I am just trying to set a sequence of questions to ask in the exam, tests to order and examination to do so that I am not all over the place in the exam.
So here's what I am going to do if a case of amenorrhea shows up - Ask about general menstrual history and then go to symptoms specific for differentials:
Menstrual history: How long do they last, how many pads, menarche, LMP, cramps with periods, vaginal discharge, blahblahblah.
Pregnancy: Sexual activity, birth control, previous pregnancies.
Workup: Urine HCG
Hyperprolactinemia symptoms: Galactorrhea, oligomenorrhea leading to amennorrhea, infertility, anti-depressant use, changes in vision.
Workup: Prolactin, TSH.
Hyperandrogenic symptoms suggestive of PCOS: Skin changes (acne), hair and voice changes.
Symptoms suggestive of premature ovarian failure: Hot flashes, vaginal dryness, itching.
Secondary amenorrhea: Eating disorders
Workup: FSH, LH
For examination:
Eye exam and visual field: "EOMI, visual fields full to confrontation, no lid lag, diplopia."
Ask patient to swallow: "No thyromegaly"
Check DTR: "Normal DTR bilaterally"
Optional: Auscultate heart, lungs. Palpate abdomen.
Mention need for pelvic exam and breast exam.
Mnemonic for differentials: PPPPAT
Pregnancy
Prolactinoma
Pause (Premature menopause)
PCOS
Anorexia
Thyroid
Extra tip:
History findings suggestive of pregnancy -
Amenorrhea
Sexually active (I didn't know you could write this xD)
Previously successful pregnancy
--------------------------------------------------------------------------------------------------------------
Here's my sample note I wrote in 10 minutes after practicing the case from first aid:
History :
36 yo F c/o amenorrhea since 3 months. Her periods last for 5-6 days and she usually one pad per
day since the past one year. Normally her periods last for 4-5 days and she uses 2-3 pads per day.
Also complaints of galactorrhea since a few days. Denies visual field loss.
C/o hirsutism, weight gain. Denies voice changes, acne.
Denies cold or heat intolerance, diarrhea or constipation.
Denies hot flashes, vaginal dryness, itching or discharge.
OBGYN: Menarche at age 14, had one child 10 years ago, NVFTD, child is alive and well. Sexually
active with husband, uses pills since 8 years.
PMH / PSH / FH: None
Medications: None
Allergies: NKDA
SH: Denies EtOH, smoking, drugs
Physical Examination :
Pt is NAD
VS: WNL
HEENT: PERRLA, EOMI, no nystagmus, lid lag, drooping eyelids.
Neck: No thryomegaly.
Extremities: No edema feet.
Diagnosis 1 :
Pregnancy
History Findings
1) Amenorrhea
2) Previous successful pregnancy
Diagnosis 2 :
PCOS
History Findings
1) Weight gain
2) Hirsutism
3) Amenorrhea
Diagnosis 3 :
Prolactinoma
History Findings
1) Oligomenorrhea followed by
Amenorrhea
2) Galactorrhea
Diagnostic Study/Studies - Labs
1) Breast and pelvic exam
2) Urine HCG
3) Prolactin / TSH
4) FSH / LH
Feedback from my friend:
The only thing missing is past history is details of menses - like were they regular before, irregular etc. The supporting point here for pregnancy is also sexually active.
So here's what I am going to do if a case of amenorrhea shows up - Ask about general menstrual history and then go to symptoms specific for differentials:
Menstrual history: How long do they last, how many pads, menarche, LMP, cramps with periods, vaginal discharge, blahblahblah.
Pregnancy: Sexual activity, birth control, previous pregnancies.
Workup: Urine HCG
Hyperprolactinemia symptoms: Galactorrhea, oligomenorrhea leading to amennorrhea, infertility, anti-depressant use, changes in vision.
Workup: Prolactin, TSH.
Hyperandrogenic symptoms suggestive of PCOS: Skin changes (acne), hair and voice changes.
Symptoms suggestive of premature ovarian failure: Hot flashes, vaginal dryness, itching.
Secondary amenorrhea: Eating disorders
Workup: FSH, LH
For examination:
Eye exam and visual field: "EOMI, visual fields full to confrontation, no lid lag, diplopia."
Ask patient to swallow: "No thyromegaly"
Check DTR: "Normal DTR bilaterally"
Optional: Auscultate heart, lungs. Palpate abdomen.
Mention need for pelvic exam and breast exam.
Mnemonic for differentials: PPPPAT
Pregnancy
Prolactinoma
Pause (Premature menopause)
PCOS
Anorexia
Thyroid
Extra tip:
History findings suggestive of pregnancy -
Amenorrhea
Sexually active (I didn't know you could write this xD)
Previously successful pregnancy
--------------------------------------------------------------------------------------------------------------
Here's my sample note I wrote in 10 minutes after practicing the case from first aid:
History :
36 yo F c/o amenorrhea since 3 months. Her periods last for 5-6 days and she usually one pad per
day since the past one year. Normally her periods last for 4-5 days and she uses 2-3 pads per day.
Also complaints of galactorrhea since a few days. Denies visual field loss.
C/o hirsutism, weight gain. Denies voice changes, acne.
Denies cold or heat intolerance, diarrhea or constipation.
Denies hot flashes, vaginal dryness, itching or discharge.
OBGYN: Menarche at age 14, had one child 10 years ago, NVFTD, child is alive and well. Sexually
active with husband, uses pills since 8 years.
PMH / PSH / FH: None
Medications: None
Allergies: NKDA
SH: Denies EtOH, smoking, drugs
Physical Examination :
Pt is NAD
VS: WNL
HEENT: PERRLA, EOMI, no nystagmus, lid lag, drooping eyelids.
Neck: No thryomegaly.
Extremities: No edema feet.
Diagnosis 1 :
Pregnancy
History Findings
1) Amenorrhea
2) Previous successful pregnancy
Diagnosis 2 :
PCOS
History Findings
1) Weight gain
2) Hirsutism
3) Amenorrhea
Diagnosis 3 :
Prolactinoma
History Findings
1) Oligomenorrhea followed by
Amenorrhea
2) Galactorrhea
Diagnostic Study/Studies - Labs
1) Breast and pelvic exam
2) Urine HCG
3) Prolactin / TSH
4) FSH / LH
Feedback from my friend:
The only thing missing is past history is details of menses - like were they regular before, irregular etc. The supporting point here for pregnancy is also sexually active.
Great read! It’s easy to dismiss irregular periods, but they can be a huge source of anxiety when trying to conceive. Learning about female infertility and options like IVF treatment makes the process feel much less overwhelming. Highly recommend seeing an infertility specialist sooner rather than later!
ReplyDelete