The Clinical Case
I saw a female patient in her early thirties seeking medical attention for a chronic history of an irregular menstrual cycle. The patient had not had menses in six months and had been diagnosed with polycystic ovarian syndrome (PCOS) several years ago.
After reviewing my notes, I realized her symptoms were not consistent with those of a typical PCOS patient. Although she was a little overweight and had irregular menses, she did not have hirsutism, commonly associated with PCOS, and she mentioned experiencing hot flashes, a symptom uncharacteristic of a patient with PCOS.
I couldn't help but wonder if the presence of amenorrhea and hot flashes were an indication that the initial diagnosis had been incorrect, so I turned to UpToDate.
Diagnosis and Treatment
My initial search in UpToDate for a general workup of amenorrhea resulted in a recommendation to check hCG and evaluate the patient's FSH levels. I ordered a set of labs, and the results showed a negative hCG and elevated FSH levels. Based on this new information, I suspected that the patient could be presenting with signs of primary ovarian insufficiency, which is less common than PCOS.
"UpToDate helped me deliver a correct diagnosis quickly and saved my patient the anxiety of waiting to see a specialist for answers and a further delay in appropriate management."
— Dr. Beth Klug, Second-year resident in Family Medicine, VCU/Riverside Family Medicine, Virginia
Since the first FSH came back just slightly high, but not in the postmenopausal range, I repeated the FSH to rule out a lab abnormality. Based on the recommendations in UpToDate, I also ordered an estradiol, a PRL, and a TSH. The second FSH came back in the postmenopausal range and the estradiol was low. This new data supported a diagnosis of primary ovarian insufficiency, and I was able to counsel my patient accordingly.
Primary ovarian insufficiency can be a devastating diagnosis for a young woman, particularly if she is planning a future pregnancy. People with PCOS have difficulty getting pregnant, but it's a possibility. With primary ovarian insufficiency, this woman will likely never be able to become pregnant because her ovaries have shut down.
Now that she has a proper diagnosis, we can provide supplemental hormones like estrogen and progesterone to help her avoid health issues, like osteoporosis, later in life.
Trust in UpToDate
UpToDate helped me deliver a correct diagnosis quickly and saved my patient the anxiety of waiting to see a specialist for answers and a further delay in appropriate management.
"As residents, my colleagues and I use UpToDate because it's an easy, fast resource to help us make the right decisions for our patients... We trust UpToDate because it is tried, true, and tested."
— Dr. Beth Klug
In fact, when I referred her case to a reproductive endocrinologist, she was surprised that (a) I had known to repeat the FSH to ensure that it was really primary ovarian insufficiency and not just a lab abnormality, and (b) I had done a full hormonal work-up to rule out other causes of amenorrhea.
As residents, my colleagues and I use UpToDate because it's an easy, fast resource to help us make the right decisions for our patients. It's fully referenced and we can easily see the clinical evidence behind each recommendation. These references are also a great starting point for formal clinical research assignments. We trust UpToDate because it is tried, true, and tested.
Dr. Klug attended Eastern Virginia Medical School (EVMS) in Norfolk, VA, did her residency in Family Medicine at VCU/Riverside Family Medicine in Newport News, VA, and currently works as a Hospitalist at Riverside Hospital in Newport News.
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