DIP Episode 373 - Progestin and Estrogen Challenge Tests

Okay, welcome everyone. This is a piece of 372 of the Divine Intervention podcasts. To be honest with you, this is probably going to be one of my shortest podcasts ever. Basically, the reason I'm making this podcast is I saw some person ask a question on Reddit. How do I know about the, what's with the Progestian Challenge Test or the Estrogen Progestian Challenge Test? And they're like, okay, I don't understand these tests and all that stuff. So we're just going to talk about those tests in this podcast and then that'll be it. So it should be a short podcast, you know, kind of cup of the weekend. Just a real quick thing I would say if you're taking your USML East Tech 2 CTO Step 3 or complex level 2 or 3 exams, within the next three to four weeks here, I'll encourage you to sign up for the NBME Test Ticking Strategy course that is going to be taking place on Monday, actually like three days from now, from 2 to 4 30 PM mountain time, or also have the 24 hour review course for Step 2 CTO Step 3 taking place from next week to use data Friday from 70 PM to 1 PM mountain time. Again, tons of people have attended these courses, tons of people have done extremely well on the exams. The course is going to be held over a Zoom. Then if you're taking Step 2 CTO in the summer, have a Step 2 CK school, call it the disk school, it's taking place in the first two weeks of May, there's a 40% cup on that because it's going to be a very involved school, right?

If you're very serious about crushing your exams, that's a school you want to attend in the summer. So let's go ahead and jump right into it. The thing is, to be honest with you, this is a test of the estrogen-progesting challenge test. This is something that the NBME cares about, but in the real world, not many people, if anyone really does this test. To be honest with you, I've not really seen anyone do this test in my entire career as a physician. It's one of those things that kind of like the Schilling's test for B2 L deficiency, to localize the lesion. It's almost like a localized lesion test. The NBM Es, one of the best easiest ways for them to test physiology, is just to see if you can localize lesions. So the thing is, whenever there is a localized lesion test, like a provocative test or anything like that, the NBM Es love you to know those things, even if they are no longer clinically relevant. So let's talk about the projecting challenge test. Who do we do it in? Well, the thing is, we're going to do this test in a person that has a menoria. That is like the first thing I want you to understand. You do these tests in people that have a menoria. A menoria, right? So the thing is, there are two kinds of these tests you can do. You can do the projecting challenge test, or you can do the estrogen-progesting challenge test. The first rule I want you to understand is that you always do the projecting challenge test first. That's very high you to know and understand.

You always do the projecting challenge test first. If the projecting challenge test does not give you the thing is, whenever you do any of these tests, you're trying to look for. Oh, after I stop this agent, does the person bleed? Right? So if you do the projecting challenge test, I notice that the person does not bleed. Then you proceed sequentially to step two, which is the estrogen-progesting challenge test. The thing is, to understand these challenge tests, you just need to, they're actually pretty simple, but they're little complex, but also pretty simple. The thing is, if you can understand it from the perspective that, oh, whenever you're doing a challenge test, you're trying to figure out if this is the deficiency that a person has, then you're going to be pretty much set. Let me explain. I just said that the projecting challenge test is something you do first. Okay? Well, if you're doing a projecting challenge test, you're doing a test, where you're giving a person a projecting, then you're wondering, huh? Is the cause of this person's amovolation? I mean, is the cause of this person's immemorial, the fact that they are unovolating, meaning that they are not ovulating, because if you think about it, if you look at the menstrual cycle, the first thing that happens is, you're going to have the follicular phase, we are producing a ton of estrogen, that's going to build up the endometrial cavity. And then after that, you have the elixirge, right?

The ovaries essentially explode, and you shoot out an egg, that's ovulation, right? Ovulation. When you ovulate and form the egg, the remnant of the egg is what is going to be called the corpus luteum. Is that corpus luteum that then produces projecting, that it makes it possible for us to protect the endometrial cavity and convert it from proliferative endometrium to a secretory endometrium? So, if you have an ovulation, if you don't ovulate, everything in the menstrual cycle you do is just fine. You make estrogen, you, everything is great for the follicular phase, but everything afterwards does not work, because if you don't ovulate and ovulation, right? If you don't ovulate, then you don't form the corpus luteum, then you don't make progestin, right? So, the thing is, if you do a progestin challenge test, the way it's done is you give a person progestin, right? And then you, for a few days, you then stop the progestin. Usually about two to seven days after you stop the progestin, those people should have a withdrawal bleed, right? But if you notice that, wow, okay, I give this person progestin, give them for a few days, stop it, and then wait two to seven days, and I notice that, wow, this person just bleeds. Then that means by giving that progestin, you fulfilled a need for progestin that the body had. You give them back progestin, right? So, that tells you that, hmm, that means the problem that is causing this person's immunitis, because they did not make progestin.

And if you walk your way backwards and localize the lesion, if the person was not making progestin, then that means that they probably need not ovulate, right? So that means an ovulation, right? So a classic disorder like PCOS will be one where you do the progestin challenge test, right? And you will draw that progestin, and you notice that the person bleeds, right? So an ovulation is the very first thing you should think about when you tell your name being the exams, that the person is progestin challenge test is positive, right? And again, it's positive when you have a withdrawal bleed. Now, if you notice that, wow, you give this progestin in the progestin challenge test. And the person, you know, you give the progestin, you withdraw it after two to seven days, and you notice that, wow, the person did not bleed, that tells you something. That tells you that it is not just a progestin deficiency that is causing the problem. It is an estrogen deficiency that is causing the problem, okay? It is an estrogen deficiency that is causing the problem. So in that case, you're going to proceed sequentially, right? To the next step, which is the estrogen progestin challenge test, right? The way you do that test is you give estrogen first. You're essentially trying to simulate the menstrual cycle. You give the estrogen first, I think you give the estrogen, right?

You then give progestin, and then after giving the progestin, you withdraw it and wait for two to seven days to see what happens, right? If you notice that the person has a withdrawal bleed, the name is, oh, wow, okay. I give progestin alone initially, nothing happened, but then I give estrogen, and then I give progestin, and then I withdraw it, and I see this withdrawal bleed. And that tells you that it's a hypoestrogen state that caused the person's problem. Okay, so what are the hypoestrogen states that can cause these problems? Well, think about if you have a turner syndrome, right? If your ovaries don't work, streak ovaries, right? You're not making any estrogen, right? Well, if you have like a hypo thalamic pituitary access problem, like common syndrome, for example, we're not making generic, right? Obviously, if you don't make generic, you don't make a ph SHLH, and you make estrogen, all those things will all cause a low estrogen state, right? So whenever they do an estrogen-progesting challenge test, and you notice that, wow, okay, the person then has a withdrawal bleed. And that tells you that the person has a low estrogen and progestin issue that is causing their problems. That's actually very high, you know, it tells you it's a hypoestrogen state. But now, to take this even further, what if you do the progestin challenge test, you see no withdrawal bleed, you do the estrogen-progesting challenge test, you see no withdrawal bleed, and what does that tell you?

That tells you that the person has either a problem that is intrinsic to the uterus, where the uterus doesn't work, like ashram and syndrome, or they have like an off-floor track problem, right? Like a problem where, for whatever reason, even if they are forming everything, the endometrium is good and everything, they're not able to get out that blood, right? And that's the way it is from those men's, they're not able to get those things out, right? That tells you that they are dealing with an off-floor track problem. To be honest with you, I will say for the purposes of ease, think of ashram and syndrome as being one of like two problems rolled into one. One, you have a problem with the endometrial cavity itself where it cannot respond to a estrogen. And two, you also have an off-floor track problem, because there's a lot of like, almost think of it as having strictures in your uterus, right? Ashram and syndrome, right? And again, remember, ashram and syndrome is something to give people to have multiple recurring deletions and curatages. So, I think I'm going to go ahead and stop here. So, I really hope that this makes sense to you, right? Again, in summary, if the projecting challenge test, and you get a withdrawal bleed, that tells you that an ovulation was the cause of the presence of the menoria.

If you don't get it, we draw bleed, then that tells you that, okay, this person has an estrogen problem that is causing it, and there are many causes of estrogen problems, as I highlighted in this podcast. And if you notice that you do the projecting challenge test, and then you do the estrogen projecting challenge test, and you get an overdraw bleed from any of those tests, then that tells you that you have an outflow track problem, right? That either your endometrium is not responding to stimulation by hormones, or you have an outflow track problem, like I don't know, like, what is this thing called? Like, transverse vaginal septum, or imppefroid hymen, that's causing any of those things, right? So, these tests are very easy to understand, right? Again, you just need to understand the physiology, right? Many times when people say, well, I'm confused by something, it's usually just a problem with understanding. So, thank you for listening. Again, I offer tutoring for all the USMEL exams, I offer a review courses for step 2, step 3, and complex level 2 and 3. In fact, I have a courses taking place next week, and by the way, if you're a person that is just studying out your third year, and you want to get good at test taking strategies for your MBME shelf exams, my MBME test taking and taking strategies courses is also something that would help you. And then, I have these podcasts on all the major podcast apps, I have a You Tube channel, right?

Divine Intervention USMEL podcast and videos. And then, I also have a website called Divine Intervention Lifelessens.com. There are now 60 episodes on there, where I just post short podcast 10 to 15 mini podcasts on life lessons, many of them are by boobies. So, thank you for listening to me, have a wonderful weekend, and God bless you, I will see you next week. Thank you, bye for now.

Localized lesion tests or provocative tests, similar to Schilling's test.

Always perform the Progestin Challenge Test first.

It suggests that anovulation or impaired corpus luteum function (failure to produce endogenous progesterone) is the cause of menorrhagia.

A withdrawal bleed after administering estrogen followed by progestin, but no bleed after just progestin alone.

An outflow tract problem or intrinsic uterine defect (e.g., Asherman's syndrome).

Turner syndrome (gonadal failure) or hypothalamic/pituitary dysfunction (e.g., low GnRH/LH/FSH).

To localize the cause of menorrhagia by determining if the deficiency is estrogenic, progestinic, or due to outflow obstruction.

Failure in corpus luteum formation/function, leading to inadequate endogenous progesterone production (anovulation).

A hypoestrogenic state originating from upstream pituitary or hypothalamic failure.

Asherman's syndrome (or other outflow tract obstructions like imperforate hymen).

Progestin deficiency suggests failure after ovulation; Estrogen deficiency suggests failure in building up the uterine lining itself.

Always perform the Progestin Challenge Test before proceeding to the Estrogen-Progestin Challenge Test.

To localize the cause of menorrhagia by determining if the deficiency is estrogenic, progestinic, or due to outflow obstruction.

Failure in corpus luteum formation/function, leading to inadequate endogenous progesterone production (anovulation).

A hypoestrogenic state originating from upstream pituitary or hypothalamic failure.

Asherman's syndrome (or other outflow tract obstructions like imperforate hymen).

Progestin deficiency suggests failure after ovulation; Estrogen deficiency suggests failure in building up the uterine lining itself.

Always perform the Progestin Challenge Test before proceeding to the Estrogen-Progestin Challenge Test.