Autoimmune hypothyroidism and intermittent ovarian failure - Case Report

Case presentation: a 35 year-old physical educator sought gynecological care for secondary amenorrhea and infertility. She denied the occurrence of similar problems in her family and referred to hypothyroidism as her only comorbidity, for which she was on levothyroxine 88µg daily. She was tested for beta-HCG, prolactin and TSH levels. She was negative for beta-HCG, and had prolactin and TSH levels of 19ng/ml and 2.04 mIU/ml, respectively. Her progesterone test was negative. The combined test (estradiol + norethisterone acetate) was positive, excluding the possibility of an anatomical cause. One month later, her blood tests were as follows: FSH 100mIU/ml, TSH 1.54mIU/ml, free T4 1.22ng/dl, and anti-TPO 261U/ml. Her FSH level was above 100 and she was diagnosed with premature ovarian failure. Reproductive treatment with donor eggs was proposed as an option. Karyotyping and a test for fragile X syndrome were ordered. A few months later the patient came to our clinic saying she was having menstrual cycles. Blood tests were as follows: FSH 9.2mIU/ml; TSH 2.21mIU/ml; and anti-TPO 14U/ml. Transvaginal ultrasound showed a normal uterus with a thin endometrium and atrophic ovaries. After two years of irregular menstrual cycles, she became amenorrheic again. She chose not to undergo assisted reproduction. This paper discusses the diagnosis of premature ovarian failure in light of current protocols and the association of this condition with diseases such as Hashimoto's thyroiditis, and looks into the difficulty of performing differential diagnosis against Savage syndrome and of offering reproductive counseling especially in cases where the menstrual cycle returns.