Approach to Secondary Amenorrhea

amenorrhea-secondary

Whereas Primary Amenorrhea is defined as a lack of menses in a woman who had never previously menstruated, Secondary Amenorrhea is:

  • Cessation of menses for 6 months, in a female who was previously menstruating.

The causes of Secondary Amenorrhea are different from those causing Primary Amenorrhea:

  • Pregnancy, lactation, menopause: 95%
  • Other causes: 5%
    • ↓gonadotrophic ↓gonadism: 66%
      • (including hypothalamic abnormalities, PCOS)
    • ↑ PRL: 13%
    • Ovarian failure: 12%
    • Anatomic abnormality: 7%
    • ↑ androgens: 2%

To evaluate Secondary Amenorrhea, a thorough history and physical exam are of course of vital importance. Since these patients by definition have menstruated in the past, the overriding question to answer is, “what is now stopping this patient from having menses?” In the vast majority of cases, normal pregnancy or menopause drives the amenorrhea. Many of the topics to discuss are the same as in the assessment of Primary Amenorrhea, but also talk to the patient about:

  • Symptoms of menopause: hot flushing, vaginal dryness, poor sleep, decreased libido
  • Obs/Gyn history: past endometritis, D&C, significant hemorrhage. These factors may point to a diagnosis of Asherman’s syndrome (scarring of endometrium).
  • Pregnancy: Potential for pregnancy, currently breastfeeding
  • Lifestyle factors such as stress, nutrition, exercise, weight changes
  • Medication: THC, antipsychotics, or irradiation
  • Associated symptoms:
    • Hyperprolatinemia: galactorrhea
    • Hyperandrogenism: hair loss/excess, acne, voice change
    • CNS tumor: headaches, visual field deficits, polyuria/polydipsia
    • Family history: PCOS

physical exam

  • Vitals, height, weight
  • Breasts: galactorrhea?
  • Thyroid: exopthalmos, goiter, abnormal deep tendon reflexes
  • Hyperandrogenism: hirsuitism, acne, hair loss
  • Hypercortisolemia: striae, hyperpigmentation
  • Pelvic exam

The labs used to work up Secondary Amenorrhea can be quite informative:

  • βHCG: To rule out pregnancy.
  • TSH, PRL: To test for hypo/hyperthyroidism and hyperprolactinemia.
  • LH, FHS: For practicality’s sake, these would probably be ordered at the same time as TSH, PRL.
    • If levels are high may indicate premature ovarian failure.
    • If levels are very low, that may point to a sellar tumor, so obtain an MRI.
    • If levels are normal, there may be a functional hypothalamic cause for the amenorrhea (e.g., malnutrition).
  • +/- Androgens (testosterone, DHEAS, 17-alpha-hydroxyprogesterone): May indicate PCOS or androgen-secreting tumor
  • +/- Estradiol: These assays lack sensitivity, standardization, and only capture a single time point.
  • Progestin challenge: To test the patient’s estrogen status. Administer a course of progesterone (~ 7 days).
    • If this results in bleeding, there is evidence the patient is progesterone deficient, anovulatory, or has an androgen excess.
    • If there is a lack of withdrawal bleeding, there are still a few causes to examine, so try the estrogen/progesterone challenge.
  • Estrogen/progesterone challenge: Give a course of estrogen/progesterone.
    • If there is withdrawal bleeding, it is apparent the patient has an estrogen deficiency.
    • If there is no bleeding in response to the challenge, the suspicion for an anatomic abnormality is heightened, so visualization of the uterus is indicated (e.g., hysteroscopy).

Treatment goals

  • Treat underlying cause
    • Lifestyle
    • Discontinue offending medications
    • Surgery (e.g., lysis of intrauterine adhesions)
  • Preserve fertility
  • Reduce risk of complications
    • Young women with premature ovarian failure can take hormone replacement to protect against early bone loss, menopause symptoms, and improve sexual health. These benefits may outweigh the associated increase in risk of MI, stroke, or breast cancer.

Master-Hunter T, Heiman DL. 2006. Amenorrhea: evaluation and treatment; 73:1374.
The Practice Committee of the American Society for Reproductive Medicine. 2008. Current approach to amenorrhea. Fertility and Sterility;90:S219.
Welt CK, Barieri RL. Etiology, diagnosis, and treatment of secondary amenorrhea. In: UpToDate (Eds: Snyder PJ, Crowley Jr WF, Kirkland JL). Accessed 2013.10.05.

Approach to Primary Amenorrhea

amenorrhea---primary

Primary Amenorrhea is defined as the absence of menses:

  • By age 13/14 without normal development of secondary sexual characteristics; OR,
  • By age 15/16, with normal secondary sexual characteristics.

In contrast, Secondary Amenorrhea refers to a loss of menses after it has already been established.

The causes of amenorrea are myriad, with an important one being pregnancy.

Causes of Amenorrhea
Hypothalamus Stress, malnutrition, exercise, lactation, immaturity, Kallmann syndrome
Pituitary Tumor, empty sella, apoplexy, hyperprolactinemia/prolactinoma
Ovaries Gonadal dysgenesis, premature ovarian failure, menopause, ovarian tumor, polycystic ovarian syndrome (PCOS), ovarian enzyme deficiency, chromosomal abnormalities (e.g., 45XO)
Uterus Intrauterine scarring, cervical agenesis, androgen insensitivity
Outflow Tract Imperforate hymen, transverse vaginal septum, cervical stenosis, Mullerian agenesis
Thyroid Hypo/hyperthyroidism
Pregnancy
Other Constitutional delay of puberty, hyperandrogenism, Cushing’s syndrome, medications

The most common pathologic causes of Primary Amenorrhea are:

  • Chromosomal abnormalities: 50%
  • Hypothalamic abnormalities: 20%
  • Mullerian agenesis: 5%
  • Pituitary abnormalities: 5%

Determining the etiology of Primary Amenorrhea depends on careful history-taking and a targeted physical exam. Key points to address in the history include:

  • Potential for pregnancy, current lactation
  • Develop of secondary sexual characteristics
    • On a side note, the general order of female sexual development is: breasts, pubic hair, growth spurt, menses; or, “boobs, pubes, grow, flow”
  • Lifestyle factors such as stress, nutrition, exercise, weight changes
  • Medication: THC, antipsychotics, or irradiation
  • Associated symptoms:
    • Hyperprolatinemia: galactorrhea
    • Hyperandrogenism: hair loss/excess, acne, voice change
    • CNS tumor: headaches, visual field deficits, polyuria/polydipsia
    • Family history: Does everyone have relatively late puberty?

In terms of physical exam:

  • Vitals, height, weight
  • Secondary sexual characteristics: breasts, pubic/axillary hair
  • Thyroid: exopthalmos, goiter, abnormal deep tendon reflexes
  • Hyperandrogenism: hirsuitism, acne, hair loss
  • Hypercortisolemia: striae, hyperpigmentation
  • Turner syndrome: webbed neck, low hair line, widely-spaced nipples, short stature
  • Pelvic exam: hymen, vaginal septum, ultrasound for uterine anatomy

Laboratory investigations can offer lots of insight:

  • βHCG: Gotta rule out this common reason first!
  • TSH, PRL: To test for hypo/hyperthyroidism and hyperprolactinemia.
  • LH, FHS: For practicality’s sake, these would probably be ordered at the same time as TSH, PRL.
  • +/- Androgens (testosterone, DHEAS, 17-alpha-hydroxyprogesterone): May indicate PCOS or androgen-secreting tumor, androhen insensitivity syndrome, or 5-alpha-reductase deficiency.
  • +/- Estradiol: These assays lack sensitivity, standardization, and only capture a single time point.

Since chromosomal abnormalities account for half of the pathologic cases of Primary Amenorrhea, karyotyping will be useful for patients who are found to have abnormal uterine anatomy on ultrasound or have elevated FSH, LH. Patients with an absent uterus may be worked-up for abnormal Mullerian development (46XX karyotype and normal female testosterone levels) versus a deficit in masculinization (i.e., androgen insensitivity syndrome, 5-alpha-reductase deficiency). There is a normal uterus, and LH and FSH are high, that means there is nothing feeding back to stop their release; karyotype may reveal Turner syndrome (45XO), while normal karyotype (46XX) may indicate Mullerian agenesis.

The over all treatment goals are to:

  • Treat underlying cause:
    • Lifestyle
    • Discontinue offending medications
    • Surgery
  • Preserve fertility
  • Reduce risk of complications (e.g., remove undescended tests in androgen insensitive patients to mitigate cancer risk).
  • Master-Hunter T, Heiman DL. 2006. Amenorrhea: evaluation and treatment; 73:1374.
  • The Practice Committee of the American Society for Reproductive Medicine. 2008. Current approach to amenorrhea. Fertility and Sterility;90:S219.
  • Welt CK, Barieri RL. Etiology, diagnosis, and treatment of primary amenorrhea. In: UpToDate (Eds: Snyder PJ, Crowley Jr WF, Kirkland JL). Accessed 2013.05.05.

The Standard Drink

standard_drink

A “standard drink” is a measure of pure ethanol consumed. One standard drink represents 10 grams of pure ethanol.

This means that based on the alcohol percentage of certain drinks, the “standard” size changes. The important thing to be aware of is to think of it as a Standard Drink because the size that equals 10 g of ethanol isn’t necessarily the standard size that is served. This is why it’s a good habit when asking “how many glasses of _______ do you drink” to ask about the size of the glass.

This design was actually originally made for an event, but I’m reposting it here because it’s useful and I like it and I haven’t had a chance to draw anything new recently.

Hemostasis & How to Recognize Bleeding Disorders

Hemostasis – What stops us from bleeding out.

Three main steps:

  1. Vasoconstriction
  2. Primary hemostasis (platelet plug) – the temporary way to stop bleeding
  3. Secondary hemostasis (clotting cascade) – the more permanent way

Bleeding disorders can be broadly divided into whether they affect platelet plug formation or the clotting cascade (if you need a refresher, click here)

 Platelet Disorder Clotting Cascade Disorders
Immediate bleeding
Muscosal and cutaneous
Bruises and petechiae
Nose bleeds (epistaxis)
Menorrhagia (heavy periods)
von Willebrand
Thrombocytopenia
DIC 
Delayed Bleeding
Deep (muscles and joints)
Palpable bruises, large spreading hematomas
Hemarthrosis
Post-surgical bleeding
Hemophilia A (factor VIII)
Hemophilia B (factor IX)
Warfarin

Biopsychosocial Formulation for Psychiatry (with printable PDF)

The biopsychosocial model for psychiatry is a way to formulate what factors are in play in an individual’s illness. It can also be used as a way to approach what aspects you need to consider when deciding on a treatment plan.

The biological factors include things such as genetics, general medical conditions and drugs (pharmacotherapy).

The psychological factors include a person’s coping strategies, personality and therapy (cognitive behavioural therapy, psychodynamic psychotherapy, dialectic behavioural therapy, etc).

The social factors include a person’s living situation, their support (both family and friends), finances, situation at work/school, etc.

 

And because that’s a teeny weeny image, here is a lovely PDF to download and print:

DOWNLOAD PDF TO PRINT

Substance abuse vs substance dependence

Substance abuse can be generally thought of as a misuse of a substance but with no prominent physiological or psychological tolerance (needing more for the same effect) or withdrawal (negative symptoms when without the substance).

Substance Abuse (DSM IV Criteria)

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

  1. Recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home
  2. Recurrent substance use in situations in which it is physically hazardous
  3. Recurrent substance-related legal problems
  4. Continued substance use despite having persistent social or interpersonal problems caused or worsened by the substance

B. Has never met the criteria for Substance Dependence for this class of substance.

Substance Dependence (DSM IV Criteria)

Substance dependence is sort of like the next step. It’s still affecting the person’s life (if not more) but now the person physiologically and/or psychologically needs the substance. You can’t count it as abuse if they have the symptoms of dependence.

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

  1. Tolerance, as defined by either of the following:
    • A need for markedly increased amounts of the substance to achieve intoxication or desired effect
    • Markedly diminished effect with continued use of the same amount of the substance
  2. Withdrawal, as manifested by any of the following:
    • The characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
    • The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  3. The substance is often taken in larger amounts or over a longer period than was intended
  4. There is a persistent desire or unsuccessful efforts to cut down or control substance use
  5. A great deal of time is spent in activities necessary to obtaining, using or recovering from the substance
  6. Important activities are given up or reduced because of substance use.
  7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
Mnemonic for substance dependence: The 3 Cs
  1. Compulsive use
  2. Loss of Control
  3. Consequences of use

Note: for polysubstance dependence a person meets the criteria for dependence and is using 3 or more substances. There is no polysubstance abuse (it is assumed that if you’re using more than 3, you’re dependent).

DSM Criteria for Delirium

Delirium, not to be confused with dementia.

The DSM criteria for delirium:

  1. Disturbance of consciousness
  2. Change in cognition
  3. Develops over a short period of time (hours to days) and fluctuates
  4. There is an identifiable general medical condition (or is substance induced)

It is important to recognize a delirium so that the underlying condition can be treated. It is also important because the delirium itself can be harmful to the patient, for example if someone who is delirious walks out into the cold with only a housecoat.

The longer one has delirium, the longer is takes to resolves, even after the underlying condition is treated.

If someone asks you to asses the level of competency of a person with delirium, it’s best to defer. Competency is both TIME- and QUESTION-dependent, so if you are asking someone when they are lucid, they could still be deemed competent, even if they are likely going to return to being delirious.

Mnemonic for delirium: I WATCH DEATH

  1. Infectious: UTIs, pneumonia, meningitis
  2. Withdrawal: alcohol, benzos
  3. Acute metabolic: liver or kidney failure, electrolytes
  4. Trauma: post-op, head injury
  5. CNS pathology: tumor, stroke, seizure
  6. Hypoxia: anemia, PE, heart failure
  7. Deficiencies in vitamins: thiamine, B12, folate
  8. Endocrine: Glucose, thyroid, adrenal, parathyroid (hypercalcemia)
  9. Acute vascular: shock, hypertensive ecephalopathy
  10. Toxins: alcohol, benzos, anticholinergics, opioids, anesthetics, anticonvulsants, dopaminergic agents, steroids, insulin, antibiotics (quinolines), NSAIDs
  11. Heavy metals: lead, arsenic, mercury

Work up

Standard

  1. CBC, BUN, Creatinine
  2. Extended electrolytes (Na, K, HCO3, Ca, PO, Mg)
  3. Glucose
  4. Liver function tests
  5. Albumin
  6. Urine culture
  7. TSH
  8. Vitamin B12 & folate

And maybe

  • ECG
  • CXR
  • Blood cultures
  • CT head
  • Heavy metal screen
  • VDRL, HIV
  • Lumbar puncture
  • EEG

But I want to earn the radiologist tons of money…
Only if they have:

  • Focal neurological deficit
  • Acute change in status
  • Anticoagulant use
  • Acute incontinence
  • Gait abnormality
  • History of cancer

Important aspects of the cardiac history

Just some important things to ask about when you suspect a patient has a cardiac problem. The risk factors are very important to ask almost everyone (because practically everyone in North America is at risk for/has heart disease).

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