--- module: 026-02 language: en chapter: 26 title: "Endocrine and Reproductive Examination and Investigation" module_title: "Phenotype-led endocrine testing and reproductive diagnostic safety" source_sha256: a9d6a1831b442d5eebaac8ccbc54379daff5f9c81c6d953a498974b5b1ad1785 --- # Phenotype-led endocrine testing and reproductive safety ## Build the phenotype before ordering ### Common symptoms have low specificity #### Value rises with coherent cluster, signs, time course ### Define axis and suspected mechanism #### Excess, deficiency, resistance, compression #### Target, controller, timing, distorting factor ### Broad panels create incidental, contradictory results ### Medication history must include route #### Inhaled, injected, ocular steroids suppress adrenal axis #### Supplements: biotin, iodine, undeclared hormones #### Opioids lower gonadal drive, dopamine blockers raise prolactin ## Examination tests the mechanism ### True proximal weakness is shoulder or hip power #### Needs localisation: bulk, reflexes, sensation, gait ### Skin specificity comes from morphology #### Broad violaceous striae with bruising and weakness #### Diffuse crease and mucosal pigment: adrenocorticotropic drive #### Velvety flexural pigment suggests insulin resistance ### Thyroid eye: more than prominence #### Colour desaturation, pupillary defect, corneal injury #### Optic nerve or cornea at risk: urgent review ### Palpation cannot settle thyroid function #### Normal gland may be dysfunctional, large may be euthyroid ## Pair hormone and regulator ### Thyroid-stimulating hormone and thyroxine: primary or central ### Calcium with parathyroid hormone: appropriate response ### Gonadal steroid with luteinising and follicle-stimulating ### Judge regulator against physiological demand #### Normal parathyroid hormone in hypercalcaemia: inappropriate #### Normal thyroid-stimulating hormone despite low thyroxine ### Sample pairs under the same conditions #### Discordance: repeat and discuss before rare diagnoses ## Dynamic tests and pre-test probability ### Stimulation when baseline indeterminate, reserve matters ### Suppression when autonomy suspected ### Performance falls outside validated populations ### Cortisol: steroids, oestrogen, binding proteins, sleep #### Dexamethasone fails: absorption, induction, adherence #### Abnormal screen gives neither source nor image target ### Aldosterone-renin: posture, sodium, potassium #### Hypokalaemia suppresses aldosterone: false negative ### Water testing can shift sodium dangerously #### Baseline osmolality and output often narrow diagnosis ## Reproductive history as temporal physiology ### Cycle interval, duration, volume, change from baseline ### Irregular cycles: inconsistent ovulation, cause unknown ### Quantify heavy bleeding objectively #### Flooding, clots, night protection, missed activity ### Sexual history separates each phase of function #### Neutral questions still require asking about coercion ## Intimate examination as consent process ### Consent is ongoing, not one-time #### Reconfirm before external to internal step ### Trauma-informed: control over position and support ### Silence is not consent #### Distress or withdrawal: pause and reassess ### Bimanual has limited sensitivity #### Normal result excludes neither ectopic nor torsion ### Sudden testicular pain is time-critical #### Strong torsion picture: urgent surgical assessment ### Hard painless mass: malignant until assessed ## Early pregnancy and uncertainty ### Location may not be settled at one visit #### Integrate trends, ultrasound, dates, symptoms, haemodynamics ### High value without sac raises concern, not proof ### Pregnancy of unknown location is temporary #### Early intrauterine, failing, or ectopic #### Clear return advice and ownership of repeat tests ### Instability or peritonism: resuscitate, not serial tests ## Infertility as a paired assessment ### Both partners in parallel #### One-partner testing delays care, misplaces blame ### Progesterone timed to ovulation, not calendar ### Reserve tests do not predict natural conception ### Each test answers a limited question #### Tubal patency shows passage, not all function #### Laparoscopy carries procedural risk ## Diabetes surveillance and final report ### Close actionable loops #### Foot risk sets education, footwear, referral #### Injection sites prompt technique change ### Autonomic clues: orthostasis, bladder, sweating ### Schedule eye, kidney, heart, mental-health surveillance ### Review time below range and alert usefulness ### Report separates phenotype, localisation, uncertainty #### Name danger and ownership of follow-up