Amenorrhea in the athlete.

Amenorrhea in the athlete is commonly encountered in clinical practice. The work-up of an athlete with amenorrhea should include consideration of all the physiological and pathological conditions that give rise to amenorrhea in any adolescent. Delay or failure to recognize and manage these patients may result in the emergence of athletic triad with potential serious consequences of increased stress fractures, scoliosis, and thin body mass. This article reviews amenorrhea in the adolescent athlete with respect to body composition, disordered eating, osteoporosis, psychological factors, warning signs, treatment, and outcomes. Need for further strategies specific to prevention, surveillance, research, health consequences, medical care, and public and professional education is addressed.

Uterine myomas and factors associated with hysterectomy in premenopausal women.

OBJECTIVE: Our purpose was to describe clinical characteristics in premenopausal women with uterine myomas and to identify factors associated with hysterectomy. STUDY DESIGN: Data were collected by chart abstraction in 421 premenopausal women with myomas and analyzed by univariate and multivariable regression. RESULTS: Over a median follow-up period of 29 months, 86% of women had symptoms associated with myomas and 40% had an increase in uterine size of > 2 gestational weeks. By multivariable regression, bleeding symptoms at presentation and previous surgical history of cholecystectomy and adhesiolysis were significantly associated with greater odds of hysterectomy. There was a significant interaction between age and uterine size, so that as age increased, uterine size had a greater impact on the likelihood of hysterectomy. CONCLUSIONS: In this cohort of premenopausal women myomas were associated with symptoms in almost all women over the follow-up period. Hysterectomy was performed in 22% of women overall.

Anatomical variation in the rudimentary horns of a unicornuate uterus: implications for laparoscopic surgery.

A case of laparoscopic excision of a rudimentary horn is presented. The anatomical features of this case are contrasted with others in the published literature. A 23 year old nulligravida presented with severe dysmenorrhoea and a pelvic mass. At laparoscopy a unicornuate uterus with a rudimentary horn was identified. The patient had stage III endometriosis. The rudimentary horn was attached to the unicornuate uterus by a band of tissue. The blood supply was identified within this band of tissue. The rudimentary horn was removed laparoscopically with no complications. There are two anatomical variations in the attachment of the rudimentary horn to the unicornuate uterus. Knowledge of both types is important to avoid complications such as bleeding and possible compromise of myometrial wall thickness.

Prevalence of abnormal eating attitudes and behaviors in hospital-based primary and tertiary care clinics: a window of opportunity?

OBJECTIVE: The "athletic triad" of amenorrhea, osteopenia, and eating disorders (EDs) has received increasing attention in the past decade. Adolescents may seek care for amenorrhea or other menstrual irregularity before disclosure of an eating disorder to a primary care clinician. The purpose of this study was to determine the prevalence of abnormal eating attitudes and behaviors in adolescent girls going to a clinic for reproductive endocrinology (RE) visits versus the prevalence in girls going for health maintenance (HM) visits. DESIGN: All patients aged 8-22 years going to RE or HM clinics were given a 26-item modified eating attitudes test (EAT) and two pages of questions on other eating issues and demographics. Informed consent was obtained from all participants, and also from the parents of those less than 18 years of age. SETTING: All subjects were seen at a hospital-based ambulatory (HM) or subspecialty (RE) clinic, with both clinics located on the same floor. PARTICIPANTS: The study included 53 girls from the RE clinic and 108 girls from the HM clinic. All demographics were similar except that the RE patients were slightly older and had significantly more parents with masters or doctorate degrees. MAIN OUTCOME MEASURES: Study variables were compared between RE and HM groups using either the Student's t test or the Chi-square test, with statistical significance defined as p < 0.05. A score of 20 or higher on the modified EAT was correlated with a high risk of EDs and was used as a measure of prevalence of abnormal eating attitudes and behaviors. RESULTS: Modified EAT scores were 11.8 +/- 8.9 in RE patients vs 7.0 +/- 7.2 in HM patients (p < 0.001), with 10 (18.9%) RE patients and 7 (6.5%) HM patients having scores of at least 20 (p = 0.016). No differences in daily exercise, dairy consumption, or use of vomiting or laxatives to control weight were found. As expected, RE patients were significantly more likely to experience menstrual irregularities than the HM patients (p < 0.001). CONCLUSIONS: Adolescents attending a reproductive endocrinology clinic showed a higher prevalence of abnormal eating attitudes and behaviors than did those going to a clinic for HM visits. Early detection of eating disorders may occur both within and outside of the primary care setting through use of a modified EAT.

Depression, chronic fatigue, and the premenstrual syndrome.

Depression, chronic fatigue, and premenstrual syndrome often coexist in women seeking treatment for premenstrual distress. A reliable diagnosis can be made by prospectively rating symptoms for two cycles, taking a careful history, performing physical and gynecologic examinations, and obtaining basic laboratory test results and a psychosocial evaluation. Appropriate dietary, hormonal, or antidepressant treatment provided in a caring and competent manner can benefit many women suffering from this otherwise disabling/condition.

Gynecologic problems of androgen excess.

The patient with androgen excess may present with amenorrhea, oligomenorrhea, painless metromenorrhagia, or infertility. Adrenal and ovarian tumors, though uncommon, must be excluded in the workup. The long-term sequelae of untreated anovulation includes adenomatous hyperplasia and cancer of the endometrium. Treatment can range from uncomplicated follow-up with cosmetic advice to the use of potent drugs that induce ovulation.

Menstrual dysfunction in hirsute women.

Hirsutism in women is frequently associated with increased levels of androgens. Studies of biochemical changes, however, have yielded conflicting results. This study compares the findings in 30 hirsute women with normal menses and those of 30 hirsute women with abnormal cycles. Of the women with abnormal menstruation, 73% had oligoamenorrhea only and the others had dysfunctional uterine bleeding. The abnormally menstruating group had a similar mean age but tended to have heavier body weights than those with normal cycles. Free and total testosterone levels were significantly higher in the abnormal group (total testosterone, 54 +/- 35 ng/dl vs 35 +/- 12 ng/dl, p = 0.004; free testosterone, 7.8 +/- 4.9 pg/ml vs 4.2 +/- 1.4 pg/ml, p = 0.002). The abnormal group tended to have higher levels of androstenedione than the normal group (227 +/- 116 ng/dl vs 139 +/- 59 ng/dl) but dehydroepiandrosterone sulfate (DHEAS) levels were similar (320 +/- 142 mg/dl vs 298 +/- 169 pg/dl). Levels of thyroxin, thyrotropin, and prolactin were comparable in the two groups. Among hirsute women those with abnormal menses tended to be heavier and to have higher levels of total testosterone, free testosterone, and androstenedione. This is consistent with the clinical impression, not previously documented, that of hirsute women, those with abnormal menses have more severe endocrine abnormalities than those with normal cycles.

Treatment of androgenic disorders with dexamethasone: dose-response relationship for suppression of dehydroepiandrosterone sulfate.

Glucocorticoids are effective in suppressing androgens in many women whose levels of these steroids are elevated. Their use has been controversial because of inconsistent reports about efficacy and concern about safety. We investigated the dose-response relationship for suppression of dehydroepiandrosterone sulfate (DHEAS) with the use of dexamethasone. Thirty women with an initial DHEAS value of greater than or equal to 300 micrograms/dl were studied. All had cystic or inflammatory acne, hirsutism, or androgenic alopecia. Dexamethasone was given as a single bedtime dosage of 0.125, 0.250, or 0.375 mg. Mean dosage required for suppression was 0.256 mg daily. Suppression of the DHEAS level to less than or equal to 200 micrograms/dl was achieved with 0.125 mg in 25% of women, 0.250 mg in an additional 50%, and 0.375 mg in a further 20%. Most patients were taking spironolactone when the study was performed. Effective suppression is attained with dexamethasone doses significantly lower than previously thought. Use of these doses was not associated with a significant incidence of adverse effects.

Laparoscopic cauterization of endometriosis for fertility: a controlled study.

Ninety infertility patients with moderate endometriosis were randomized between laparoscopic electrocautery and 6 months of danazol therapy and studied for 7 months after treatment. Twenty of the 45 patients undergoing electrocautery conceived (44%) during the follow-up interval. Forty-one of the 45 patients in the danazol group completed the course of therapy, and 16 of those conceived (39%) during the same follow-up interval. There was no statistical difference between the two groups (P less than 0.53). No patients in the electrocautery group experienced complications. This demonstrates that electrocautery is safe and effective in the treatment of moderate endometriosis.

Vaginal bleeding in adolescents.

Abnormal vaginal bleeding in the teenage years usually has nonorganic causes; however, a careful elimination of organic causes is necessary before the diagnosis of dysfunctional uterine bleeding is made. The differential diagnosis in the case of such a complaint and a management plan are discussed.

PIP: This discussion of vaginal bleeding in adolescents reviews the causes of dysfunctional uterine bleeding (complications of pregnancy, pelvic inflammatory disease and/or complications of the use of oral contraceptives or IUDs, blood dyscrasias, trauma and foreign bodies, tumors, and other causes) as well as the diagnosis and treatment of dysfunctional uterine bleeding. Menstrual irregularities are the most common cause of abnormal vaginal bleeding in adolescence and can be managed easily in the office. On occasion an adolescent needs to be hospitalized for acute menorrhagia; very rarely a surgical procedure such as dilatation and curettage is necessary. Dysfunctional uterine bleeding is defined as abnormal uterine bleeding without local anatomic causes. It is a diagnosis of exclusion and requires an adequate examination of the vagina, cervix, and other pelvic organs. Some local bleeding presents as irregular vaginal bleeding in adolescents and is diagnosed as dysfunctional bleeding. The diagnosis of pregnancy and related complications (threatened abortion, incomplete or complete abortion, ectopic pregnancy, and postabortal trophoblastic disease) may present as irregular bleeding in the practitioner's office. A teenager may give a history of pregnancy if she is questioned about it closely and confidentially. A high index of suspicion will help the clinician to make this diagnosis. Salpingitis should be suspected in any teenager who presents with low abdominal tenderness, pain, abnormal bleeding, low grade fever, and tenderness on cervical movement. Approximately 10% of teenagers with blood dyscrasias present with cyclic hypermenorrhea. Vaginal ulcerations and objects introduced into the vagina occasionally cause irregular bleeding. Such tumors as clear cell adenocarcinoma of the vaginal and sarcoma botyroides may present as metrorrhagia. These etiologic factors comprise as most only about 5% of adolescents who complain of irregular vaginal bleeding. The most common cause of such bleeding is anovulation or oligoovulation due to the noncyclic release of follicle stimulating hormone (FSH) and luteinizing hormone (LH) during adolescence. Although the most common cause of this cyclic disturbance is the hypothalamic pituitary ovarian axis, some well known endocrine disorders can also produce this picture. 95-97% of adolescents will have no organic reason for their irregular bleeding. The diagnosis of dysfunctional uterine bleeding is then made. Detailed suggestions are provided on how to proceed which will prevent grave errors in the diagnosis and treatment of dysfunctional uterine bleeding in adolescents. The patient who has been bleeding very heavily and has a hematocrit less than 30 may have to be hospitalized. A medical D and C can be done with a progestational agent. Such patients may need a transfusion of packed cells and should be kept on oral iron. They also need cycling with Ovral for 2-3 months and must be followed carefully.

Osteopenia in hypoestrogenic young women with anorexia nervosa.

Replacement estrogen therapy for premenopausal women with secondary hypogonadism (exercise/weight loss amenorrheas) remains controversial. In a group of 14 women with anorexia nervosa, amenorrhea, and no evidence of other endocrinopathy or protein-calorie malnutrition, significant osteopenia was demonstrated as assessed by cortical thickness of carpal bones. The degree of bone thinning was related to the duration and age at onset of amenorrhea as well as abnormalities of pubertal milestone progression. In the young women with "constitutionally delayed" menarche, or with secondary amenorrhea and hypogonadism, significant osteopenia may also be present. For those women with (1) hypoestrogenism and amenorrhea of over 36 months' duration, (2) pubertal delay, and (3) early onset of secondary amenorrhea, evaluation of osteopenia radiographically, and serious consideration for estrogen replacement, is important.

The "luteal breast": hormonal and sonographic investigation of benign breast disease in patients with cyclic mastalgia.

The pathophysiology, malignant potential, and hormonal therapy for benign breast disease remain controversial. This report investigates the anatomic and endocrinologic correlates of luteal phase mastodynia patients, compared with asymptomatic control subjects. Objective sonographic evidence of fibrocystic disease (FCD) was found in one-half of both mastodynia and control groups. Endocrine abnormalities observed in the mastodynia group included (1) significantly lower luteal phase progesterone and (2) prolactin hyperresponsiveness to thyroid-releasing factor. The presence or absence of anatomic FCD was not correlated with endocrine abnormalities. These data suggest that (1) cyclic mastalgia may be the end result of a dyshormonal milieu resembling the inadequate luteal phase; (2) FCD may be hormonally independent; and (3) cyclic mastalgia and FCD are different, if often coexistent, factors in benign breast disease syndromes.

Prolactin-secreting pituitary adenoma: occurrence following prenatal exposure to diethylstilbestrol.

PIP: A case is reported of a prolactin-secreting pituitary adenoma in a young woman who had been referred for evaluation of amenorrhea with a history of in utero exposure to diethylstilbestrol. Following prolactin suppression ans stimulation tests bromocriptine (Parlodel), 2.5 mg orally, twice a day was prescribed. Followup at 1, 2, and 3 years after diagnosis with the use of sector scans of the sella turcica showed a decrease in size of the tumor from 12 x 12 mm in 1980 to 9 x 6 in 1982, over 50% reduction. Serum prolactin level measured 3 months after initiation of treatment was reduced by about 2/3 to 124 ng/ml. The direct role of estrogen in pituitary tumorigenesis in animals has been suggested both by the demonstration of estrogen receptors in the cytosol of estrogen-induced prolactinomas and growth inhibition of a transplantable estrogen-induced prolactin-secreting pituitary tumor by the administration of tamoxifen. In this case bromocriptine, a dopaminergic agonist, was successful in reducing both serum prolactin levels and tumor size.^ieng