Endocrine Abstracts

A 17-year-old young lady presented with tiredness, weight loss, palpitations, hot flushes and irregular menstruation in April 2016 and her initial TFTs showed TSH <0.03 mU/l with a fT4 of 48.2 pmol/l. She was treated with carbimazole 40 mg daily and further investigation confirmed she had had Graves’ disease as TSH receptor antibodies (2.10 U/l), TPO antibodies (>1300 IU/ml), thyroid ultrasound scan demonstrated mildly enlarged and thyroiditis. She had only six periods between October 2015 and September 2016 and was having hot flushes and night sweats despite her Graves’ disease improving biochemically. Therefore, sex hormones were screened to rule out premature ovarian failure. LH raised at 72.8 U/l, FSH raised at 129.7 U/l, with Oestradiol <90 pmol/l, SHBG 89 nmol/l and negative ovarian antibody. She was diagnosed as likely autoimmune ovarian insufficiency with a low egg count. She would have only a 5% to 15% chance of getting pregnant. Ultrasound scan of the pelvis done for abdominal discomfort showed small quiescent ovaries and normal uterus. HRT (Femoston 2/10) was commenced. Her Graves’ disease went into remission (TSH 0.73 mU/l, fT4 16.9 pmol/l, fT3 5 pmol/l) after 12 months and carbimazole was stopped in March 2017. Unfortunately, her Graves’ disease relapsed in July 2017 (fT4 65 pmol, TSH < 0.03 mU/l, fT3 >30.8 pmol/l) and carbimazole 40 mg re-commenced. Secondary treatment such as radioiodine and surgery were discussed but she was not very keen those options as she was concerned, they would affect her fertility. In November 2017, Carbimazole was increased to 60 mg as her fT4 was 50 pmol/l, TSH<0.03 mU/l. When this did not produce an improvement, she was switched to Propylthiouracil 400 mg. In January 2018, as her thyrotoxicosis improved, PTU was reduced to 150 mg BD with TSH < 0.03 mU/l, fT4 11.5 pmol/l. In April 2018, she was well from a thyroid point of view and gradually reducing PTU doses to 100 mg AM and 50 mg PM. An ultrasound pelvis scan was organized to investigate lower abdominal pain during that visit and it revealed a 5 weeks gestation pregnancy. She delivered a baby uneventfully and her Graves’ disease was stable during pregnancy.

Discussion: Treatment with HRT for premature ovarian failure and good control of her Graves’ disease with PTU, provided the correct environment for a much longed-for pregnancy against the odds.