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
Female infertility:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Inability to achieve pregnancy after having regular intercourse without contraception for at least 1 year suggests infertility. (In women older than age 35, many clinicians use 6 months rather than 1 year as a cutoff point.)
Diagnosis requires a complete physical examination and health history, including specific questions on the patient’s reproductive and sexual function, past diseases, mental state, previous surgery, types of contraception used in the past, and family history. Irregular, painless menses may indicate anovulation. A history of PID may suggest fallopian tube blockage. Sometimes PID is silent, and no history may be known.
The following tests assess ovulation:
❑ Basal body temperature graph shows a sustained elevation in body temperature postovulation until just before the onset of menses, indicating the approximate time of ovulation.
❑ Endometrial biopsy, done on or about day 26, provides histologic evidence that ovulation has occurred. However, endometrial biopsy is retrospective, which diminishes its utility.
❑ Progesterone blood levels, measured when they should be highest, can show a luteal phase deficiency or presumptive evidence of ovulation.
The following procedures assess structural integrity of the fallopian tubes, the ovaries, and the uterus:
❑ Urinary LH kits, available without a prescription, can sensitively detect the LH surge about 24 hours preovulation, allowing couples to time coitus.
❑ Hysterosalpingography provides radiologic evidence of tubal obstruction and uterine cavity abnormalities by injecting radiopaque contrast fluid through the cervix.
Male-female interaction studies include the following:
❑ Postcoital test (Sims’-Huhner test) examines the cervical mucus for motile sperm cells following intercourse that takes place at midcycle (as close to ovulation as possible).
❑ Immunologic or antibody testing detects spermicidal antibodies in the female’s sera.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Male infertility:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
A detailed patient history may reveal abnormal sexual development, delayed puberty, infertility in previous relationships, and a medical history of prolonged fever, mumps, impaired nutritional status, previous surgery, or trauma to genitalia. After a thorough patient history and physical examination, the most conclusive test for male infertility is semen analysis. The specimen is collected after 2 to 3 days of complete abstinence to determine volume and viscosity as well as sperm count, motility, swimming speed, and shape.
Other laboratory tests include gonadotropin assay to determine the integrity of the pituitary gonadal axis, serum testosterone levels to determine end organ response to luteinizing hormone (LH), urine 17-ketosteroid levels to measure testicular function, and testicular biopsy to help clarify unexplained oligospermia and azoospermia. Vasography and seminal vesiculography may be necessary.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
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
Infertility:
Differential Overview
(Field Guide to Bedside Diagnosis)
Female Factors
❑ Anovulation
❑ Tubal obstruction
❑ Endometriosis
❑ Polycystic ovary disease
❑ Luteal phase dysfunction
❑ Cervical factors
❑ Uterine leiomyoma
❑ Testicular feminization
Male Factors
❑ Genitourinary infection
❑ Erectile dysfunction
❑ Drugs
❑ Retrograde ejaculation
❑ Varicocele
❑ Germinal compartment failure
❑ Partial androgen resistance
❑ Hypogonadotrophic hypogonadism
❑ Primary hypogonadism
Diagnostic Approach
Couples should be encouraged to attempt to conceive (unprotected intercourse) for 1 year before undergoing evaluation. Ovulation usually occurs if there have been spontaneous, regular, cyclic menses, but this can be confirmed by daily measurement of basal body temperature. The sperm count and motility can be ascertained to be adequate only by semen analysis. Male factors account for about 25% of infertility.
Interpersonal issues such as career stress, differences in desire for children (a clue is that one partner only seeks evaluation), or unacknowledged homosexual preference may interfere with effective coitus.
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Source: Field Guide to Bedside Diagnosis, 2007
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
Infertility, female:
Diagnosis
(Handbook of Diseases)
Diagnosis requires a complete physical examination and health history, including specific questions on the patient’s reproductive and sexual function, past diseases, mental state, previous surgery, types of contraception used in the past, and family history. Irregular, painless menses may indicate anovulation. A history of PID may suggest fallopian tube blockage.
Clinical tip Infertility is a disorder of couples, so both partners should be evaluated.
Tests that assess ovulation
❑ Basal body temperature graph shows a sustained elevation in body temperature after ovulation until just before onset of menses, indicating the approximate time of ovulation. Oral temperatures are taken every morning before rising. This method isn’t as diagnostically useful as other methods.
❑ Endometrial biopsy, done on or about day 5 after the basal body temperature rises, provides histologic evidence that ovulation has occurred.
❑ Progesterone blood levels, measured when they should be highest, can show a luteal phase deficiency. Over-the-counter ovulation predictor kits are less expensive and quite accurate.
Procedures that assess structural integrity
❑ Hysterosalpingography provides radiologic evidence of tubal obstruction and abnormalities of the uterine cavity by injecting radiopaque contrast fluid through the cervix.
❑ Endoscopy confirms the results of hysterosalpingography and visualizes the endometrial cavity by hysteroscopy or explores the posterior surface of the uterus, fallopian tubes, and ovaries by culdoscopy. Laparoscopy allows visualization of the abdominal and pelvic areas.
Male-female interaction studies
❑ Postcoital test (Sims-Huhner test) examines the cervical mucus for motile sperm cells after intercourse that takes place at midcycle (as close to ovulation as possible).
❑ Immunologic or antibody testing detects spermicidal antibodies in the sera of the female. Further research is being conducted in this area.
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Source: Handbook of Diseases, 2003
Infertility, male:
Diagnosis
(Handbook of Diseases)
A detailed patient history may reveal abnormal sexual development, delayed puberty, infertility in previous relationships, and a medical history of prolonged fever, mumps, impaired nutritional status, previous surgery, or trauma to the genitalia.
After a thorough patient history and physical examination, the most conclusive test for male infertility is semen analysis. Other laboratory tests include gonadotropin assay to determine the integrity of the pituitary gonadal axis, serum testosterone levels to determine organ response to luteinizing hormone (LH), urine 17-ketosteroid levels to measure testicular function, and a testicular biopsy to help clarify unexplained oligospermia and azoospermia. Vasography and seminal vesiculography may be necessary.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
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.
Physical assessment
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: Signs & Symptoms: A 2-in-1 Reference for Nurses, 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
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