A 45-year-old woman comes to the office due to increasing difficulty sleeping for the past few months. She is unable to concentrate at work and is not exercising due to fatigue. The patient reports a 4.5-kg (9.9-lb) weight gain and is now unable to wear her normally fitting clothing. She has no mood changes, hair loss, weakness, or changes in bowel or bladder function. She has no chronic medical problems or previous surgeries. The patient's menstrual periods have become irregular over the last 2 years; her last period was 3 months ago. She is currently sexually active. She does not use tobacco, alcohol, or illicit drugs. Blood pressure is 120/70 mm Hg and pulse is 80/min. BMI is 31 kg/m². The patient has moist mucous membranes with normal capillary refill. There is no acanthosis nigricans. The abdomen is obese; there is no hepatosplenomegaly or ascites. On bimanual examination, the uterus is symmetrically enlarged. There are no palpable adnexal masses. Which of the following is the best next step in management of this patient?

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This patient has insomnia, fatigue, weight gain, amenorrhea, and an enlarged uterus consistent with pregnancy. Women begin the menopausal transition (ie, perimenopause) years before the final menstrual period and onset of menopause (average age 51). Ovulation still occurs during this time, and women may become pregnant despite lower conception rates. Symptoms of perimenopause include irregular menstrual periods, insomnia, fatigue, and weight gain, which often overlap with symptoms of early pregnancy. All women of reproductive age with amenorrhea and signs of pregnancy should be evaluated with an hCG level. (Choice A) Ovarian cancer may present with fatigue, increased abdominal circumference due to ascites, and weight loss (rather than weight gain). Physical examination findings include ascites and an adnexal mass, rather than a uniformly enlarged uterus. Evaluation of ovarian cancer includes an abdominal CT scan and pelvic ultrasound. (Choice B) Menopause can cause symptoms similar to those of pregnancy. However, patients typically have a decreased uterine size. Decreased ovarian function from menopause can be confirmed with an elevated FSH level. (Choice D) Nocturnal polysomnography evaluates for the presence of sleep disorders (eg, sleepwalking, nocturnal epilepsy). This patient's insomnia and fatigue are common in pregnancy and require no further evaluation. (Choice E) Thyroid disorders may present with fatigue and menstrual disturbances; diagnosis is with abnormal TSH levels. This patient does not have other typical symptoms of hypothyroidism - mood changes, hair loss, weakness, and changes in bowel function. In addition, thyroid disorders do not cause uterine enlargement. Educational objective: Pregnancy can present in a perimenopausal woman with insomnia, fatigue, weight gain, amenorrhea, and an enlarged uterus. Patients with amenorrhea and other signs of pregnancy should be evaluated with an hCG level. References: Perimenopausal conception. (http://www.ncbi.nlm.nih.gov/pubmed/14644814)

A 45-Year-Old Woman Comes to the Office Due to Increasing