Confirming diagnosis A history of failure to menstruate in a female older than age 18 confirms primary amenorrhea.
Secondary amenorrhea can be diagnosed when a change is noted in a previously established menstrual pattern (absence of menstruation for 3 months). A thorough physical and pelvic examination rules out pregnancy, as well as anatomic abnormalities such as cervical stenosis that may cause false amenorrhea (cryptomenorrhea), in which menstruation occurs without external bleeding.
Onset of menstruation within 1 week after administration of pure progestational agents, such as medroxyprogesterone and progesterone, indicates a functioning uterus. If menstruation doesn’t occur, special diagnostic studies are appropriate.
Blood and urine studies may reveal hormonal imbalances, such as lack of ovarian response to gonadotropins (elevated pituitary gonadotropins), failure of gonadotropin secretion (low pituitary gonadotropin levels), and abnormal thyroid levels. Tests for identification of dominant or missing hormones include cervical mucus ferning, vaginal cytologic examinations, basal body temperature, endometrial biopsy (during dilatation and curettage), urinary 17-ketosteroids, and plasma progesterone, testosterone, and androgen levels. A complete medical workup, including appropriate X-rays, laparoscopy, and a biopsy, may detect ovarian, adrenal, and pituitary tumors. (See Diagnosing amenorrhea.)
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Ectopic pregnancy:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Clinical features, patient history, and the results of a pelvic examination suggest ectopic pregnancy. The following tests help confirm it:
❑ Serum pregnancy test shows presence of human chorionic gonadotropin.
❑ Real time ultrasonography determines extrauterine pregnancy (performed if serum pregnancy test is positive).
❑ In culdocentesis, fluid is aspirated from the pouch of Douglas through the posterior vaginal fornix to detect free or nonclotting blood in the peritoneum (sometimes performed if ultrasonography fails to detect a gestational sac in the uterus).
❑ Laparoscopy or laparotomy is used to diagnose as well as to treat an ectopic pregnancy by either removal of the tube (salpingectomy) or removal of the pregnancy with preservation of the tube (salpingostomy).
Decreased hemoglobin levels and hematocrit due to blood loss support the diagnosis. Differential diagnosis must rule out uterine abortion, appendicitis, ruptured corpus luteum cyst, salpingitis, and torsion of the ovary.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Abdominal distention:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heartbeat, and difficulty breathing deeply or breathing when lying flat. The patient may also feel unable to bend at his waist. Be sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.
Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, or inflammatory bowel disease. (See Detecting ascites.) Also note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, like falling off a stepladder.
Perform a complete physical examination. Don’t restrict the examination to the abdomen because you could miss important clues to the cause of abdominal distention. Next, stand at the foot of the bed and observe the recumbent patient for abdominal asymmetry to determine if distention is localized or generalized. Then assess abdominal contour by stooping at his side. Inspect for tense, glistening skin and bulging flanks, which may indicate ascites. Observe the umbilicus. An everted umbilicus may indicate ascites or an umbilical hernia. An inverted umbilicus may indicate distention from gas; it’s also common in obese individuals. Inspect the abdomen for signs of an inguinal or femoral hernia and for incisions that may point to adhesions; both may lead to intestinal obstruction. Then auscultate for bowel sounds, abdominal friction rubs (indicating peritoneal inflammation), and bruits (indicating an aneurysm). Listen for a succussion splash—a splashing sound normally heard in the stomach when the patient moves or when palpation disturbs the viscera. An abnormally loud splash indicates fluid accumulation, suggesting gastric dilation or obstruction.
Next, percuss and palpate the abdomen to determine if distention results from air, fluid, or both. A tympanic note in the left lower quadrant suggests an air-filled descending or sigmoid colon. A tympanic note throughout a generally distended abdomen suggests an air-filled peritoneal cavity. A dull percussion note throughout a generally distended abdomen suggests a fluid-filled peritoneal cavity. Shifting of dullness laterally when the patient is in the decubitus position also indicates a fluid-filled abdominal cavity. A pelvic or intra-abdominal mass causes local dullness upon percussion and should be palpable. Obesity causes a large abdomen with generalized rather then localized dullness and without shifting dullness, prominent tympany, or palpable bowel or other masses.
Palpate the abdomen for tenderness, noting whether it’s localized or generalized. Watch for peritoneal signs and symptoms, such as rebound tenderness, guarding, rigidity, McBurney’s point, obturator sign, and psoas sign. Female patients should undergo a pelvic examination; males, a genital examination. All patients who report abdominal pain should undergo a digital rectal examination with fecal occult blood testing. Finally, measure abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference point for subsequent measurements. (See Abdominal distention: Causes and associated findings, pages 6 and 7.)
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Amenorrhea:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin by determining whether the amenorrhea is primary or secondary. If it’s primary, ask the patient at what age her mother first menstruated because age of menarche is fairly consistent in families. Form an overall impression of the patient’s physical, mental, and emotional development because these factors as well as heredity and climate may delay menarche until after age 16.
If menstruation began at an appropriate age but has since ceased, determine the frequency and duration of the patient’s previous menstrual cycles. Ask her about the onset and nature of any changes in her normal menstrual pattern, and determine the date of her last menses. Find out if she has noticed any related signs, such as breast swelling or weight changes.
Determine when the patient last had a physical examination. Review her health history, noting especially any long-term illnesses, such as anemia, or use of hormonal contraceptives. Ask about exercise habits, especially running, and whether she experiences stress on the job or at home. Probe the patient’s eating habits, including number and size of daily meals and snacks, and ask if she has gained weight recently.
Observe her appearance for secondary sex characteristics or signs of virilization. If you’re responsible for performing a pelvic examination, check for anatomic aberrations of the outflow tract, such as cervical adhesions, fibroids, or an imperforate hymen.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Amenorrhea:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Menstrual and reproductive history. What was the patient’s age at menarche? When was the patient’s last menstrual period and her previous menstrual pattern? Document pregnancy history with attention to any complications. Is there a history of gynecologic or obstetric procedures?
1. A history of postpartum infection or curettage (Asherman’s syndrome) may suggest destruction of the endometrium and subsequent outflow tract problem.
2. A history of severe postpartum bleeding requiring transfusion may suggest pituitary failure (Sheehan’s syndrome).
B. Other history. Were there any significant medical or psychosocial events preceding amenorrhea? Is there any galactorrhea? Does the patient have any endocrine, metabolic, or eating disorders? Is there a history of recent weight gain or loss? Document the medication history. Is there a history of prolonged and intense exercise? Is there a family history of menstrual problems or endocrine or autoimmune disorders (Section 14)?
1. Stressful situations or events are often associated with amenorrhea (3).
2. The incidence of amenorrhea is greatest among competitive endurance athletes and ballet dancers (2).
3. Premature ovarian failure can be caused by autoimmune disease (4).
4. Medications associated with amenorrhea include antipsychotics, tricyclic antidepressants, calcium channel blockers, methyldopa, reserpine, digitalis, and chemotherapeutic drugs.
Physical examination
The purpose of the focused examination is to screen for abnormal anatomy or development and signs of endocrinopathies. A breast examination should document the presence or absence of galactorrhea which, with hair distribution, should provide an evaluation of normal secondary sexual characteristics (Tanner stage). Palpate the thyroid for enlargement or nodules. A careful pelvic examination is essential to detect any structural abnormalities or lesions. Signs of possible androgenic excess are truncal obesity, hirsutism, acne, male pattern baldness, and clitoral enlargement (Chapter 14.3).
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Secondary Amenorrhea:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Pregnancy
❑ Menopause
❑ Functional hypothalamic amenorrhea
❑ Drugs
❑ Anorexia nervosa
❑ Post-contraceptive
❑ Endometrial scarring
❑ Endocrinopathy
❑ Hyperprolactinemia
❑ Premature ovarian failure
❑ Polycystic ovary syndrome
❑ Chromophobe adenoma
❑ Ovarian tumors
❑ Panhypopituitarism
❑ Müllerian dysgenesis
Diagnostic Approach
Evaluation should always begin with a history and a urine hCG for pregnancy. On physical examination, attention should be paid to darkening of the areola, and evidence of estrogenization of the vagina.
Estrogen sufficiency can be assessed by observing a fern-like pattern of cervical mucous on a slide or by giving medroxyprogesterone for 5 days and looking for withdrawal bleeding. Bleeding suggests suppression of LH surge as seen in functional amenorrhea or polycystic ovary syndrome.
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Source: Field Guide to Bedside Diagnosis, 2007
Abdominal distention:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient’s abdominal distention isn’t acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heart, and difficulty breathing when lying flat or breathing deeply. The patient may also feel unable to bend at his waist. Be sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.
Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, and inflammatory bowel disease. (See Detecting ascites.) Also note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones, like falling off a stepladder.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Amenorrhea:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin by determining whether the amenorrhea is primary or secondary. If it’s primary, ask the patient at what age her mother first menstruated because age of menarche is fairly consistent in families. Form an overall impression of the patient’s physical, mental, and emotional development because these factors as well as heredity and climate may delay menarche until after age 16.
If menstruation began at an appropriate age but has since ceased, determine the frequency and duration of the patient’s previous menses. Ask her about the onset and nature of any changes in her normal menstrual pattern, and determine the date of her last menses. Find out if she has noticed any related signs, such as breast swelling or weight changes.
Determine when the patient last had a physical examination. Review her health history, noting especially any long-term illnesses such as anemia or use of hormonal contraceptives. Ask about exercise habits, especially running, and whether she experiences stress on the job or at home. Probe the patient’s eating habits, including the number and size of daily meals and snacks, and ask if she has gained weight recently.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Abdominal distention:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient's abdominal distention isn't acute, ask about its onset and duration and associated signs. A patient with localized distention may report a sensation of pressure, fullness, or tenderness in the affected area. A patient with generalized distention may report a bloated feeling, a pounding heart, and difficulty breathing deeply or when lying flat.
The patient may be unable to bend at the waist. Make sure to ask about abdominal pain, fever, nausea, vomiting, anorexia, altered bowel habits, and weight gain or loss.
Obtain a medical history, noting GI or biliary disorders that may cause peritonitis or ascites, such as cirrhosis, hepatitis, or inflammatory bowel disease. (See Detecting ascites.) When did the patient last have a bowel movement? Note chronic constipation. Has the patient recently had abdominal surgery, which can lead to abdominal distention? Ask about recent accidents, even minor ones such as falling off a stepladder.
Perform a complete physical examination. Don't restrict the examination to the abdomen because you could miss important clues to the cause of abdominal distention. Next, stand at the foot of the bed and observe the recumbent patient for abdominal asymmetry to determine if distention is localized or generalized. Then assess abdominal contour by stooping at his side. Inspect for tense, taut skin and bulging flanks, which may indicate ascites. Observe the umbilicus. An everted umbilicus may indicate ascites or umbilical hernia. An inverted umbilicus may indicate distention from gas; it's also common in obesity and pregnancy. Inspect the abdomen for signs of inguinal or femoral hernia and for healed incisions that may point to adhesions. Both may lead to intestinal obstruction. Auscultate for bowel sounds, abdominal friction rubs (indicating peritoneal inflammation), and bruits (indicating an aneurysm). Listen for succussion splash—a splashing sound normally heard in the stomach when the patient moves or when palpation disturbs the viscera. An abnormally loud splash indicates fluid accumulation, suggesting gastric dilation or obstruction.
Next, percuss and palpate the abdomen to determine if distention results from air, fluid, or both. A tympanic note in the left lower quadrant suggests an air-filled descending or sigmoid colon. A tympanic note throughout a generally distended abdomen suggests an air-filled peritoneal cavity. A dull percussion note throughout a generally distended abdomen suggests a fluid-filled peritoneal cavity. Shifting of dullness laterally with the patient in the decubitus position also indicates a fluid-filled abdominal cavity. A pelvic or intra-abdominal mass causes local dullness upon percussion and should be palpable. Obesity causes a large abdomen without shifting dullness, prominent tympany, or palpable bowel or other masses, with generalized rather then localized dullness.
Palpate the abdomen for tenderness, noting whether it's localized or generalized. Watch for peritoneal signs and symptoms, such as rebound tenderness, guarding, rigidity, McBurney's point, obturator sign, and psoas sign. Female patients should undergo a pelvic examination; males, a genital examination. All patients who report abdominal pain should undergo a digital rectal examination with fecal occult blood testing. Finally, measure the patient's abdominal girth for a baseline value. Mark the flanks with a felt-tipped pen as a reference for subsequent measurements.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Amenorrhea:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin by determining whether the amenorrhea is primary or secondary. If it's primary, ask the patient at what age her mother first menstruated because age of menarche is fairly consistent in families. Form an overall impression of the patient's physical, mental, and emotional development because these factors as well as heredity and climate may delay menarche until after age 16.
If menstruation began at an appropriate age but has since ceased, determine the frequency and duration of the patient's previous menses. Ask her about the onset and nature of any changes in her normal menstrual pattern, and determine the date of her last menses. Find out if she has noticed any related signs, such as breast swelling or weight changes.
Determine when the patient last had a physical examination. Review her health history, noting especially any long-term illnesses, such as anemia, or use of hormonal contraceptives. Ask about exercise habits, especially running, and whether she experiences stress on the job or at home. Ask about the patient's eating habits, including the number and size of daily meals and snacks, and ask if she has gained or lost weight recently.
Observe her appearance for secondary sex characteristics or signs of virilization. If you're responsible for performing a pelvic examination, check for anatomic aberrations of the outflow tract, such as cervical adhesions, fibroids, or an imperforate hymen.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
HYPOMENORRHEA AND AMENORRHEA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Obviously the first thing to do is rule out pregnancy both by
examination and a pregnancy test, preferably the serum β -subunit human
chorionic gonadotropin (HCG). One must keep an ectopic pregnancy in mind
even if the examination is normal and plan follow-up examinations and
ultrasonography should the situation warrant. Altered secondary sex
characteristics should be noted. If the examination fails to show evidence
of pregnancy, congenital anomalies, or tumors of the ovaries, the physician should order thyroid
function studies, a Wassermann test, CBC, and sedimentation rate. If these
tests are normal, a gynecologist should be consulted. The gynecologist may
give a test dose of intramuscular progesterone to prove that the endometrium
functions well. He or she may do a D & C first. Then serum or urine FSH,
LH, and prolactin levels are done; if the FSH level is high, the ovary is
probably the site of the trouble. If the levels are low, even after
gonadotropin-releasing factor (GRF) is administered, the pituitary is
responsible. X-rays of the skull, CT scans, culdoscopy, and exploratory
laparotomy all share their place in the workup.
CASE PRESENTATION #52
A 34-year-old white mother of three complained of amenorrhea and weight
loss. A pregnancy test was negative. She has been under a lot of emotional
distress for several months and has lost her appetite.
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