14.4.1400 Case presentation-Suspected aromatase def and TBG def

• This week case vignette is about a 41-year-old married woman with history of menstrual disorders following her first pregnancy.
• In about 4 years ago, after the cesarean section and excessive bleeding, a significant decrease in serum hemoglobin concentration (11 g/dL to 7.2 g/dL) occurred and two units of packed RBCs were infused. Ten days after the parturition, the volume of breast milk declined remarkably and breastfeeding continued in combination with formula feeding. Three months later, regular menstrual cycles resumed.
• During gestation, she took levothyroxine 25 µg daily based on the results of thyroid function tests indicating serum TSH of 3.7 mIU/L and total T4 of 4.7 µg/dL! Consumption of levothyroxine 50 µg daily for weight reduction was started seven months after the parturition.
• Two years ago, despite infrequent breastfeeding, amenorrhea happened; at this time, she stopped consumption of levothyroxine. Imaging and laboratory work-ups were performed: multiple uterine myomas, endometrial hyperplasia (16.5 mm) and a 45 x 30 mm cyst at the left ovary were reported; TSH: 2.6 mIU/L, T4: 8.5 µg/dL, T3: 0.6 ng/mL, T3 uptake: 30%, free T4: 1.2 ng/dL, FSH: 1.9 mIU/mL. Duphaston 10 mg daily for ten days monthly was prescribed and with four cycles of Duphaston, she had 9 times of menstruation during 9 months. Thereafter, amenorrhea returned again; considering her overall history, with suspicion of Sheehan’s syndrome, assessment of pituitary axes and pituitary MRI were requested: MRI was normal; TSH: 3.14 mIU/L, T4: 5.52 µg/dL, free T4: 13.8 pmol/L, FSH: 8.5 mIU/mL, LH: 16 mIU/mL, Estradiol: 522 pg/mL, Progesterone: 0.4 ng/mL, Prolactin: 7.4 ng/mL, Cortisol: 7 µg/dL (Cosyntropin test: normal response), IGF-1: 183 ng/mL.
• PMH:
• Her menarcheal age was 13 years and menstrual cycles were normal before these years’ presentation.
• She tells about history of dyslipidemia.
• In about 3 years ago, she experienced episodic attacks of palpitation and dyspnea followed by diffuse urticarial lesions, flushing and night sweats. Biopsy of skin lesions documented urticarial vasculitis and her symptoms were improved with high-dose corticosteroid and antihistamine therapy for nearly two months.