A 42-year-old woman comes to the office due to night sweats and insomnia. For the past month, the patient has awakened soaked with sweat almost every night, despite having turned down the thermostat. She has also had difficulty concentrating at work and controlling her emotions, which is putting a strain on her marriage. The patient has had irregular menstrual periods for the past 6 months. She has a history of hypertension controlled with medication. The patient quit smoking 5 years ago and does not use illicit drugs. She typically has an alcoholic beverage before bedtime. Temperature is 36.7 C (98.1 F), blood pressure is 140/90 mm Hg, pulse is 80/min, and respirations are 14/min. Examination of the skin is normal and there is no periorbital edema. The thyroid is nonenlarged and nontender, and there are no masses. Abdominal examination is normal. The uterus is small and anteverted. There are no palpable adnexal masses. Urine pregnancy test is negative. Which of the following is the best next step in management of this patient?

Question

A 42-year-old woman comes to the office due to night sweats and insomnia.  For the past month, the patient has awakened soaked with sweat almost every night, despite having turned down the thermostat.  She has also had difficulty concentrating at work and controlling her emotions, which is putting a strain on her marriage.  The patient has had irregular menstrual periods for the past 6 months.  She has a history of hypertension controlled with medication.  The patient quit smoking 5 years ago and does not use illicit drugs.  She typically has an alcoholic beverage before bedtime.  Temperature is 36.7 C (98.1 F), blood pressure is 140/90 mm Hg, pulse is 80/min, and respirations are 14/min.  Examination of the skin is normal and there is no periorbital edema.  The thyroid is nonenlarged and nontender, and there are no masses.  Abdominal examination is normal.  The uterus is small and anteverted.  There are no palpable adnexal masses.  Urine pregnancy test is negative.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d9c9_2e1a_bc81_b1a1f248b731_MD0003_00 This 42-year-old woman with irregular menstrual periods for the past 6 months has abnormal uterine bleeding (AUB). With the addition of vasomotor symptoms (eg, night sweats) and cognitive changes (eg, difficulty concentrating), her presentation is suggestive of menopause; however, menopause most commonly occurs at age ≥45 (average age 51). In younger patients, other etiologies of AUB (including pregnancy) require consideration; therefore, this 42-year-old patient requires an age-based evaluation as follows: Women age ≥45 with AUB and classic menopausal symptoms (eg, hot flashes) are most likely in menopause, a clinical diagnosis that requires no additional testing. These patients may benefit from hormone replacement therapy and patient education on menopause (Choices D and E). Select patients within this age group who have additional signs of thyroid disorder (eg, tachycardia, goiter) or hyperprolactinemia (eg, galactorrhea) should undergo measurement of TSH and prolactin levels. In contrast, menopause is a less common cause of AUB in women age <45, even in patients with classic menopausal symptoms. An underlying endocrine disorder causing AUB must first be excluded. Therefore, patients in this age group require measurement of FSH (to assess for hypothalamic amenorrhea), TSH (to assess for thyroid disorder), and prolactin (to assess for hyperprolactinemia). (Choice A) Measurement of 24-hour urinary catecholamines can be used to diagnose pheochromocytoma, an uncommon cause of night sweats and hypertension. Other symptoms of pheochromocytoma (eg, tachycardia, palpitations, weight loss) that indicate adrenergic hyperstimulation are not seen in this patient. (Choice C) Urine toxicology screening can identify illicit drugs (eg, cocaine) that can cause diaphoresis, insomnia, and difficulty concentrating. However, illicit drug use does not typically present with irregular menses. Educational objective: Women age ≥45 with abnormal uterine bleeding and classic menopausal symptoms (eg, night sweats, insomnia, difficulty concentrating) are likely in menopause and require no additional testing. In contrast, women age <45 with these symptoms require FSH, TSH, and prolactin levels to exclude an underlying endocrine disorder (eg, hyperthyroidism). References: Amenorrhea: a systematic approach to diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/31259490) Biomarkers in abnormal uterine bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/30388215)

A 42-Year-Old Woman Comes to the Office Due to Night