Using an algorithmic approach to secondary amenorrhea: Avoiding diagnostic error

Roberts, Tiffany K.; Spencer, Jessica B.; Fantz, Corinne R.

doi:10.1016/j.cca.2013.04.007

Cited by 10 publications

(9 citation statements)

References 60 publications

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“…Appropriate treatment of this patient for Cushing disease was delayed due to misdiagnosis, which is frequent in patients with this fairly rare condition. It is imperative that clinicians be aware of conditions that present similarly and the relevant tests to correctly differentiate between those conditions (1,3,7 ). Definitive diagnosis relies on proper laboratory evaluation, and this case illustrates that a defined, sequential approach to laboratory testing should be used to arrive at the correct diagnosis quickly and efficiently.…”

Section: Discussionmentioning

confidence: 99%

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Easy Bruising in a Patient with Secondary Amenorrhea

Roberts

Fantz

2014

Clinical Chemistry

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A 33-year-old woman presented with amenorrhea and weight gain of 27.2-31.8 kg, despite diet and exercise, as well as progressively worsening acne. Symptoms began subsequent to a spontaneous abortion 5 years earlier and had become especially concerning during the past year. There was no notable family medical history. The patient did not report taking any prescription or over-the-counter medication and denied tobacco, alcohol, or illicit drug use. She had a blood pressure of 144/86 mmHg, heart rate of 88 beats/min, temperature of 37.1°C, and was 1.8 m tall and weighed 105.7 kg (body mass index, 33.4). The results of a physical examination were otherwise normal.Initial laboratory evaluation results included a negative point-of-care urine human chorionic gonadotropin test and concentrations within reference intervals for thyroid-stimulating hormone (TSH), 2 prolactin, leutinizing hormone (LH), and follicle-stimulating hormone (FSH) ( Table 1). Further testing revealed a low estradiol concentration (20 pg/mL, reference interval, 24 -706 pg/mL), as well as increased total testosterone [96 ng/dL (DPC, Siemens, Malvern PA), reference interval, 10 -80 ng/dL] and dehydroepiandrosterone-S (DHEA-S) (594 g/dL, reference interval, Ͻ340 g/ dL) ( Table 1). She was diagnosed with polycystic ovary syndrome (PCOS) and treated with metformin, which she did not tolerate, and local creams for her acne were ineffective.Approximately 1 year later, the patient presented with continuing amenorrhea and complained of mood swings and depression as well as easy bruising and hirsutism. She was referred to an endocrinologist for further evaluation. Laboratory testing at this time included a basic metabolic panel. All measurands were within reference intervals, as were concentrations of TSH, LH, and FSH (Table 1). A random 17-hydroxyprogesterone (17-OHP) was within reference intervals, and estradiol was at the lower limit of the reference interval (28 pg/mL). Prothrombin time and partial thromboplastin time were both within reference intervals. Total testosterone (132 ng/dL) and DHEA-S (812 g/dL) remained increased. DISCUSSION OVERVIEW OF SECONDARY AMENORRHEAAmenorrhea is classified as either primary (failure to achieve menarche) or secondary, which is the cessation of menses for 3 months or more. Secondary amenorrhea is not, in itself, a cause for concern; however, it can be a symptom of other pathological states. Secondary amenorrhea will affect approximately 5% of women of reproductive age and those who are affected often will not demonstrate an obvious etiology for their symptoms. Therefore, a systematic evaluation is required to establish a definitive diagnosis (1 ).The most common underlying cause of secondary amenorrhea is pregnancy. Once pregnancy is ruled out, TSH and prolactin can be measured to investigate other causes such as hypothyroidism and hyperprolactinemia. In the absence of hypothyroidism and hyperprolactinemia, secondary amenorrhea is likely due to either outflow tract obstruction or hypogonadism. The low estrogen concentr...

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Section: Discussionmentioning

confidence: 99%

“…Secondary amenorrhea will affect approximately 5% of women of reproductive age and those who are affected often will not demonstrate an obvious etiology for their symptoms. Therefore, a systematic evaluation is required to establish a definitive diagnosis (1 ).…”

Section: Overview Of Secondary Amenorrheamentioning

confidence: 99%

Easy Bruising in a Patient with Secondary Amenorrhea

Roberts

Fantz

2014

Clinical Chemistry

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“…Indeed, some authors define the chemotherapy-induced amenorrhea in referring to the end of chemotherapy, while others consider a certain delay from the start of the chemotherapy [4]. We have retained the three-month period by referring to the definition of secondary amenorrhea, which is the absence of menses for more than three months in a woman who has normal menses previously [8]. The variability of the incidence's data reflects the heterogeneity of definitions, characteristics of the populations studied and treatment protocols.…”

Section: Discussionmentioning

confidence: 99%

“…The chemotherapy regimens used were as follows: 4 or 6 FAC (5-fluorouracil 600 mg/m The variable of interest was secondary amenorrhea, which was defined as any cessation of menses for at least three months after the beginning of chemotherapy in a woman with normal menses previously [8] after ruling out a pregnancy. The characteristics of patients and disease were analyzed by the mean, median and proportion according to cases.…”

Section: Methodsmentioning

confidence: 99%

Chemotherapy Induced Amenorrhea in Women Treated with Chemotherapy for Breast Carcinoma in Yalgado Ouédraogo Teaching Hospital in Ouagadougou, Burkina Faso

Bambara¹,

Zamané²,

Sawadogo³

et al. 2017

OJOG

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Background: We conducted this study to identify factors associated with the onset and reversibility of chemotherapy-induced amenorrhea in Yalgado Ouédraogo Teaching Hospital of Ouagadougou. Methods: A historical cohort study was performed and covered the period from 1 January 2014 to 31 July 2015. No menopausal patients managed for a histologically confirmed breast carcinoma and having benefited from chemotherapy were included in the study. Logistic regression analysis was used to determine the factors associated with the occurrence of chemotherapyinduced amenorrhea as well as its reversibility. Results: Seventy patients were included. The mean age was 38.5 years. Thirteen patients were obese and 19 (40.4%) had their menarche after age of 15 years. Adjuvant chemotherapy was administered to 31 patients while 12 had received neoadjuvant chemotherapy. Sequential chemotherapy with an anthracycline and a taxanetherapeutic protocol was the most used. Forty-seven patients had a chemotherapy-induced amenorrhea. The risk of having a chemotherapy-induced amenorrhea increases by 25% for each additional year of age at diagnosis of cancer (p = 0.0001). Obesity and menarche after age 15 were found to be protective factors. After adjusting these variables together, age, obesity, and age at menarche were factors independently associated with the occurrence of the chemotherapy-induced amenorrhea. The reversibility was effective in 11 cases (37.9%) and especially concerned patients younger than 40 years (p = 0.03). Conclusion: Age is the primary risk factor. Reliable markers of ovarian function need to be developed to better select fertility conservation protocols.

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“…Elevated LH and FSH concentrations are suggestive of primary ovarian failure, while low or normal levels in the absence of regular menses are more consistent with a hypothalamic or pituitary pathology, although it must be emphasized that low and low‐normal LH and FSH levels can also be seen in polycystic ovarian syndrome and at times during the normal menstrual cycle. Ideally, FSH and LH should be measured on day 3 of the menstrual cycle; however, this timing is often not possible when menses are irregular or absent . For women with cirrhosis in whom anovulation is suspected, serum progesterone may also provide useful information.…”

Section: Sd and Reproductive Dysfunction In Cirrhosismentioning

confidence: 99%

Sexual Dysfunction and Sex Hormone Abnormalities in Patients With Cirrhosis: Review of Pathogenesis and Management

2019

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Healthy sexual function is important to maintain a good quality of life but is frequently impaired in patients with cirrhosis. The degree of sexual dysfunction appears to be linked with the degree of hepatic dysfunction. In men, sexual dysfunction can be related to the hyperestrogenism of portal hypertension and/or to decreased testosterone resulting from testicular dysfunction. In women, suppression of the hypothalamic–pituitary–gonadal axis appears to be a principal contributor, with no significant effect of portal hypertension. There is also a huge psychological barrier to break through as there is a component of depression in many patients with cirrhosis. Sexual dysfunction is often underdiagnosed in the cohort with cirrhosis. Management of sexual disorders in patients with cirrhosis can be challenging as they are often multifactorial. A multidisciplinary approach is key in managing these patients. We review the current literature on the pathogenesis of sexual dysfunction in patients with cirrhosis and propose a stepwise algorithm to better manage these patients.

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Using an algorithmic approach to secondary amenorrhea: Avoiding diagnostic error

Cited by 10 publications

References 60 publications

Easy Bruising in a Patient with Secondary Amenorrhea

Easy Bruising in a Patient with Secondary Amenorrhea

Chemotherapy Induced Amenorrhea in Women Treated with Chemotherapy for Breast Carcinoma in Yalgado Ouédraogo Teaching Hospital in Ouagadougou, Burkina Faso

Sexual Dysfunction and Sex Hormone Abnormalities in Patients With Cirrhosis: Review of Pathogenesis and Management

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Using an algorithmic approach to secondary amenorrhea: Avoiding diagnostic error

Cited by 10 publications

References 60 publications

Easy Bruising in a Patient with Secondary Amenorrhea

Easy Bruising in a Patient with Secondary Amenorrhea

Chemotherapy Induced Amenorrhea in Women Treated with Chemotherapy for Breast Carcinoma in Yalgado Ou&#233;draogo Teaching Hospital in Ouagadougou, Burkina Faso

Sexual Dysfunction and Sex Hormone Abnormalities in Patients With Cirrhosis: Review of Pathogenesis and Management

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Chemotherapy Induced Amenorrhea in Women Treated with Chemotherapy for Breast Carcinoma in Yalgado Ouédraogo Teaching Hospital in Ouagadougou, Burkina Faso