DOORWAY INFORMATION
Opening Scenario
Patricia Garrison, a 36-year-old female, comes to the office complaining of not having menstrual periods recently.
Vital Signs
BP: 120/85 mm Hg Temp: 98.0°F (36.7°C)
RR: 13/minute HR: 65/minute, regular
Examinee Tasks
1. Take a focused history.
2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).
3. Explain your clinical impression and workup plan to the patient.
4. Write the patient note after leaving the room.
Checklist/SP Sheet
Patient Description
Patient is a 36 yo F.
Notes for the SP
None.
Challenging Questions to Ask
“Am I going through menopause?”
Sample Examinee Response
“I doubt it. It would be extremely unusual at your age. I need to learn more by asking you about other symptoms and doing an exam. Then we can discuss possible reasons you are not having periods.”
Examinee Checklist
Building the Doctor-Patient Relationship Entrance
□ Examinee knocked on the door before entering.
□ Examinee introduced self by name.
□ Examinee identified his/her role or position.
□ Examine correctly used patient’s name.
□ Examinee made eye contact with the SP.
Reflective Listening
□ Examinee asked an open-ended question and actively listened to the response.
□ Examinee asked the SP to list his/her concerns and listened to the response without interrupting.
□ Examinee summarized the SP’s concerns, often using the SP’s own words.
Information Gathering
□ Examinee elicited data efficiently and accurately.
Connecting with the Patient
□ Examinee recognized the SP’s emotions and responded with PEARLS.
Physical Examination
□ Examinee washed his/her hands.
□ Examinee asked permission to start the exam.
□ Examinee used respectful draping.
□ Examinee did not repeat painful maneuvers.
Closure
□ Examinee discussed initial diagnostic impressions.
□ Examinee discussed initial management plans:
□ Follow-up tests: Examinee mentioned the need for pelvic and breast exams.
□ Examinee asked if the SP had any other questions or concerns.
Sample Closure
Mrs. Garrison, there are a few reasons you may not be having regular periods. The first thing we need to do is determine whether you are pregnant. We can do that with a simple urine test. The other thing we need to do is conduct breast and pelvic exams, especially since you have had some nipple discharge, and look for any signs of menopause. Menopause is highly unlikely at your age, but on rare occasions it may occur. A blood test to measure your hormone levels will also help us determine if you are menopausal or have a hormonal imbalance. This will give us a good start in figuring out why you haven’t had your period, and we will go from there. Do you have any questions for me?
History
HPI: 36 yo F c/o amenorrhea for 3 months. She recently noticed some milky discharge from her left breast as well as abnormal facial hair but denies visual changes or headache. She also describes oligomenorrhea, hypomenorrhea, and a 15-lb weight gain over the past year but denies dry skin, cold intolerance, voice change, constipation, depression, fatigue, or sleep problems. She also denies hot flashes and vaginal dryness or itching.
OB/GYN: Menarche at age 14. For the past year, menses have cycled every 5-6 weeks and lasted for 7 days, with decreased blood flow. Before that, menses cycled every 4 weeks. G1P1; 1 uncomplicated vaginal delivery 10 years ago. Last Pap smear 10 months ago; no history of abnormal Pap smears. Sexually active with husband once a week on average; uses OCPs for contraception.
ROS: Negative except as above.
Allergies: NKDA.
Medications: None.
PMH/PSH: None.
SH: Denies tobacco, alcohol, or illicit drug use. Exercises regularly. Vegetarian; hasn't changed her diet recently.
FH: Mother had menopause at age 55.
Physical Examination
Patient is in no acute distress.
VS: WNL.
HEENT: EOMI without diplopia or lid lag; visual fields full to confrontation.
Neck: No thyromegaly
Chest: Clear breath sounds bilaterally.
Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.
Abdomen: Soft, nontender, nondistended, © BS, no hepatosplenomegaly
Extremities: No edema, no tremor.
Neuro: See HEENT. Normal DTRs in lower extremities bilaterally.
Differential Diagnosis
CASE DISCUSSION
Patient Note Differential Diagnoses
■ Pregnancy: Although this patient’s symptoms suggest a hormonal cause of oligomenorrhea, any change in the menstrual cycle warrants consideration of pregnancy. Pregnancy is the most common cause of secondary amenorrhea in women of childbearing age and should be ruled out during the initial evaluation. Menstruation may not necessarily cease completely during pregnancy.
■ Hyperprolactinemia: This causes menstrual cycle disturbances, galactorrhea, and infertility. It may result from a variety of conditions, including pregnancy, pituitary lesions, hypothyroidism, renal failure, and cirrhosis, or it can be a side effect of medications. Roughly 70% of women with secondary amenorrhea and galactorrhea will have hyperprolactinemia.
■ Polycystic ovary syndrome (PCOS): This manifests variably as hirsutism, obesity, virilization, infertility, and glucose intolerance. About one-half of patients have amenorrhea (due to chronic anovulation). The patient’s oligomenorrhea and hirsutism in the context of recent weight gain suggest this diagnosis.
Additional Differential Diagnoses
■ Thyroid disease: Both hyper- and hypothyroidism can cause menstrual irregularities, although amenorrhea is more commonly due to hypothyroidism. Except for galactorrhea and weight gain, the patient does not have other signs or symptoms of thyroid disease.
■ Premature ovarian failure: This refers to primary hypogonadism that occurs before age 40. Causes include autoimmunity against the ovary, pelvic radiation therapy, chemotherapy, surgical bilateral oophorectomy, and familial factors. The patient’s lack of menopausal symptoms (eg, fatigue, insomnia, headache, diminished libido, depression, and hot flashes) makes this diagnosis unlikely.
■ Asherman's syndrome: This describes amenorrhea due to endometrial scarring, which can occur following uterine infections. The vaginal estrogen effect is normal.
Diagnostic Workup
■ Urine hCG: To rule out pregnancy.
■ Pelvic and breast exams: Required to check for genital virilization (ie, clitoromegaly), uterine or adnexal enlargement, and estrogen effects (via inspection of vaginal mucosa) and to elicit breast discharge.
■ Prolactin, TSH: To screen for hyperprolactinemia and thyroid disease. FT4 is also useful if hyperthyroidism (or central hypothyroidism) is suspected.
■ LH/FSH: PCOS is a clinical diagnosis; an increased LH/FSH ratio is often seen but is neither necessary nor sufficient to make the diagnosis. Physiologically, increased levels of estrone (derived from obesity) are believed to suppress pituitary FSH, leading to a relative increase in LH. Constant LH stimulation of the ovary then results in anovulation (and often amenorrhea). An elevated FSH (> 40 mIU/mL) is diagnostic for premature ovarian failure.
■ Electrolytes, BUN/Cr, glucose, AST/ALT/bilirubin/alkaline phosphatase: To check renal and hepatic function and to screen for evidence of hypercortisolism (eg, high sodium and low potassium).
■ Testosterone, DHEAS: To screen for hyperandrogenism when amenorrhea is accompanied by hirsutism and virilization. Mild elevations are often due to PCOS, but high levels may be due to ovarian or adrenal tumors.
■ MRI—brain: Required to evaluate the pituitary region in patients suspected of having amenorrhea due to a mass effect (eg, prolactinoma).
■ Hysteroscopy: To look for endometrial adhesions that are diagnostic for Asherman’s syndrome.