Pediatric emergency medicine trisk 1014 1014
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nutritional deficits. It should be noted that diagnosis of stress as the cause of
oligomenorrhea is one of exclusion.
Pseudocyesis is a rare cause of amenorrhea in women who believe they are
pregnant and who exhibit many presumptive symptoms and signs of pregnancy,
including nausea, vomiting, hyperpigmented areolae, galactorrhea, and abdominal
distension. The diagnosis is made when a patient who insists that she is pregnant
nevertheless has no true uterine enlargement, no demonstrable fetal parts or heart
sounds, and a negative pregnancy test result. Psychiatric consultation should be
obtained for such patients.
APPROACH TO DIAGNOSIS
Patients with oligomenorrhea but few other symptoms or signs of disease may
require laboratory evaluation to differentiate among the many potential causes of
oligomenorrhea after pregnancy has been excluded. This workup is usually done
in an outpatient setting. Figure 51.1 outlines a strategy for initial emergency
diagnostic evaluation. Helpful labs to be obtained in the ED include TSH and
prolactin. An elevated TSH level points to hypothyroidism either as the cause of
oligomenorrhea or as a concomitant condition while a low TSH could point to
hyperthyroidism. An elevated prolactin level suggests a pituitary adenoma in nonbreastfeeding patients who are not taking any of the drugs known to cause
hyperprolactinemia and galactorrhea ( Table 51.3 ). For the purposes of the
emergency clinician, once pregnancy and life-threatening causes are ruled out,
patients can be referred to their primary care physician, adolescent physician, or
gynecologist for further evaluation. If an Emergency Provider were to send
additional labs to assist in the outpatient workup, the following would be helpful:
LH, FSH, free and total testosterone levels. The finding of a mildly elevated total
or free testosterone level constitutes strong evidence for a diagnosis of PCOS. A
total testosterone level of more than 200 ng per dL suggests an ovarian or adrenal
tumor. FSH values of more than 40 mIU per mL confirm ovarian failure. If the
laboratory evaluation discloses no abnormalities or only a low FSH level, the
patient likely has one of the many conditions that cause hypothalamic–pituitary
suppression.
