Progesterone challenge test ;can someone explain it

[zeevee]

Can someone please explain how this test is done and what is the interpretation .
What does positive and negative mean here .

I searched earlier replies on this topic and found this:

"if there is no withdrawal bleed after a progestin challenge, it's an indication that the deficiency is "further up the tract", so to speak. the ovaries are not producing sufficient estrogen, either as a primary deficit, secondary deficit (fsh + lh), or tertiary deficit (gnrh.)

if a withdrawal bleed occurs, it means that the ovaries and uterus are connected and functioning properly, the vagina is patent, and a sufficient amount of estrogen is being produced (which generally indicates proper functioning of lsh, fh and gnrh.)

i find it more helpful to think of anovulatory cycles not as "too much estrogen", but rather, "not enough progesterone", hence the reason for the progestin challenge. "too much estrogen" should be the link you draw to endometriosis."

However I still dont get it completely Not enough atleast to pick an answer within seconds in the real test .
🙂

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[cake321]

I'll take a stab at this, but someone please correct me if i'm wrong!

Normally, an estrogen surge stimulates LH, which then causes ovulation. During the luteal phase, the corpus luteum produces progesterone and once these levels drop off, menses ensues.

The progestin challenge will watch to see if there is bleeding after progesterone has been given to the patient. If you see bleeding, then you know it is not an anatomic defect. This probably indicates anovulation. If ovulation did not occur, then estrogen levels will remain high and no progesterone will be made. Therefore, by giving the patient progesterone, you will see withdrawal bleeding.

If there is no bleed, then the patient's amenorrhea may be due to a variety of reasons like low estradiol, problems with the HPA, or anatomical defects (like in Asherman syndrome).

I hope this made sense and that my explanation was correct!

 

[zeevee]

Thankyou yes it does help a lot .
A couple of doubts still though .
If she does menstruate on withdrawing progesterone does that mean she was deficient in progesterone to begin with ?

Also if she bleeds is that a positive test or a negative test ?

 

[cake321]

if the patient bleeds after progesterone is given, then it means she has an anovulatory cycle. If you did not ovulate, then there is no corpus luteum synthesizing progesterone and therefore no progesterone.

I'm not sure about positive vs negative test, but i don't think that's super important. Know how to interpret the results so that you can determine the cause of the patient's amenorrhea.

 

[zeevee]

I think the pt will bleed on withdrawal of progesterone only.You are essentially creating a complete menstrual cycle to see where is the defect .But I am still not getting the concept clearly enough 🙁

 

[Auvelity]

well what causes the menstrual bleeding?
when there is a sudden drop on estrogen and progesterone levels(mainly the progesterone). so if the patient is going through an anovulatory cycle, where there is low levels of both there there is no peak or sudden drop, so to speak, so no menstruation can occur.
but if you give her a fair amount of progesterone and the body recognizes it(meaning endometrium, ovaries, and everything is working fine), its a big dosis that will have a sudden decrease after blood clears it up, patient will present menstrual bleeding because it recognize the progesterone drop.
Idk if I made myself clear(it makes sense in my head lol)

 

[zeevee]

So progesterone challenge test tells us there was lack of progesterone in the patient ? That is why we replenish her progesterone and then withdraw it to induce bleeding .
Bleeding on withdrawal confirms lack of progesterone was there ; which means that her follicles form but she never gets to the stage of releasing the egg and forming a corpus to secrete progesterone on her own >> anovulatory cycle
Bleeding also tells that she is capable of expelling blood and there are no anatomical defects ( septum , absent paramesonephric ducts derivatives ) in the birth canal

Guess you guys were saying this from the beginning but I just caught onto it late .

 

[florida2001]

what is considered bleeding. If there is brown discharge "spotting" after progesterone pill test does it means there is no anatomic defect and therefore annavolutary cycle?

 

[Rahas]

Normal menstrual cycle goes like this:
(1)estrogen develops a proliferative endometrium
(2)progesterone develops a secretory endometrium
(3)progresterone withdrawal removes support for the secretory endometerium -> sloughs off as menses

Anovulation creates an estrogen only environment, with no progression to step 2 (and hence 3), since ovulation is the prerequisite for granulosa and theca cells to transform into luteal cells (which secrete progesterone > estrogen).

For a woman with amenorrhea:

1.Progesterone challenge test:
Give her progesterone for a few days -> then stop -> if bleeding occurs, this is anovulation, since she already had step (1) and you provided (2)

If no bleeding occurs, you proceed to the

2.Estrogen-progesterone challenge test:
Give her estrogen, then progesterone, then stop and see if she menstruates. You're now providing her with steps (1), (2), and (3)

Bleeding implies an HPO axis problem, since both estrogen and progesterone were deficient, but theres obviously an endometrium capable of responding to female sex hormones, and no structural defect

Lack of bleeding would imply a structural defect