A 42-year-old woman comes to the office for evaluation of amenorrhea for the past 3 months. She previously had relatively regular menses, typically occurring monthly with 4-5 days of moderate bleeding. The patient has had 1 or 2 irregular cycles each year, but usually went no more than 6-8 weeks without a menstrual period. She has had increasing fatigue and a 2.7-kg (6-lb) weight gain over the past few months, but has had no changes in vision or in heat or cold intolerance. She has no chronic medical conditions. The patient had a cesarean delivery with a bilateral tubal ligation 10 years ago.
Blood pressure is 130/80 mm Hg and pulse is 78/min. BMI is 23 kg/m². Cardiopulmonary examination is normal. The abdomen is soft and nontender. Pelvic examination reveals a uniformly enlarged, anteverted uterus; there are no adnexal masses.
Which of the following is the most likely diagnosis in this patient?

Question

Quizplus · Accepted Answer

Tubal sterilization (eg, bilateral tubal ligation) is considered an effective form of permanent contraception; however, failure rates are as high as 36 per 1,000 procedures. Therefore, regardless of sterilization status, a pregnancy test is performed in all reproductive-age women with secondary amenorrhea (>3 months in previously regular cycles or >6 months in previously irregular cycles). This patient's recent fatigue, weight gain, secondary amenorrhea, and uterine enlargement suggest early pregnancy. (Choice A) Adenomyosis typically presents in women age >40 with an enlarged, symmetrical uterus; however, patients have heavy, painful menses rather than amenorrhea. Adenomyosis (Choice B) Endometrial cancer typically presents as abnormal uterine bleeding in premenopausal patients with chronic unopposed estrogen exposure (eg, anovulation, obesity, polycystic ovary syndrome). This patient with a normal BMI had relatively regular menstrual cycles prior to amenorrhea, making this diagnosis unlikely. (Choice C) Patients with hypothyroidism can have fatigue, weight gain, and secondary amenorrhea. However, patients typically have concomitant bradycardia and cold intolerance, which are not seen in this patient. In addition, there is no associated uterine enlargement with hypothyroidism. (Choice D) Menopause is diagnosed in patients without menses ≥12 months, making this diagnosis unlikely. Educational objective: Common signs of early pregnancy include fatigue, weight gain, secondary amenorrhea, and uterine enlargement. A pregnancy test is indicated in all reproductive-age women regardless of sterilization status. __________ References: ACOG practice bulletin no. 133: benefits and risks of sterilization. (http://www.ncbi.nlm.nih.gov/pubmed/23344305) Amenorrhea: an approach to diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/23939500)

A 42-Year-Old Woman Comes to the Office for Evaluation of Amenorrhea