The reasons many patients have the anovulatory type of bleeding, the endocrine problems we see with thyroid, pituitary. Ovarian problems: they may have polycystic ovaries. Drugs such as many of the psychiatric drugs will create problems, related back to endocrine. Many of the psychiatric drugs will raise the prolactin and cause problems. Stress can cause changes in it. We all know about nutritional problems, especially in the bulimic patients that create menstrual problems such as amenorrhea, total amenorrhea and so forth.
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Thyroid problems we see both in the hyper and hypo thyroid. If the patient has any other symptoms of either, such as hyperthyroid - if she’s one of those patients that can get all her housework done and have time to go shopping and all the rest of that, then I get suspicious. They may be a little hyperthyroid, and if they are not gaining weight slowly over the decades, and you should. Your metabolism changes by about 2% every five years so that the natural history is that we gain about 5 to 10 pounds every decade of life. So if she is not into that group and she is able to get all her housework done and everything else, she may be a little bit on the hyperthyroid side. I’ve also seen several patients who came in because of dysfunctional bleeding that were hypothyroid. Their doctors had put them on thyroid medication, had gotten them balanced, then they found if they self-medicated a little bit - gee, I feel a little bit better and I can do a little bit more. And I had one that had a TSH of 0.3 or something like that. It was hard to convince her to stop self-medicating but we finally got her to do it. Her menstrual periods straightened out, her bleeding problems corrected. Hypothyroid; I look for those patients, especially those that are having trouble with more weight gain than you would expect. Ones that just don’t have the energy to get things done and so forth. Thyroid testing is really easy to do with a TSH and a 3T4. Order discount Clearitol
Adrenal problems, hyperplasia and tumors, are things we see. Patients who have anovulatory cycling, doing laboratory testing for this is very easy. It’s a simple blood test to do and if it’s normal you can pretty well count out the adrenal tumors and so forth. The test is DHEA sulfate. And that’s a simple test to order. If it comes back normal, you don’t have adrenal problems. Hypothalamic pituitary problems; we see failures. The classic is Sheehan’s postpartum necrosis of the pituitary gland. Other ones we see failure in: had a very interesting patient yesterday that was totally amenorrheic since the age of 28 because of a pituitary tumor and had acromegaly because of excessive growth hormone and so forth. She was totally … had a total pituitary failure because of treatment but nobody had ever thought to put her on estrogen replacement therapy. They had essentially made her a postmenopausal patient by destroying her pituitary with surgery and radiation but hadn’t treated her with hormones, and set her up for osteoporosis and heart disease and so forth that are the hallmarks of the postmenopausal patient.
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Neoplasias of the hypothalamic gland; doing serum prolactins is easy. Try and draw them in the morning. That’s when they are going to be at their highest level. Hyperprolactinemia’s are fairly frequent. You need to be careful in treating them with bromocriptine because of seizures, but I’ve only seen one patient in the 15 years I’ve been using bromocriptine that had seizures. Diabetic patients also have trouble with their endocrinologic system and also with their bleeding and their menses. One point I want to put out, which I put out to all medical students, oral contraceptives in the diabetic are extremely good. They are extremely safe. JAMA and all the internal medicine articles that are written show that they have no increase, in diabetic patients, no increase in insulin requirements, not increase in retinopathy, no increase in neuropathy of anything. But then they’ll still tell the patient, “Oh, no, you are diabetic. You shouldn’t be on birth control pills.” There’s nothing worse than having a pregnancy diabetic because they are very difficult to control and take care of. So birth control pills are good in this group for menstrual problems and so forth.
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