 of ANILCA decided the part of the Range not considered Wilderness should be part of ANWR, although it must be researched before it was decided whether or not it should be designated as Wilderness or used for oil development. This disputed section is called the 1002 Area (Alaska Wilderness League 2003a; Ecological Society of America, 2002; Gibbs, 2001; U. S. Fish and Wildlife Service, 2000b). Studies conducted in the 1002 Area showed that oil and gas development would cause great harm to its wildlife (U. S. Fish and Wildlife Service, 2000b). Unfortunately, the oil companies do not seem to see the beauty of this wild area, only the possible profit in it. The oil industry would still like to drill in the 1002 Area (the Coastal Plain), an area of 1. 5 million acres between the Arctic Ocean and the Brooks Range (Alaska Wilderness League 2003a; Ecological Society of America, 2002; Gibbs, 2001; Sierra Club, 2001). However, the Coastal Plain is vital to the continued existence of many organisms and is full of life during the short spring and summer months, giving it the nickname â€Å"America's Serengeti† (Alaska Wilderness League 2003a; Alaska Wilderness League 2003b; Defenders of Wildlife, 2001b). The Porcupine River caribou herd of about 130,000 goes to the Coastal Plain on an annual basis to bear and nurse their young before migrating to warmer climates (Alaska Wilderness League 2003b; Gibbs, 2001; U. S. Fish and Wildlife Service, 2000b; Roth, 1995). Polar bears use it as their most vital denning area on land (Alaska Wilderness League 2003b; Roth, 1995). Musk oxen, grizzly bears, wolves, wolverines, foxes, golden eagles, and snowy owls assemble there to stalk their prey and build their dens. Dall sheep, whales, moose, 36 fish species, and eight other marine mammals thrive in the region, too. About 300,000 snow geese also stop there in the fall to eat after coming from their nesting grounds in Canada (Alaska Wilderness League 2003a; U. S. Fish &Wildlife Service, 2002). Another 135 species of birds use the land to breed, nest, raise their young, feed, or rest before they migrate to areas throughout the United States and beyond (Alaska Wilderness League 2003b; Babbitt, 1995). The 1002 Area is home to a variety of wildlife. So, drilling should not occur in the 1002 Area because it would be detrimental to the animals living there. Oil development could hurt the wildlife in many ways. The emissions from aircrafts, scents of workers, and the noise of vehicles and other engines could displace the animals (Gibbs, 2001). Roads and pipelines would also displace the wildlife because their normal routes would be blocked (Alaska Wilderness League, 2003b). Drilling would cause great harm to the animals that rely on the Coastal Plain of ANWR. Additionally, the 135 species of birds that nest and feed in the 1002 Area would be affected. Many of the birds would lose critical habitat, causing population declines for already small populations. Also, the oil fields would attract predators, further lowering their numbers (Audubon, 2002). Other studies around the other Alaskan oil fields have shown tundra swans to nest over 650 feet from the roads (Gibbs, 2001). Many of the other migratory birds are also sensitive to disturbances, and oil production in ANWR would interrupt migration patterns that have been occurring for many years (Alaska Wilderness League 2003b). The migratory species would carry the effects with them throughout the world (UNEP, 2001). Caribou are also sensitive to disturbances. Caribou with young stay at least 2. 5 miles away from roads (Gibbs, 2001). So, the caribou would be pushed into the foothills of the Brooks Range, an area with more predators (Ecological Society of America, 2002). A computer model estimated that calf survival would be reduced about 14 percent by oil production in ANWR (Gibbs, 2001). And, the U. S. Fish and Wildlife Service believes that lowering the calf survival by only five percent would cause the Porcupine caribou herd to suffer population declines (Alaska Wilderness League 2003b). The musk oxen's population would also drop, too. They live on the Coastal Plain year-round (Montgomery, 2003). They need to conserve their energy and move very little to live on the Coastal Plain in the winter because there is little to eat, and it is very cold. The musk oxen would be forced off of the 1002 Area by drilling, and the Department of the Interior thinks this would lower their population 25 to 50 percent (Alaska Wilderness League 2003). The polar bears need the Coastal Plain to continue their current population numbers as well. It is needed for pregnant polar bears to nest upon and raise their cubs. The cubs need to be protected in their dens for three months. Any sort of disturbance would cause them to leave their dens early, which would harm their newborn cubs (Alaska Wilderness League 2003b). Bowhead whales also migrate past the Coastal Plain. They are needed by the Kaktoviks (the people indigenous to the North Slope) for food and cultural activities. However, the oil development occurring presently has already displaced them 9 to 15 miles from any noise (Montgomery, 2003). So, the Kaktoviks need areas without drilling to continue their subsistence way of life. Furthermore, all of the aquatic animals (including bowhead whales and polar bears) would be greatly harmed by an oil spill. Development in the waters is not significant as of yet, but if more development occurs on land, then more development may occur offshore. Many animals are very vulnerable to the effects of an oil spill, so more development should not occur (Montgomery, 2003). In addition to harming wildlife, oil development would harm the physical environment as well. The drilling west of the refuge (near Prudhoe Bay) has already done considerable damage. It has turned 400 square miles of undisturbed wilderness into 1500 miles of roads and pipelines, 1400 wells, three airports, 17 sewage treatment plants, and hundreds of large waste pits. The drilling has discharged into the environment more that 43,000 tons of nitrogen oxides each year, contributing to smog and acid rain production, and 100,000 metric tons of methane that leads to global warming. There have been about 1,600 spills containing 1. 2 million gallons of oil, diesel fuel, acid, drilling fluid, and many other harmful substances between 1994 and 1999 (Indigenous Environmental Network, 2001). There is about one spill each day (Alaska Wilderness League 2003c). All of this could occur in ANWR if the oil companies get what they want. And, you would think that there must be a gold mine of oil under the 1002 Area if they would sacrifice such an important area of land. However, the U. S. Geological Survey predicts there is only enough oil beneath the Coastal Plain to sustain the energy needs of America for six months (Alaska Wilderness League 2003a; Alaska Wilderness League 2003c). The Department of the Interior has estimated that â€Å"there is only a one-in-five chance of finding any economically recoverable oil in the refuge† (Roth, 1995). It is not worth ruining a pristine wilderness supporting many animals for very little oil that may not even be â€Å"economically recoverable. † Not only is there little oil under the Coastal Plain, it is also found in only small accumulations rather than one large oil field (like Prudhoe Bay). So, there would have to be more development areas, increasing the effect on the wildlife and environment (Ecological Society of America, 2002). Overall, the drilling would cause a lot of damage. A pristine wilderness would be turned into a noisy, polluted, developed area. Millions of species of animals would be harmed. They would no longer be able to use the Coastal Plain to feed, mate, nest, and hunt. They would be forced onto marginal lands, and their numbers would be negatively affected (Alaska Wilderness League 2003b; Gibbs, 2001; U. S. Fish and Wildlife Service, 2000b). And, the drilling could cause many environmental problems, including global warming, smog, and acid rain (Indigenous Environmental Network, 2001). Plus, the drilling would not even solve the energy problems in the U. S. So, drilling in ANWR should be prevented!

Analysis Of The Outsiders - 769 Words

Robert Frost wrote this poem to express how he feels about polotics.The peom can relate to S.E. Hintons The Outsiders by showing that things will get better it just takes time. The poem is a short narritive peom that tells a story. The story that Robert Frost is trying to tell us is that things might not be the best at the time but it will come to and end. The title of the poem is four words. Four words that show you that it will all eventually come to an end. By it all coming to an end things might just get better. Things getting better will repeat the process when a decision is made. Nothig Gold Can Stay can mean many things, one of those thing is that we all may die when things get rough. Another way to think of it is if times are†¦show more content†¦It would seem as if they were facing the pain instead of us. In reality we are using the plants to better explain our attitude towards the subject. The mood of this poem is kind of deathly and gloomy. Frost demonstarates that things are coming to an end and they wont stay long. The tone of this poem is that, nothign will stay as long as you want it too so enjoy it while you can. The theme of Robert Frosts poem, being that nothign really lasts forever, so cherish it, is understood by most readers. The rhythm of the poem could seem like a journal entry where they are realizing something bad happening in their life, analyzing it, and making that realization come to life by using this to express their feelings. the rhyming of the poem fits it well because it is a repeating pattern where it repeats itsself for two then changes. It goes well because when you read it you want to slow down at the end to get the feel that nothing gold can stay. The poem shows a couple of signals of stress through out the poem. It shows distress, discomfort, and realization by the author showing something may have happened in his life. Im not sure if Frost was planning on readrs but the imagery I had while reading this peom was a beautiful flower dying and not coming back. Frost may have envisioned for readers to have the same concept but thatsShow MoreRelatedAnalysis Of The Outsider 1397 Words   |  6 PagesCamus uses pathetic fallacy to describe the importance of the physical world in the novel The Outsider, through his character Meursault. Camus uses the elements to exhibit the importance of an individual s physical needs, and how they shape their personality. Meursault is a character that requires his physical needs to be met before he is able to make logical decisions for himself. 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He readily admits that he is smart at school, but sometimesRead MoreAnalysis Of The Book The Outsiders 2098 Words   |  9 Pages Analysis of Disenfranchisement in The Outsiders by S.E. Hinton Survival instincts allow individuals to persevere during times of hardship and struggle. Unfortunately, many families in America are struggling lower-middle class or live in poverty. It’s nice to think a person can easily go from being dirt poor to filthy rich, but it doesn’t usually work that way. The Outsiders by S. E. Hinton depicts the hardships and struggles experienced by two rival gangs, â€Å"The Greasers† from the lower middleRead MoreLiterary Analysis : The Outsiders 2595 Words   |  11 PagesGina Cabano Eng-150 Whetstine Literary Analysis 05/04/15 Inside The Outsiders The Outsiders, a coming-of-age novel, written by S.E. Hinton who was a teenager at the time of writing is firmly based upon groups of teenagers divided amongst their social classes. The novel takes on the rival battles of the Socials and the Greasers. Susan Eloise Hinton as known as, S.E. Hinton was born July 22, 1950 in Tulsa, Oklahoma. She had grown up as a voluntary tom boy in love with horses. Susan could not writeRead MoreLiterary Analysis Of The Outsiders1429 Words   |  6 Pagesthere are some popular novels that attempt to imitate this, such as the coveted The Fault in Our Stars or Divergent. These selections, while widespread in the hands of young adult readers today, will not stand the test of time in the way that The Outsiders has, written by S. E. Hinton in 1967, has. This novel, both produced by and intended for teenagers, instead is a better candidate of realistic young adult fiction. Other selections, from Hinton’s era and from today, do not radiate the same relatable