Diagnostic Tests for Menstrual conditions
Menstrual conditions Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Menstrual conditions:
- Pregnancy -- Related Home Testing:
- Menopause: Related Home Testing:
- Vaginal Health: Home Testing:
- Breast Cancer: Related Home Tests:
Menstrual conditions Diagnosis: Book Excerpts
Diagnosis of Menstrual conditions: medical news summaries:
The following medical news items
are relevant to diagnosis of Menstrual conditions:
Diagnostic Tests for Menstrual conditions: Online Medical Books
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AMENORRHEA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
The first thing to do is a pregnancy test, as pregnancy is the most common cause of secondary amenorrhea. If the pregnancy test is negative, referral to a gynecologist may be done at this time. If a specialist is not handy, one may proceed with the workup. A trial of medroxyprogesterone acetate (ProveraŽ) may be done by intermuscular injection or by mouth. If bleeding occurs on withdrawal of the progesterone, then it is established that the uterus is functional. It also establishes that the cervix and vagina are patent. If bleeding does not occur, uterine pathology is likely, and referral to a gynecologist is necessary.
If there is no galactorrhea, a normal response to progesterone, and the patient is a teenager, one may simply discontinue studies at this point and observe for the normal onset of the menstrual cycle.
If the patient with primary amenorrhea has already reached her twenties or if there is definite secondary amenorrhea, then further diagnostic studies should be done. If there is galactorrhea, a serum for prolactin should be done. If that is elevated, a CT scan of the brain should be done to look for a pituitary tumor or hypothalamic tumor. If there is no galactorrhea, one should still order a prolactin, but also order tests for follicle-stimulating hormone (FSH), luteinizing hormone (LH), and serum estradiol. If the FSH and LH are elevated and the estradiol is decreased, primary ovarian failure must be considered. A buccal smear for sex chromogens should be done to rule out Turner's syndrome. Other causes of primary ovarian failure are ovarian agenesis and polycystic ovary syndrome. An elevated free testosterone will support the diagnosis of polycystic ovary syndrome (Stein-Leventhal syndrome).
If the FSH, LH, and estradiol are all decreased, then hypopituitarism should be considered, as well as hypothalamic disorders. Referral to an endocrinologist is wise at this point. When an adrenocortical tumor is suspected, a serum cortisol and cortisol suppression test should be done.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
DYSMENORRHEA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine studies should include a CBC, sedimentation rate, chemistry panel, and thyroid profile. If there is vaginal discharge, a smear and culture should be done for gonorrhea and chlamydia. A cervical and rectal culture for these organisms may also be necessary. If there is a tubo-ovarian mass or enlarged uterus, abdominal ultrasound may help in differentiating the cause. A pregnancy test should be done. The pregnancy test of choice is
radioimmunoassay
for the beta subunit of human chorionic gonadotropin (HCG), which will be positive within a week of fertilization. If a ruptured ectopic pregnancy is expected, a peritoneal tap or culdocentesis may help if abdominal ultrasound is not conclusive. Laparoscopy may also be helpful in the diagnosis. A fern test and basal body temperature may help diagnose endometriosis. An exploratory laparotomy may be the only way to make a diagnosis in cases of a pelvic mass. If the pelvic examination is perfectly normal, sometimes a course of progesterone hormones is useful in alleviating the problem. A dilation and curettage may also be done to address the problem. Referral to a gynecologist is usually made before doing expensive diagnostic tests.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
MENORRHAGIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine studies include a CBC, sedimentation rate, urinalysis, pregnancy test, chemistry panel, ANA titer, VDRL test, coagulation profile, thyroid profile, and flat plate of the abdomen. A Pap smear and vaginal smear and culture should be done.
If these tests are negative, referral to a gynecologist should be made before undertaking expensive tests such as pelvic ultrasound or CT scan of the abdomen and pelvis. Some clinicians will probably ignore this advice. A gynecologist will often be able to resolve the diagnostic dilemma with a good pelvic examination. Laparoscopy, culdocentesis, endometrial biopsy, and dilation and curettage are just a few of the diagnostic tools at his disposal.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
METRORRHAGIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine studies include a CBC, sedimentation rate, urinalysis, pregnancy test, chemistry panel, ANA test, coagulation profile, thyroid profile, and flat plate of the abdomen. A Pap smear and vaginal smear and culture should also be done.
If these are negative, referral to a gynecologist should be made before undertaking expensive diagnostic tests such as ultrasound or CT scans of the abdomen and pelvis. Alternatively, a trial of cyclical estrogen and progesterone hormones may be done if dysfunctional bleeding is suspected before referral is made. A gynecologist may be able to resolve the diagnostic dilemma with a good pelvic examination or, if that is unsuccessful, may perform laparoscopy or culdocentesis. A dilation and curettage or office endometrial biopsy are among the additional procedures at the gynecologist's disposal. An endocrinologist may be of help in deciding whether pituitary or ovarian dysfunction is responsible. An FSH of greater than 40 ml suggests ovarian failure. The endocrinologist may note hirsutism and order a free testosterone and 17-hydroxy progesterone to rule out adrenal or ovarian neoplasm.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
RESPIRATION ABNORMALITIES:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
The basic workup includes a CBC, sedimentation rate, urinalysis, chemistry panel, EKG, chest x-ray, urine drug screen, blood alcohol level, arterial blood gases, and pulmonary function tests. If there is fever, blood cultures, febrile agglutinins, and tuberculin and other skin tests may be ordered. If there is coma, further diagnostic workup may be found on
page 84
. If there is dyspnea, further diagnostic workup may be found on
page 131
.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
PUPIL ABNORMALITIES:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Patients with bilateral dilated or constricted pupils should have a urine drug screen and possibly a blood test for alcohol level. If there is fever or a history of trauma with dilated or constricted pupils or other pupillary abnormalities, a neurologist or neurosurgeon should be consulted immediately before ordering expensive diagnostic tests.
Primary eye conditions can be excluded by tonometry, slit lamp examination, or ophthalmology consultation. Intracranial neoplasms and aneurysms must be excluded by CT scans, MRIs, and possibly angiography. A spinal tap will help diagnose central nervous system lues or multiple sclerosis. VEP studies will help diagnose multiple sclerosis. The workup for Horner's syndrome can be found on
page 227
.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Amenorrhea:
History and physical examination
(Handbook of Signs & Symptoms (Third 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 menses. Ask her about the onset and nature of any changes in her normal menstrual pattern, and determine the date of her last period. 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.
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: Handbook of Signs & Symptoms (Third Edition), 2006
Dysmenorrhea:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient complains of dysmenorrhea, have her describe it fully. Is it intermittent or continuous? Sharp, cramping, or aching? Ask where the pain is located and whether it's bilateral. When does the pain begin and end, and when is it severe? Does it radiate to the back? How long has she been experiencing the pain? If it's a recent complaint, obtain a human chorionic gonadotropin level to determine if the patient is or was pregnant, because miscarriage can cause painful bleeding. Explore associated signs and symptoms, such as nausea and vomiting, altered bowel or urinary habits, bloating, water retention, pelvic or rectal pressure, and unusual fatigue, irritability, or depression.
Then obtain a menstrual and sexual history. Ask the patient if her menstrual flow is heavy or scant. Have her describe vaginal discharge between menses. Does she experience pain during sexual intercourse? Does it occur with menses? Find out what relieves her cramps. Does she take pain medication? Is it effective? Note her method of contraception, and ask about a history of pelvic infection. Does she have signs and symptoms of urinary system obstruction, such as pyuria, urine retention, or incontinence? Determine how she copes with stress. Determine her risk of sexually transmitted diseases.
Next, perform a focused physical examination. Take the patient's vital signs, noting fever and accompanying chills. Inspect the abdomen for distention, and palpate for tenderness and masses. Note costovertebral angle tenderness.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Menorrhagia:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
When the patient’s condition permits, obtain a history. Determine her age at menarche, the duration of menstrual periods, and the interval between them. Establish the date of the patient’s last menses, and ask about recent changes in her normal menstrual pattern. Have the patient describe the character and amount of bleeding. For example, how many pads or tampons does the patient use? Has she noted clots or tissue in the blood? Also ask about the development of other signs and symptoms before and during her period.
Next, ask if the patient is sexually active. Does she use a method of birth control? If so, what kind? Could the patient be pregnant? Be sure to note the number of pregnancies, the outcome of each, and any pregnancy-related complications. Find out the dates of her most recent pelvic examination and Papanicolaou smear and the details of any previous gynecologic infections or neoplasms. Also, be sure to ask about previous episodes of abnormal bleeding and the outcome of treatment. If possible, obtain a pregnancy history of the patient’s mother, and determine if the patient was exposed in utero to diethylstilbestrol. (This drug has been linked to vaginal adenosis.)
Be sure to ask the patient about her general health and medical history. Note particularly if the patient or her family has a history of thyroid, adrenal, or hepatic disease; blood dyscrasias; or tuberculosis because these may predispose the patient to menorrhagia. Also, ask about the patient’s past surgical procedures and recent emotional stress. Find out if the patient has undergone X-ray or other radiation therapy, because this may indicate prior treatment for menorrhagia. Obtain a thorough drug and alcohol history, noting the use of anticoagulants or aspirin. Perform a pelvic examination, and obtain blood and urine samples for pregnancy testing.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Metrorrhagia:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin your evaluation by obtaining a thorough menstrual history. Ask the patient when she began menstruating and about the duration of menstrual periods, the interval between them, and the average number of tampons or pads she uses. When does metrorrhagia usually occur in relation to her period? Does she experience other signs or symptoms? Find out the date of her last menses, and ask about other recent changes in her normal menstrual pattern. Get details of previous gynecologic problems. If applicable, obtain a contraceptive and obstetric history. Record the dates of her last Papanicolaou smear and pelvic examination. Ask the patient when she last had sex and whether or not it was protected. Next, ask about her general health and any recent changes. Is she under emotional stress? If possible, obtain a pregnancy history of the patient’s mother. Was the patient exposed in utero to diethylstilbestrol? (This drug has been linked to vaginal adenosis.)
Perform a pelvic examination if indicated, and obtain blood and urine samples for pregnancy testing.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Oligomenorrhea:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
After asking the patient’s age, find out when menarche occurred. Has the patient ever experienced normal menstrual cycles? When did she begin having abnormal cycles? Ask her to describe the pattern of bleeding. How many days does the bleeding last, and how frequently does it occur? Are there clots and tissue fragments in her menstrual flow? Note when she last had menstrual bleeding.
Next, determine if she’s having symptoms of ovulatory bleeding. Does she experience mild, cramping abdominal pain 14 days before she bleeds? Is the bleeding accompanied by premenstrual symptoms, such as breast tenderness, irritability, bloating, weight gain, nausea, and diarrhea? Does she have cramping or pain with bleeding? Also, check for a history of infertility. Does the patient have children? Is she trying to conceive? Ask if she’s currently using hormonal contraceptives or if she has ever used them in the past. If she has, find out when she stopped taking them.
Then ask about previous gynecologic disorders such as ovarian cysts. If the patient is breast-feeding, has she experienced problems with milk production? If she hasn’t been breast-feeding recently, has she noticed milk leaking from her breasts? Ask about recent weight gain or loss. Is the patient less than 80% of her ideal weight? If so, does she claim that she’s overweight? Ask if she’s exercising more vigorously than usual.
Screen for metabolic disorders by asking about excessive thirst, frequent urination, or fatigue. Has the patient been jittery or had palpitations? Ask about headaches, dizziness, and impaired peripheral vision. Complete the history by finding out what drugs the patient is taking.
Begin the physical examination by taking the patient’s vital signs and weighing her. Inspect for increased facial hair growth, sparse body hair, male distribution of fat and muscle, acne, and clitoral enlargement. Note if the skin is abnormally dry or moist, and check hair texture. Also, be alert for signs of psychological or physical stress. Rule out pregnancy by a blood or urine pregnancy test.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third 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.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Dysmenorrhea:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient complains of dysmenorrhea, have her describe it fully. Is it intermittent or continuous? Sharp, cramping, or aching? Ask where the pain is located and whether it’s bilateral. How long has she been experiencing it? When does the pain begin and end, and when is it severe? Does it radiate to the back? Explore associated signs and symptoms, such as nausea and vomiting, altered elimination habits, bloating, water retention, pelvic or rectal pressure, and unusual fatigue, irritability, or depression.
Then obtain a menstrual and sexual history. Ask the patient if her menstrual flow is heavy or scant. Have her describe any vaginal discharge between menses. Does she experience pain during sexual intercourse? Does it occur with menses? Find out what relieves her cramps. Does she take pain medication? Is it effective? Note her method of contraception, and ask about a history of pelvic infection. Does she have any signs and symptoms of urinary system obstruction, such as pyuria, urine retention, or incontinence? Determine how she copes with stress. Determine her risk for sexually transmitted diseases.
Next, perform a focused physical examination. Take vital signs, noting fever and accompanying chills. Inspect the abdomen for distention, and palpate for tenderness and masses. Note costovertebral angle tenderness.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Menorrhagia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
When the patient’s condition permits, obtain a history. Determine her age at menarche, the average duration of menstrual periods, and the interval between them. Establish the date of the patient’s last menses, and ask about any recent changes in her normal menstrual pattern. Have the patient describe the character and amount of bleeding. For example, how many pads or tampons does the patient use? Has she noted clots or tissue in the blood? Also ask about the development of other signs and symptoms before and during the menstrual period.
Next, ask if the patient is sexually active. Does she use a method of birth control? If so, what kind? Could the patient be pregnant? Be sure to note the number of pregnancies, the outcome of each, and any pregnancy-related complications. Find out the dates of her most recent pelvic examination and Papanicolaou smear and the details of any previous gynecologic infections or neoplasms. Also, be sure to ask about any previous episodes of abnormal bleeding and the outcome of any treatment. If possible, obtain a pregnancy history of the patient’s mother, and determine if the patient was exposed in utero to diethylstilbestrol. (This drug has been linked to vaginal adenosis.)
Be sure to ask the patient about her general health and medical history. Note particularly if the patient or her family has a history of thyroid, adrenal, or hepatic disease; blood dyscrasias; or tuberculosis because these may predispose the patient to menorrhagia. Also, ask about the patient’s past surgical procedures and any recent emotional stress. Find out if the patient has undergone X-ray or other radiation therapy, because this may indicate prior treatment for menorrhagia. Obtain a thorough drug and alcohol history, noting the use of anticoagulants or aspirin. Perform a pelvic examination, and obtain blood and urine samples for pregnancy testing.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Metrorrhagia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin your evaluation by obtaining a thorough menstrual history. Ask the patient when she began menstruating and about the duration of menstrual periods, the interval between them, and the average number of tampons or pads she uses. When does metrorrhagia usually occur in relation to her period? Does she experience other signs or symptoms? Find out the date of her last menses, and ask about any other recent changes in her normal menstrual pattern. Get details of any previous gynecologic problems. If applicable, obtain a contraceptive and obstetric history. Record the dates of her last Papanicolaou smear and pelvic examination. Ask the patient when she last had sex and whether or not it was protected. Next, ask about her general health and any recent changes. Is she under emotional stress? If possible, obtain a pregnancy history of the patient’s mother. Was the patient exposed in utero to diethylstilbestrol? (This drug has been linked to vaginal adenosis.)
Perform a pelvic examination if indicated, and obtain blood and urine samples for pregnancy testing.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Oligomenorrhea:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
After asking the patient’s age, find out when menarche occurred. Has the patient ever experienced normal menstrual cycles? When did she begin having abnormal cycles? Ask her to describe the pattern of bleeding. How many days does the bleeding last, and how frequently does it occur? Are there clots and tissue fragments in her menstrual flow? Note when she last had menstrual bleeding.
Next, determine if she’s having symptoms of ovulatory bleeding. Does she experience mild, cramping abdominal pain 14 days before she bleeds? Is the bleeding accompanied by premenstrual symptoms, such as breast tenderness, irritability, bloating, weight gain, nausea, and diarrhea? Does she have cramping or pain with bleeding? Also, check for a history of infertility. Does the patient have any children? Is she trying to conceive? Ask if she’s currently using hormonal contraceptives or if she’s ever used them in the past. If she has, find out when she stopped taking them.
Then ask about previous gynecologic disorders such as ovarian cysts. If the patient is breast-feeding, has she experienced any problems with milk production? If she hasn’t been breast-feeding recently, has she noticed milk leaking from her breasts? Ask about recent weight gain or loss. Is the patient less than 80% of her ideal weight? If so, does she claim that she’s overweight? Ask if she’s exercising more vigorously than usual.
Screen for metabolic disorders by asking about excessive thirst, frequent urination, or fatigue. Has the patient been jittery or had palpitations? Ask about headache, dizziness, and impaired peripheral vision. Complete the history by finding out what drugs the patient is taking.
Begin the physical examination by taking the patient’s vital signs and weighing her. Inspect for increased facial hair growth, sparse body hair, male distribution of fat and muscle, acne, and clitoral enlargement. Note if the skin is abnormally dry or moist, and check hair texture. Also, be alert for signs of psychological or physical stress. Rule out pregnancy by a blood or urine pregnancy test.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Amenorrhea:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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).
Testing
A. Clinical laboratory tests. Serum or urine human chorionic gonodotropin, thyroid-stimulating hormone, prolactin, follicle-stimulating hormone, and luteinizing hormone are usually the only tests required to make a diagnosis (section V). Additional tests for premature ovarian failure should include free thyroxine (T4), thyroid antibodies, morning cortisol, calcium, phosphorus and antinuclear antibody, rheumatoid factor, erythrocyte sedimentation rate, and a complete blood count. Further adrenal evaluation of women who exhibit signs of hyperandrogenism with anovulation (“hyperandrogenic chronic anovulation”) includes fasting serum testosterone, dehydroepiandrosterone (DHEA)-S, and 17-hydroxyprogesterone (17-HP).
B. Other laboratory evaluation. Karotyping is indicated in all women with premature ovarian failure prior to age 30 years or with any physical evidence suggestive of Turner’s syndrome (short stature, web neck, shield-shaped chest, lack of secondary sexual characteristics) (3). Endometrial biopsy should be considered in women with prolonged amenorrhea or with evidence of estrogen or androgen excess to exclude endometrial hyperplasia.
C. Provocative tests
1. Progesterone challenge test. Oral progesterone acetate (10 mg daily for 15 days). A positive test is withdrawal bleeding between days 2 and 7 after finishing medication; alternatively, parenteral progesterone (200 mg) in oil or micronized progesterone 200 mg at bedtime.
2. Estrogen-progesterone challenge test. Oral conjugated estrogen (1.25 mg) or 2 mg estadiol qd for days 1 through 21 with oral progesterone acetate (10 mg) on days 17 through 21. A positive test is withdrawal bleeding between days 2 and 7 after finishing medication.
D. Diagnostic imaging. A coned lateral view of the sella turcica is indicated as a screening examination for galactorrhea if the prolactin level is less than 100 ng/ml. A magnetic resonance imaging scan, which is more sensitive, is indicated for elevated prolactin, abnormal screening x-ray film, or diagnosis of hypothalamic amenorrhea (section V).
Diagnostic assessment
Use the approach outlined in Figure 11.1 to guide diagnosis (1–3).
References
1. Speroff L, Glass RH, Kase NG. Clinical gynecologic endocrinology and infertility, 5th ed. Baltimore: Williams & Wilkins, 1994:401–456.
2. Kiningham RB, Apgar BS, Swenk TL. Evaluation of amenorrhea. Am Fam Physician 1996;53:1185–1194.
3. Scott J, DiSaia P, Hammond C, Spellacy W, eds. Danforth’s obstetrics and gynecology, 7th ed. Philadelphia: JB Lippincott, 1994:665–679.
4. Alper MM, Garner PR. Premature ovarian failure: its relationship to autoimmune disease. Obstet Gynecol 1985;66:27–30.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Dysmenorrhea:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
As with all menstrual complaints, a thorough physical examination is an essential part of making a diagnosis.
A. The general condition of the patient needs to be assessed. Are the vital signs stable or is the patient showing signs of systemic illness such as fever, which can indicate pelvic infection. Hypotension and pallor can indicate a ruptured ectopic pregnancy.
B. A general physical assessment with attention to the back, sacrum, spine abdomen, and bladder is important.
C. A thorough pelvic examination is key. The external genitalia may show signs of cyanosis, as is seen with pregnancy, or abnormal discharge, as is seen with infection. Palpate the vaginal area for nodules which may present on the anterior cul-de-sac or on the posterior vaginal fornix on bimanual examination; they could indicate endometriosis. Cervical motion tenderness and cervical leukorrhea may be present in PID. Uterine tenderness is often present and uterine displacement and fixation may be noted. Ovarian enlargement or adnexa fixation, which correlates with endometriosis or adnexal mass from neoplastic or infectious cause, may be found. Nodules may also be palpated along the uterosacral ligaments on rectovaginal examination.
Laboratory testing (3)
A. A complete blood count looking for anemia or leucocytosis is helpful.
B. If abnormal bleeding is associated with the dysmenorrhea, thyroid testing and a qualitative serum pregnancy test are indicated.
C. Urine analysis looking for hematuria should be obtained. With any indication of infection, a urine culture is often helpful.
D. A pelvic ultrasound may be helpful if any masses seem apparent on pelvic examination.
E. The definitive diagnosis of endometriosis can only be positively diagnosed with laporoscopy.
Diagnostic assessment (1)
Difficult menstrual periods occur at some point for most women during their reproductive years. If it is recurrent and significantly interferes with daily activity or relationships, it warrants treatment. Primary dysmenorrhea not associated with abnormal bleeding can often be treated successfully with nonsteroidal agents or oral contraceptives. If it does not respond to these agents or if it is associated with abnormal bleeding, further diagnostic testing is indicated. Secondary dysmenorrhea, either with or without abnormal bleeding, may point to a pelvic tumor, infection, or pregnancy. Further testing is essential in this setting.
References
1. Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain and irritable bowel syndrome in primary care practices. Obstet Gynecol 1996;87:
55–58.
2. Apgar BS. Dysmenorrhea and dysfunctional uterine bleeding. Prim Care 1997;
24(1):161–179.
3. Chan PD, Winkle CR. Gynecology and obstetrics 1999–2000. Laguna Hills, CA: Current Clinical Strategies Publishers, 1999:25–26.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Menorrhagia:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Assess vital signs and the patient’s general appearance. Signs of impending shock (e.g., hypotension and tachycardia) are likely related to pregnancy, particularly in the younger age group, but they can be related to trauma, sepsis, or cancer.
B. Pallor not associated with hypovolemia can be found with chronic blood loss associated with anovulatory cycles, leiomyoma, blood dyscrasia, or malignancy (Chapter 16.1).
C. Fever, leukocytosis, and pelvic tenderness are usually found in acute PID (Chapter 2.6).
D. Pelvic masses found on physical examination point toward abscess, ectopic pregnancy, or malignancy.
E. Signs of thyroid disease (e.g., rapid or slow pulse, reflex changes, hair changes, and thyromegaly) can be associated with menstrual abnormalities.
F. Excessive bruising can indicate nutritional deficiency, eating disorder, trauma, abuse, medication overuse, or coagulopathy (Chapter 15.3).
Testing
A. A baseline complete blood count and serum pregnancy test are essential in most pre- and perimenopausal women.
B. A bleeding disorder should be excluded with a platelet count, a prothrombin time, a partial thromboplastin time, and a bleeding time.
C. Screening for sexually transmitted diseases and thyroid dysfunction, particularly in those of childbearing age, is important.
D. Any nonpregnant woman with irregular bleeding and a pelvic mass requires evaluation with ultrasound, computed tomography (CT), or laparoscopy.
E. Endometrial sampling is recommended before initiating hormone therapy in women aged more than 30 years or in those older than 20 years with prolonged bleeding. Long-term estrogen stimulation in anovulatory patients can result in endometrial hyperplasia, which can result in endometrial carcinoma. This procedure is best done on the first day of menses to avoid an unexpected pregnancy. In the perimenopausal or postmenopausal woman, amenorrhea preceding abnormal bleeding suggests endometrial carcinoma. It is useful to obtain a transvaginal ultrasound prior to the endometrial biopsy because biopsy is often unnecessary if the endometrial stripe is less than 5 mm thick.
Diagnostic assessment (3)
Menorrhagia is defined as excessive menstrual flow. The definition of excessive varies widely among patients but “different” and “worrisome” to the patient appear to be important historical features. When excessive bleeding is regular, pregnancy and systemic illness must be excluded. Of menorrhagia, 90% of cases have no obvious cause and it is thought to be anovulatory or dysfunctional. Dysfunctional bleeding is usually not preceded by premenstrual (molimenal) symptoms. It is seen most frequently at the extremes of the reproductive years, after menarche and before the onset of menopause. Pregnancy must always be excluded as a cause in women of childbearing age. Excessive estrogen stimulation that occurs during anovulatory cycles can lead to endometrial hyperplasia and to carcinoma. Endometrial biopsy is indicated for most nonpregnant women with prolonged, irregular bleeding. Abnormal bleeding following amenorrhea in menopause is endometrial carcinoma until proved otherwise. Any pelvic mass occurring in the context of menorrhagia ought to be evaluated with ultrasound, CT, or magnetic resonance imaging. If confusion still exists, laparoscopy or hysteroscopy with saline infusion may be indicated.
References
1. Rosenfield J. Treatment of menorrhagia due to dysfunctional uterine bleeding. Am Fam Physician 1996;53:165–172.
2. Smith CB. Pinpointing the cause of abnormal uterine bleeding. Women’s Health in Primary Care 1998;1(10):835–844.
3. Nelson AL. A practical approach to dysfunctional uterine bleeding. Fam Prac Recertification 1997;19(8):14–39.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Pap Smear Abnormality:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
The cervix usually appears normal to the naked eye. Gross cervical abnormalities should prompt further evaluation. When present, discharge should be gently removed prior to the pap smear. Tests for sexually transmitted diseases, when indicated, should be obtained after the pap smear. If the cervix appears normal, vaginitis can be treated and the smear obtained after resolution of the discharge (5).
Testing
Evaluation of an abnormal pap smear may involve further testing or an attempt to diagnose and establish the extent of the lesion.
A. Repeat pap smear. Low grade lesions can be followed with serial testing. Although false–negative finding rates of 20% to 45% have been reported, rates as low as 10% have been reported, using conization specimens as the reference (1). Repeat testing at frequent intervals minimizes this risk.
B. Cervicography. Photographic evaluation of the cervix may have a sensitivity comparable to a pap smear, but it has much lower specificity (50%). A 10% to 15% rate of unsatisfactory cervicograms further limits the utility of this test (1). Current recommendations limit its use to experienced physicians who understand its limitations (2).
C. Human papillomavirus typing. HPV types 16, 18, 45, and 56 are strongly correlated with cervical cancer. Screening for HPV and HPV typing have been studied to identify high risk individuals. The positive predictive value of HPV screening is less than 10% (1), limiting its clinical usefulness. The role of typing as an adjunctive triage strategy remains under investigation.
Diagnostic assessment
A. Reactive changes associated with inflammation. Infectious causes (e.g., Candida sp., Trichomonas vaginalis, Gardnerella vaginalis, herpes simplex virus, or Chlamydia trachomatis) are common. The pathologist may be able to identify an offending organism or typical cytologic changes. However, the clinician must provide clinical correlation regarding symptoms and the need for treatment. No data support empiric therapy. The pap smear should be repeated in 3 to 6 months, regardless of cause or treatment (5).
B. Atypical squamous cells of uncertain significance (ASCUS). Multiple options are currently recommended based on the clinical setting and the patient’s risk. In a reliable patient, ASCUS can be followed with repeat cytology every 4 to 6 months for 2 years or until three consecutive, adequate, and negative smears are obtained. Recurrent ASCUS should be evaluated with colposcopy and biopsy (2,5). If the patient is postmenopausal or inflammation is present, a repeat pap smear after estrogen vaginal cream or appropriate antibiotic therapy can be considered (2). Close communication with the cytopathologist can clarify whether this process favors reactive or neoplastic changes and the relative incidence of neoplasia. ASCUS favoring a neoplastic process should be managed as a low grade squamous intraepithelial lesion (2).
C. Low grade squamous intraepithelial lesion frequently reverts to normal. In the appropriate clinical setting with a reliable patient, cytology every 4 to 6 months until three consecutive, adequate, and negative smears is appropriate. However, because of the high rate of false–negative cytology findings, further evaluation with colposcopy, including biopsy and endocervical curettage (ECC) (2,5), is appropriate. Unreliable or high risk patients should undergo more aggressive evaluation. After the entire lesion and transformation zone are visualized, the histologically confirmed lesion can be ablated, excised, or observed (5).
D. High grade squamous intraepithelial lesion. This category includes cancer in situ and moderate to severe dysplasia. Evaluation should include colposcopy, biopsy, and ECC. After identifying the entire lesion, excise or ablate the entire transformation zone (2,5).
E. Cancer. Cytology suggestive of invasive cancer should be evaluated with biopsy and referral to a physician experienced in the management of this disease.
F. Atypical glandular cells. Atypical glandular cells of undetermined significance (AGUS, AGCUS) should be subclassified according to favoring reactive process or neoplasia and by origin (endocervical or endometrial) (2). Endocervical atypia can be followed with colposcopy and ECC (5). If a neoplastic process is suspected, many believe that the best evaluation is diagnostic conization (2,5). Endometrial atypia should be evaluated by biopsy, hysteroscopy, or dilation and curretage (2,5).
References
1. US Preventive Services Task Force. Screening for cervical cancer. Guide to clinical preventive services, 2nd ed. Baltimore: Williams & Wilkins, 1996:105–117.
2. Kurman, RJ, Henson, DE, Herbst, AL, et al. Interim guidelines for management of abnormal cervical cytology. JAMA 1994;271:1866–1869.
3. Melnikow J, Nuovo J, Willan AR, et al. Natural history of cervical squamous intraepithelial lesions: a metaanalysis. Obstet Gynecol 1998;92:727–733.
4. Evaluation of cervical cytology. Summary, evidence report/technology assessment. No. 5. Rockville, MD: AHCPR, January 1999; http://www.ahcpr.gov/clinic/cervsumm.htm
5. American College of Obstetricians and Gynecologists. Cervical cytology: evaluation and management of abnormalities. Technical Bulletin No. 183. Washington, DC: American College of Obstetricians and Gynecologists, 1993.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Secondary Amenorrhea:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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
Prostate Abnormality:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
History helps in risk stratification: Men with a first degree relative with prostate cancer have a 2 to 3 fold increased incidence of prostate cancer. With 2 first degree relatives, this increases 5 to 8 fold.
The normal prostate is heart-shaped with a median raphe and a mass of 20 to 25 g. Carefully examine the posterior surfaces of the lateral lobes because this is where most prostate cancer originates. In screening for prostate cancer, digital rectal examination (DRE) looking for nodules, induration, or asymmetry may help to calibrate PSA values in the “gray zone” of 4 to 10. For example, a large gland may offer an explanation for a mildly elevated PSA, but a small gland or one with induration or asymmetry should heighten suspicion of prostate cancer. The positive predictive value for prostate cancer of an abnormal finding on DRE is 15% to 30%, increasing odds 1.5- to 2-fold. Because of low sensitivity, the value of a negative DRE to rule out prostate cancer is low. Men with an abnormality on DRE and a PSA ,4 still have a probability of prostate cancer of 12%, so biopsy is usually recommended. Examination followed by biopsy of any prostate nodule is the appropriate tactic because the clinical examination alone is not accurate enough in distinguishing benign causes from adenocarcinoma.
New suspicious findings on DRE in a patient with an initial negative baseline helps to select for aggressive tumors. Cancer found based on the first DRE has a 5 year prostate cancer mortality of 3% and 10 year mortality of 14%. Cancer found on a subsequent DRE has mortalities of 19% and 43% respectively.
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Source: Field Guide to Bedside Diagnosis, 2007
Amenorrhea:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Oligomenorrhea:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the physical assessment by taking the patient’s vital signs and weighing her. Inspect for increased facial hair growth, sparse body hair, male distribution of fat and muscle, acne, and clitoral enlargement. Note if the skin is abnormally dry or moist, and check hair texture. Also, be alert for signs of psychological or physical stress. Rule out pregnancy by a blood or urine pregnancy test.
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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.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Dysmenorrhea:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient complains of dysmenorrhea, have her describe it fully. Is it intermittent or continuous? Sharp, cramping, or aching? Ask where the pain is located and whether it's bilateral. When does the pain begin and end, and when is it severe? Does it radiate to the back? How long has she been experiencing the pain? If it's a recent complaint, obtain a human chorionic gonadotropin level to determine if the patient is or was pregnant, because miscarriage can cause painful bleeding. Explore associated signs and symptoms, such as nausea and vomiting, altered bowel or urinary habits, bloating, water retention, pelvic or rectal pressure, and unusual fatigue, irritability, or depression.
Then obtain a menstrual and sexual history. Ask the patient if her menstrual flow is heavy or scant. Have her describe vaginal discharge between menses. Does she experience pain during sexual intercourse? Does it occur with menses? Find out what relieves her cramps. Does she take pain medication? Is it effective? Note her method of contraception, and ask about a history of pelvic infection. Does she have signs and symptoms of urinary system obstruction, such as pyuria, urine retention, or incontinence? Determine how she copes with stress. Determine her risk of sexually transmitted diseases.
Next, perform a focused physical examination. Take the patient's vital signs, noting fever and accompanying chills. Inspect the abdomen for distention, and palpate for tenderness and masses. Note costovertebral angle tenderness.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Menorrhagia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
When the patient's condition permits, obtain a history. Determine her age at menarche, the duration of menses, and the interval between them. Establish the date of the patient's last menses, and ask about recent changes in her normal menstrual pattern. Have the patient describe the character and amount of bleeding. For example, how many pads or tampons does the patient use per period? Has she noted clots or tissue in the blood? Also ask about the development of other signs and symptoms before and during her menses.
Next, ask if the patient is sexually active. Does she use a method of birth control? If so, what kind? Could the patient be pregnant? Be sure to note the number of pregnancies, the outcome of each, and any pregnancy-related complications. Find out the dates of her most recent pelvic examination and Papanicolaou smear and the details of any previous gynecologic infections or neoplasms. Also, be sure to ask about previous episodes of abnormal bleeding and the outcome of any treatment. If possible, obtain a pregnancy history of the patient's mother, and determine if the patient was exposed in utero to diethylstilbestrol. (This drug has been linked to vaginal adenosis.)
Be sure to ask the patient about her general health and medical history. Note particularly if the patient or her family has a history of thyroid, adrenal, or hepatic disease; blood dyscrasias; or tuberculosis because these may predispose the patient to menorrhagia. Also, ask about the patient's past surgical procedures and recent emotional stress. Find out if the patient has undergone X-ray or other radiation therapy, because this may indicate prior treatment for menorrhagia. Obtain a thorough drug and alcohol history, noting the use of anticoagulants or aspirin. Prepare the patient for a pelvic examination, and obtain blood samples and urine specimens for pregnancy testing.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Metrorrhagia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin your evaluation by obtaining a thorough menstrual history. Ask the patient when she began menstruating, the duration of menses, the interval between them, and the average number of tampons or pads she uses each month. Establish when metrorrhagia occurs in relation to her menses. Does she experience other signs or symptoms? Find out the date of her last menses, and ask about other changes in her normal menstrual pattern. Ask for details of previous gynecologic problems. If applicable, obtain a contraceptive and obstetric history. Record the dates of her last Papanicolaou (Pap) smear and pelvic examination. Ask the patient if she is sexually active. Next, ask about her general health and any recent changes. Is she under emotional stress? If possible, obtain a pregnancy history of the patient's mother. Was the patient exposed in utero to diethylstilbestrol? (This drug has been linked to vaginal adenosis.)
Prepare the patient for a pelvic examination if indicated, and obtain blood samples and a urine specimen for pregnancy testing.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Oligomenorrhea:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
After asking the patient's age, find out when menarche occurred. Has the patient ever experienced normal menstrual cycles? When did she begin having abnormal cycles? Ask her to describe the pattern of bleeding. How many days does the bleeding last, and how frequently does it occur? Are there clots and tissue fragments in her menstrual flow? Note when she last had menses.
Next, determine if she's having symptoms of ovulatory bleeding. Does she experience mild, cramping abdominal pain 14 days before she bleeds? Is the bleeding accompanied by premenstrual symptoms, such as breast tenderness, irritability, bloating, weight gain, nausea, and diarrhea? Does she have cramping or pain with bleeding? Also, check for a history of infertility. Does the patient have children? Is she trying to conceive? Ask if she's currently using hormonal contraceptives or if she has ever used them in the past. If she has, find out when she stopped taking them.
Then ask about previous gynecologic disorders such as ovarian cysts. If the patient is breast-feeding, has she experienced problems with milk production? If she hasn't been breast-feeding recently, has she noticed milk leaking from her breasts? Ask about recent weight gain or loss. Is the patient less than 80% of her ideal weight? If so, does she claim that she's overweight? Ask if she's exercising more vigorously than usual.
Screen for metabolic disorders by asking about excessive thirst, frequent urination, or fatigue. Has the patient been jittery or had palpitations? Ask about headaches, dizziness, and impaired peripheral vision. Complete the history by finding out what drugs the patient is taking.
Begin the physical examination by taking the patient's vital signs and weighing her. Inspect for increased facial hair growth, sparse body hair, male distribution of fat and muscle, acne, and clitoral enlargement. Note if the skin is abnormally dry or moist, and check hair texture. Also, be alert for signs of psychological or physical stress. Rule out pregnancy by a blood or urine pregnancy test.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
As many as 20 to 50 percent of all women develop fibroids. These benign muscle tumors usually grow in the uterus, and can cause pain, and in some...
As many as 20 to 50 percent of all women develop fibroids. These benign muscle tumors usually grow in the uterus, and can cause pain, and in some...
Every year, thousands of woman suffering from abnormal uterine bleeding are told that their only option is hysterectomy. Some choose to undergo this...
Every year, thousands of woman suffering from abnormal uterine bleeding are told that their only option is hysterectomy. Some choose to undergo this...
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