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== Overview ==
==Overview==
[[Menopause]] should be differentiated from other [[diseases]] presenting with [[menstrual irregularities]] ([[oligomenorrhea]]/[[amenorrhea]]).<ref name="pmid9541295">{{cite journal |vauthors=Sato N, Sze G, Endo K |title=Hypophysitis: endocrinologic and dynamic MR findings |journal=AJNR Am J Neuroradiol |volume=19 |issue=3 |pages=439–44 |year=1998 |pmid=9541295 |doi= |url=}}</ref><ref name="pmid7758238">{{cite journal |vauthors=Powrie JK, Powell M, Ayers AB, Lowy C, Sönksen PH |title=Lymphocytic adenohypophysitis: magnetic resonance imaging features of two new cases and a review of the literature |journal=Clin. Endocrinol. (Oxf) |volume=42 |issue=3 |pages=315–22 |year=1995 |pmid=7758238 |doi= |url=}}</ref><ref name="pmid26262437">{{cite journal |vauthors=Honegger J, Schlaffer S, Menzel C, Droste M, Werner S, Elbelt U, Strasburger C, Störmann S, Küppers A, Streetz-van der Werf C, Deutschbein T, Stieg M, Rotermund R, Milian M, Petersenn S |title=Diagnosis of Primary Hypophysitis in Germany |journal=J. Clin. Endocrinol. Metab. |volume=100 |issue=10 |pages=3841–9 |year=2015 |pmid=26262437 |doi=10.1210/jc.2015-2152 |url=}}</ref><ref name="pmid7629223">{{cite journal |vauthors=Thodou E, Asa SL, Kontogeorgos G, Kovacs K, Horvath E, Ezzat S |title=Clinical case seminar: lymphocytic hypophysitis: clinicopathological findings |journal=J. Clin. Endocrinol. Metab. |volume=80 |issue=8 |pages=2302–11 |year=1995 |pmid=7629223 |doi=10.1210/jcem.80.8.7629223 |url=}}</ref><ref name="pmid8345854">{{cite journal |vauthors=Imura H, Nakao K, Shimatsu A, Ogawa Y, Sando T, Fujisawa I, Yamabe H |title=Lymphocytic infundibuloneurohypophysitis as a cause of central diabetes insipidus |journal=N. Engl. J. Med. |volume=329 |issue=10 |pages=683–9 |year=1993 |pmid=8345854 |doi=10.1056/NEJM199309023291002 |url=}}</ref><ref name="pmid21668725">{{cite journal |vauthors=Hsieh CY, Liu BY, Yang YN, Yin WH, Young MS |title=Massive pericardial effusion with diastolic right ventricular compression secondary to hypothyroidism in a 73-year-old woman |journal=Emerg Med Australas |volume=23 |issue=3 |pages=372–5 |year=2011 |pmid=21668725 |doi=10.1111/j.1742-6723.2011.01425.x |url=}}</ref><ref name="pmid9747750">{{cite journal |vauthors=Dejager S, Gerber S, Foubert L, Turpin G |title=Sheehan's syndrome: differential diagnosis in the acute phase |journal=J. Intern. Med. |volume=244 |issue=3 |pages=261–6 |year=1998 |pmid=9747750 |doi= |url=}}</ref>
[[Menopause]] should be differentiated from other [[diseases]] presenting with [[menstrual irregularities]] ([[oligomenorrhea]]/[[amenorrhea]]).


==Differential diagnosis of menopause from other diseases==
==Differential diagnosis of menopause from other diseases==
<small>
<small>
{| class="wikitable"
{| class="wikitable"
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|Acute
|Acute
|<nowiki>++</nowiki>
|<nowiki>++</nowiki>
| ++
| ++
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|Symptoms of:
|Symptoms of:
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*[[Breast tissue]] [[atrophy]]
*[[Breast tissue]] [[atrophy]]


* Decreased [[axillary]] and [[pubic]] hair growth
*Decreased [[axillary]] and [[pubic]] hair growth
|
|
*[[Pancytopenia]]
*[[Pancytopenia]]
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*[[Hyponatremia]]
*[[Hyponatremia]]


* Low [[fasting plasma glucose]]
*Low [[fasting plasma glucose]]


* Decreased levels of [[anterior pituitary]] [[hormones]] in blood
*Decreased levels of [[anterior pituitary]] [[hormones]] in blood


|
|
* Clinical diagnosis
*Clinical diagnosis


* Most senitive test: Low baseline [[prolactin]] levels w/o response to [[Thyrotropin-releasing hormone|TRH]]
*Most senitive test: Low baseline [[prolactin]] levels w/o response to [[Thyrotropin-releasing hormone|TRH]]
|CT/MRI:  
|CT/MRI:  


* Sequential changes of pituitary enlargement followed by:
*Sequential changes of pituitary enlargement followed by:
* Shrinkage and [[necrosis]] leading to decreased sellar volume or [[empty sella]]
*Shrinkage and [[necrosis]] leading to decreased sellar volume or [[empty sella]]
|
|
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
*Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
|-
![[Lymphocytic hypophysitis]]
![[Lymphocytic hypophysitis]]
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|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
|
* Associated with [[autoimmune]] conditions
*Associated with [[autoimmune]] conditions


* Generalized [[headache]]
*Generalized [[headache]]


* Retro-orbital or Bitemporal [[pain]]
*Retro-orbital or Bitemporal [[pain]]


* Mass lesion effect such as [[Visual field defect|visual field defects]]
*Mass lesion effect such as [[Visual field defect|visual field defects]]
|
|
*[[Diabetes insipidus|DI]]
*[[Diabetes insipidus|DI]]
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*[[Autoimmune]] [[thyroiditis]]
*[[Autoimmune]] [[thyroiditis]]
|
|
* Decreased pituitary hormones([[Gonadotropins]] most common)
*Decreased pituitary hormones([[Gonadotropins]] most common)


*[[Hyperprolactinemia]](40%)
*[[Hyperprolactinemia]](40%)
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*[[CT]] & [[MRI]]: Features of a [[Pituitary gland|pituitary]] [[mass]]
*[[CT]] & [[MRI]]: Features of a [[Pituitary gland|pituitary]] [[mass]]


* Diffuse and homogeneous contrast enhancement
*Diffuse and homogeneous contrast enhancement
|[[Assay|Assays]] for:
|[[Assay|Assays]] for:


* Anti-TPO
*Anti-TPO
* Anti-Tg Ab
*Anti-Tg Ab
|-
|-
![[Pituitary apoplexy]]
![[Pituitary apoplexy]]
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|Severe [[headache]]
|Severe [[headache]]
*[[Nausea and vomiting]]
*[[Nausea and vomiting]]
* Paralysis of eye muscles ([[diplopia]])
*Paralysis of eye muscles ([[diplopia]])
* Changes in vision
*Changes in vision
|
|
*[[Visual acuity]] defects
*[[Visual acuity]] defects
Line 112: Line 113:


|
|
* Decreased levels of [[anterior]] pituitary hormones in blood.
*Decreased levels of [[anterior]] pituitary hormones in blood.
|
|
*[[Magnetic resonance imaging|MRI]]
*[[Magnetic resonance imaging|MRI]]
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*[[Headache]]
*[[Headache]]


* Low [[libido]]
*Low [[libido]]


|
|
* Signs of raised [[intracranial pressure]] may be present
*Signs of raised [[intracranial pressure]] may be present


*[[Nipple discharge|Nipple]] discharge
*[[Nipple discharge|Nipple]] discharge
|
|
* Decreased levels of pituitary hormones in the blood.
*Decreased levels of pituitary hormones in the blood.
|
|
*[[MRI]]
*[[MRI]]
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*[[Empty sella]] containing [[Cerebrospinal fluid|CSF]]
*[[Empty sella]] containing [[Cerebrospinal fluid|CSF]]
|
|
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
*Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
|-
![[Simmond's Disease|Simmonds' disease]]/[[Pituitary]] [[cachexia]]
![[Simmond's Disease|Simmonds' disease]]/[[Pituitary]] [[cachexia]]
|Chronic
|Chronic
|<nowiki>+/-</nowiki>
|<nowiki>+/-</nowiki>
| +
| +
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|[[Oligomenorrhea|Oligo]]/[[amenorrhea]]
|
|
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*[[Premature aging|Premature]] aging
*[[Premature aging|Premature]] aging
|
|
* Progressive [[emaciation]]
*Progressive [[emaciation]]


* Loss of body hair
*Loss of body hair
|
|
* Decreased levels of anterior pituitary hormones in the blood.
*Decreased levels of anterior pituitary hormones in the blood.
|
|
*[[Magnetic resonance imaging|MRI]]
*[[Magnetic resonance imaging|MRI]]
|
|
* Done to rule out any pituitary cause
*Done to rule out any pituitary cause
|
|
* Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
*Pituitary hormone stimulation tests ([[Metoclopramide]] and [[clomiphene citrate]] stimulation tests)
|-
|-
![[Primary hypothyroidism|Hypothyroidism]]
![[Primary hypothyroidism|Hypothyroidism]]
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|[[Oligomenorrhea]]/[[menorrhagia]]
|[[Oligomenorrhea]]/[[menorrhagia]]
|
|
* Cold intolerance
*Cold intolerance
*[[Constipation]]
*[[Constipation]]
|
|
* Dry skin
*Dry skin


*[[Bradycardia]]
*[[Bradycardia]]


* Hair loss
*Hair loss


*[[Myxedema]]
*[[Myxedema]]


* Delayed relaxation phase of deep [[Tendon reflex|tendon reflexes]]
*Delayed relaxation phase of deep [[Tendon reflex|tendon reflexes]]
|
|
* Low [[T3]],[[T4]]
*Low [[T3]],[[T4]]


|
|
*[[TSH]] levels
*[[TSH]] levels
|
|
* Done to rule out any pituitary cause
*Done to rule out any pituitary cause
|
|
*Assays for anti-TPO and anti-Tg Ab
*Assays for anti-TPO and anti-Tg Ab
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*[[Hot flushes]]
*[[Hot flushes]]


* Energy and mood changes
*Energy and mood changes


* Decreased [[libido]]
*Decreased [[libido]]
|
|
*[[Breast tissue]] [[atrophy]]
*[[Breast tissue]] [[atrophy]]
* Decreased [[maturation]] of [[vaginal]] [[mucosa]]
*Decreased [[maturation]] of [[vaginal]] [[mucosa]]
|
|
* Low [[estrogen]], [[testosterone]]
*Low [[estrogen]], [[testosterone]]


* High [[FSH]]/[[Luteinizing hormone|LH]]
*High [[FSH]]/[[Luteinizing hormone|LH]]
|
|
*[[FSH]]
*[[FSH]]
*[[Luteinizing hormone|LH]]
*[[Luteinizing hormone|LH]]
|
|
* Done to rule out any pituitary cause
*Done to rule out any pituitary cause
|
|
* Genetic tests  ([[karyotype]])
*Genetic tests  ([[karyotype]])
* Measurement of total and free [[testosterone]] and [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] concentrations
*Measurement of total and free [[testosterone]] and [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] concentrations
|-
|-
!Hypoprolactinemia
!Hypoprolactinemia
Line 235: Line 236:
|
|
*[[Infertility]]
*[[Infertility]]
* Subfertility
*Subfertility
|
|
* Puerperal agalactogenesis
*Puerperal agalactogenesis
|
|
* No workup is necessary
*No workup is necessary
|
|
* Decreased prolactin levels
*Decreased prolactin levels
|
|
* Done to rule out any pituitary cause
*Done to rule out any pituitary cause
|
|
*[[Prolactin]] assay in [[3rd trimester]]
*[[Prolactin]] assay in [[3rd trimester]]
Line 260: Line 261:


*[[Polydipsia]]
*[[Polydipsia]]
* Features of [[hypothyroidism]] and [[hypoadrenalism]]
*Features of [[hypothyroidism]] and [[hypoadrenalism]]
|
|
*[[Growth failure]]
*[[Growth failure]]


* B/L [[hemianopsia]]
*B/L [[hemianopsia]]


*[[Papilledema]]
*[[Papilledema]]
|
|
* All pituitary hormones decreased
*All pituitary hormones decreased
|
|
*[[Magnetic resonance imaging|MRI]]
*[[Magnetic resonance imaging|MRI]]
|
|
* Done to rule out any pituitary cause
*Done to rule out any pituitary cause
|
|
* Left hand and wrist [[radiograph]] for [[bone age]]
*Left hand and wrist [[radiograph]] for [[bone age]]
|-
|-
![[Primary adrenal insufficiency]]/[[Addison's disease]]
![[Primary adrenal insufficiency]]/[[Addison's disease]]
|Chronic
|Chronic
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| -
| -
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
|
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*[[Hyperpigmentation]]
*[[Hyperpigmentation]]


* loss of [[pubic]] and [[axillary]] hair
*loss of [[pubic]] and [[axillary]] hair


|
|
Line 297: Line 298:
*[[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]]
*[[Plasma renin activity]] to [[Aldosterone|aldosterone ratio]]
|
|
* Abdominal [[Computed tomography|CT]]
*Abdominal [[Computed tomography|CT]]
|
|
* Abdominal [[Computed tomography|CT]]
*Abdominal [[Computed tomography|CT]]
|
|
* Serum [[cortisol]] testing
*Serum [[cortisol]] testing


* Serum [[ACTH]] testing
*Serum [[ACTH]] testing


* Anti-adrenal [[Antibody|Ab]] testing
*Anti-adrenal [[Antibody|Ab]] testing
|-
|-
![[Menopause]]
![[Menopause]]
Line 316: Line 317:
*[[Insomnia]]
*[[Insomnia]]
*[[Weight gain]] and [[bloating]]
*[[Weight gain]] and [[bloating]]
* Mood changes
*Mood changes
|
|
*[[Vaginal atrophy]]
*[[Vaginal atrophy]]
* Loss of pelvic [[muscle tone]]
*Loss of pelvic [[muscle tone]]
|
|
* ↑ [[FSH]]
*↑ [[FSH]]
* ↓ [[Estradiol]] and [[inhibin]]
*↓ [[Estradiol]] and [[inhibin]]
|
|
*[[FSH]] > [[LH]]
*[[FSH]] > [[LH]]
Line 330: Line 331:
|}
|}
<small>
<small>
 
<ref name="pmid9541295">{{cite journal |vauthors=Sato N, Sze G, Endo K |title=Hypophysitis: endocrinologic and dynamic MR findings |journal=AJNR Am J Neuroradiol |volume=19 |issue=3 |pages=439–44 |year=1998 |pmid=9541295 |doi= |url=}}</ref><ref name="pmid7758238">{{cite journal |vauthors=Powrie JK, Powell M, Ayers AB, Lowy C, Sönksen PH |title=Lymphocytic adenohypophysitis: magnetic resonance imaging features of two new cases and a review of the literature |journal=Clin. Endocrinol. (Oxf) |volume=42 |issue=3 |pages=315–22 |year=1995 |pmid=7758238 |doi= |url=}}</ref><ref name="pmid26262437">{{cite journal |vauthors=Honegger J, Schlaffer S, Menzel C, Droste M, Werner S, Elbelt U, Strasburger C, Störmann S, Küppers A, Streetz-van der Werf C, Deutschbein T, Stieg M, Rotermund R, Milian M, Petersenn S |title=Diagnosis of Primary Hypophysitis in Germany |journal=J. Clin. Endocrinol. Metab. |volume=100 |issue=10 |pages=3841–9 |year=2015 |pmid=26262437 |doi=10.1210/jc.2015-2152 |url=}}</ref><ref name="pmid7629223">{{cite journal |vauthors=Thodou E, Asa SL, Kontogeorgos G, Kovacs K, Horvath E, Ezzat S |title=Clinical case seminar: lymphocytic hypophysitis: clinicopathological findings |journal=J. Clin. Endocrinol. Metab. |volume=80 |issue=8 |pages=2302–11 |year=1995 |pmid=7629223 |doi=10.1210/jcem.80.8.7629223 |url=}}</ref><ref name="pmid8345854">{{cite journal |vauthors=Imura H, Nakao K, Shimatsu A, Ogawa Y, Sando T, Fujisawa I, Yamabe H |title=Lymphocytic infundibuloneurohypophysitis as a cause of central diabetes insipidus |journal=N. Engl. J. Med. |volume=329 |issue=10 |pages=683–9 |year=1993 |pmid=8345854 |doi=10.1056/NEJM199309023291002 |url=}}</ref><ref name="pmid21668725">{{cite journal |vauthors=Hsieh CY, Liu BY, Yang YN, Yin WH, Young MS |title=Massive pericardial effusion with diastolic right ventricular compression secondary to hypothyroidism in a 73-year-old woman |journal=Emerg Med Australas |volume=23 |issue=3 |pages=372–5 |year=2011 |pmid=21668725 |doi=10.1111/j.1742-6723.2011.01425.x |url=}}</ref><ref name="pmid9747750">{{cite journal |vauthors=Dejager S, Gerber S, Foubert L, Turpin G |title=Sheehan's syndrome: differential diagnosis in the acute phase |journal=J. Intern. Med. |volume=244 |issue=3 |pages=261–6 |year=1998 |pmid=9747750 |doi= |url=}}</ref>


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Revision as of 14:23, 15 September 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Rahmah Al-Edresi, M.D.[2]


Overview

Menopause should be differentiated from other diseases presenting with menstrual irregularities (oligomenorrhea/amenorrhea).

Differential diagnosis of menopause from other diseases

Diseases Onset Manifestations Diagnosis
History and Symptoms Physical examination Laboratory findings Gold standard Imaging Other investigation findings
Trumatic delivery Lactation failure Menstrual irregularities Other features
Sheehan's syndrome Acute ++ ++ Oligo/amenorrhea Symptoms of:
  • Clinical diagnosis
  • Most senitive test: Low baseline prolactin levels w/o response to TRH
 CT/MRI:
  • Sequential changes of pituitary enlargement followed by:
  • Shrinkage and necrosis leading to decreased sellar volume or empty sella
Lymphocytic hypophysitis Acute +/- + Oligo/amenorrhea
  • Retro-orbital or Bitemporal pain
  • Diffuse and homogeneous contrast enhancement
 Assays for:
  • Anti-TPO
  • Anti-Tg Ab
Pituitary apoplexy Acute +/- ++ Oligo/amenorrhea Severe headache
  • Decreased levels of anterior pituitary hormones in blood.
  • CT scan without contrast: Hemorrhage on CT presents as a hyperdense lesion

Blood tests may be done to check:

Empty sella syndrome Chronic - + Oligo/amenorrhea
  • Decreased levels of pituitary hormones in the blood.
Simmonds' disease/Pituitary cachexia Chronic +/- + Oligo/amenorrhea
  • Loss of body hair
  • Decreased levels of anterior pituitary hormones in the blood.
  • Done to rule out any pituitary cause
Hypothyroidism Chronic +/- - Oligomenorrhea/menorrhagia
  • Dry skin
  • Hair loss
  • Done to rule out any pituitary cause
  • Assays for anti-TPO and anti-Tg Ab
  • FNA biopsy
Hypogonadotropic hypogonadism Chronic - - Oligo/amenorrhea
  • Energy and mood changes
  • Done to rule out any pituitary cause
Hypoprolactinemia Chronic - + -
  • Puerperal agalactogenesis
  • No workup is necessary
  • Decreased prolactin levels
  • Done to rule out any pituitary cause
Panhypopituitarism Chronic - + Oligo/amenorrhea
  • All pituitary hormones decreased
  • Done to rule out any pituitary cause
Primary adrenal insufficiency/Addison's disease Chronic - - -
  • Abdominal CT
  • Abdominal CT
  • Anti-adrenal Ab testing
Menopause Chronic - +/- Oligo/amenorrhea Normal

[1][2][3][4][5][6][7]


References

  1. ↑ Sato N, Sze G, Endo K (1998). "Hypophysitis: endocrinologic and dynamic MR findings". AJNR Am J Neuroradiol. 19 (3): 439–44. PMID 9541295.
  2. ↑ Powrie JK, Powell M, Ayers AB, Lowy C, Sönksen PH (1995). "Lymphocytic adenohypophysitis: magnetic resonance imaging features of two new cases and a review of the literature". Clin. Endocrinol. (Oxf). 42 (3): 315–22. PMID 7758238.
  3. ↑ Honegger J, Schlaffer S, Menzel C, Droste M, Werner S, Elbelt U, Strasburger C, Störmann S, Küppers A, Streetz-van der Werf C, Deutschbein T, Stieg M, Rotermund R, Milian M, Petersenn S (2015). "Diagnosis of Primary Hypophysitis in Germany". J. Clin. Endocrinol. Metab. 100 (10): 3841–9. doi:10.1210/jc.2015-2152. PMID 26262437.
  4. ↑ Thodou E, Asa SL, Kontogeorgos G, Kovacs K, Horvath E, Ezzat S (1995). "Clinical case seminar: lymphocytic hypophysitis: clinicopathological findings". J. Clin. Endocrinol. Metab. 80 (8): 2302–11. doi:10.1210/jcem.80.8.7629223. PMID 7629223.
  5. ↑ Imura H, Nakao K, Shimatsu A, Ogawa Y, Sando T, Fujisawa I, Yamabe H (1993). "Lymphocytic infundibuloneurohypophysitis as a cause of central diabetes insipidus". N. Engl. J. Med. 329 (10): 683–9. doi:10.1056/NEJM199309023291002. PMID 8345854.
  6. ↑ Hsieh CY, Liu BY, Yang YN, Yin WH, Young MS (2011). "Massive pericardial effusion with diastolic right ventricular compression secondary to hypothyroidism in a 73-year-old woman". Emerg Med Australas. 23 (3): 372–5. doi:10.1111/j.1742-6723.2011.01425.x. PMID 21668725.
  7. ↑ Dejager S, Gerber S, Foubert L, Turpin G (1998). "Sheehan's syndrome: differential diagnosis in the acute phase". J. Intern. Med. 244 (3): 261–6. PMID 9747750.


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