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.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Nipple discharge:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency.
Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last menses. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for any risk factors of breast cancer—family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.
Start your physical examination by characterizing the discharge. If the discharge isn’t frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; and with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d’orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.
Is the patient taking hormones (hormonal contraceptives or hormone replacement therapy)? Is the discharge spontaneous, or does it have to be expressed?
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Nipple Discharge:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Presentation. How old is the patient? When and how was the discharge first discovered? Discharges that have been apparent for longer periods of time are more likely to be benign. The risk of cancer increases with advancing age.
B. Discharge characteristics. What is the color and consistency of the discharge? Is the discharge spontaneous or associated with manipulation or sexual activity only? Is the discharge unilateral or bilateral, uniductal or multiductal? What part of the nipple is affected?
1. A bloody, red discharge or a discharge that has the appearance of old blood is suggestive of, but not specific to, breast cancer.
2. A spontaneous, unilateral, uniductal discharge raises the level of suspicion for cancer. This does not exclude cancer from the differential diagnosis in the multiductal presentation.
C. Pain. Cyclic pain suggests a physiologic cause. Continuous pain and burning may indicate pathology related to inflammation (e.g., ductal ectasia or infection).
D. Reproductive history. What is the patient’s menstrual history? Has she had a recent pregnancy or abortion? Amenorrhea or irregular menses in a premenopausal woman with a nipple discharge suggests the need to evaluate the patient for pregnancy, hypothyroidism, or a disruption of the hypothalamic-pituitary axis (Chapters 11.1 and 11.5).
E. Medical history. Is there a history of significant chest wall trauma? Is there a recent history of herpes zoster infection? Does she have a history of atopic dermatitis? Does the patient have a history of breast cancer or breast surgery?
1. Chest wall trauma (e.g., a thoracotomy) and herpes zoster infection have been reported to cause nipple discharge.
2. Any systemic disease that affects the hypothalamic-pituitary axis or alters the clearance of prolactin can result in hyperprolactinemia. Visual disturbance or headache can be associated with the presence of a pituitary adenoma.
F. Medication. Is the patient taking any medications? Offending agents include:
1. Phenothiazines, haloperidol, and numerous other antipsychotics
2. Tricyclic antidepressants, benzodiazepines, selective serotonin reuptake inhibitors
3. Metoclopramide, cimetidine
4. Reserpine, methyldopa, digitalis, verapamil
5. Oral contraceptives, estrogens, progestins
6. Heroin, marijuana, amphetamines, cocaine
7. Isoniazid, danazol
G. Activity and lifestyle. Is the patient a jogger or does she participate in aerobic exercise? Does she smoke; if so, how much? Has the patient deliberately manipulated or traumatized the nipple? Friction of clothing on the nipple can create discharge, bleeding, and tenderness, which can result in bleeding, crusting, or traumatic erosions. Smoking increases the risk of cancer and ductal ectasia.
H. Family history. Is there a family history of breast cancer?
I. Review of symptoms. A review of systems for thyroid, renal, liver, adrenal, or pituitary disease should be included in the query. Ask about visual disturbances or headache, which can be associated with a pituitary adenoma.
Physical examination
A. Clinical breast examination (Chapter 11.2)
1. Inspection. Observe the skin of the breast for crusting or a rash on the nipple or areolar region. Document the color of any discharge. Look for evidence of nipple retraction. Locate the site of the discharge on the nipples. Magnification can assist localization. Look for chest wall scars, evidence of viral infections (e.g., herpes zoster or simplex), and signs of eczema or inflammation.
2. Palpation. Feel the skin surface for warmth in the presence of erythema. Palpate both breasts for evidence of a mass or tenderness. Palpate regional nodes for evidence of lymphadenopathy (Chapters 11.2 and 15.2).
3. Compression. Compress the nipple and areolar area of both breasts with the thumb and index finger in an effort to elicit a discharge. Perform this examination in several directions. Note the location of any discharge and the number of ducts involved, as well as whether the discharge is unilateral or bilateral.
B. Other examination components. Palpate the thyroid and liver if history indicates the need. Perform a neurologic examination, including visual fields, in patients with visual disturbance or headache.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
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).
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Nipple discharge:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency. Is the patient taking hormones (hormonal contraceptives or hormone replacement therapy)? Is the discharge spontaneous, or does it have to be expressed?
Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last menses. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for any risk factors of breast cancer — family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.
» READ BOOK EXCERPT ONLINE »
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
Nipple discharge:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Is the discharge spontaneous or does it have to be expressed? Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency. Ask about other symptoms, such as fever and malaise.
Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last menses. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for risk factors of breast cancer—family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.
Is the patient taking hormones (such as hormonal contraceptives or hormone replacement therapy), antihypertensives, or psychotropic drugs?
Start your physical examination by characterizing the discharge. If the discharge isn't frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d'orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.
» 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.
Tumors in the pituitary can release hormones that wreak havoc throughout the body. Listen to experts explain why shrinking tumors is an important...
What causes cancer and why is it so hard to treat? Leading experts provide an overview of cancer, from what goes wrong in a cell's genetic...
We all know how a restless night can lead to a terrible day. Everyday tasks become difficult; we get irritable and just feel crummy. But why?...
Germs are a fact of life and catching an infectious disease like a cold may seem inevitable. But there are simple ways to protect yourself against...