Menopause differential diagnosis

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

## Overview[edit | edit source]

Menopause should be differentiated from other diseases presenting with menstrual irregularities (oligomenorrhea/amenorrhea) that are include Sheehan's syndrome, Lymphocytic hypophysitis, Pituitary apoplexy, Empty sella syndrome, Pituitary cachexia, Hypothyroidism, Hypogonadotropic hypogonadism, Hypoprolactinemia, Primary adrenal insufficiency/Addison's disease.

## Differential diagnosis of menopause from other diseases[edit | edit source]

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

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:

* Adrenal insufficiency

* Hypothyroidism

* Breast tissue atrophy

* Decreased axillary and pubic hair growth

* Pancytopenia

* Eosinophilia

* Hyponatremia

* Low fasting plasma glucose

* Decreased levels of anterior pituitary hormones in blood

* 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

* Pituitary hormone stimulation tests (Metoclopramide and clomiphene citrate stimulation tests)

Lymphocytic hypophysitis | Acute  | +/-  | \+  | Oligo/amenorrhea |

* Associated with autoimmune conditions

* Generalized headache

* Retro-orbital or Bitemporal pain

* Mass lesion effect such as visual field defects

* DI

* Autoimmune thyroiditis

* Decreased pituitary hormones(Gonadotropins most common)

* Hyperprolactinemia(40%)

* GH excess

* Pituitary biopsy: lymphocytic infiltration

* CT & MRI: Features of a pituitary mass

* Diffuse and homogeneous contrast enhancement

| Assays for:

* Anti-TPO
* Anti-Tg Ab

Pituitary apoplexy | Acute  | +/-  | ++  | Oligo/amenorrhea | Severe headache

* Nausea and vomiting
* Paralysis of eye muscles (diplopia)
* Changes in vision

* Visual acuity defects

* CN palsies (nerves III, IV, V , and VI)

* Decreased levels of anterior pituitary hormones in blood.

* MRI

* CT scan without contrast: Hemorrhage on CT presents as a hyperdense lesion

* MRI: If inconclusive CT

Blood tests may be done to check:

* PT/INR and aPTT

* Pituitary hormonal assay

Empty sella syndrome | Chronic  | \-  | \+  | Oligo/amenorrhea |

* Erectile dysfunction

* Headache

* Low libido

* Signs of raised intracranial pressure may be present

* Nipple discharge

* Decreased levels of pituitary hormones in the blood.

* MRI

* Empty sella containing CSF

* Pituitary hormone stimulation tests (Metoclopramide and clomiphene citrate stimulation tests)

Simmonds' disease/Pituitary cachexia | Chronic  | +/-  | \+  | Oligo/amenorrhea |

* Cachexia
* Premature aging

* Progressive emaciation

* Loss of body hair

* Decreased levels of anterior pituitary hormones in the blood.

* MRI

* Done to rule out any pituitary cause

* Pituitary hormone stimulation tests (Metoclopramide and clomiphene citrate stimulation tests)

Hypothyroidism | Chronic  | +/-  | \-  | Oligomenorrhea/menorrhagia |

* Cold intolerance
* Constipation

* Dry skin

* Bradycardia

* Hair loss

* Myxedema

* Delayed relaxation phase of deep tendon reflexes

* Low T3,T4

* TSH levels

* Done to rule out any pituitary cause

* Assays for anti-TPO and anti-Tg Ab
* FNA biopsy

Hypogonadotropic hypogonadism | Chronic  | \-  | \-  | Oligo/amenorrhea |

* Hot flushes

* Energy and mood changes

* Decreased libido

* Breast tissue atrophy
* Decreased maturation of vaginal mucosa

* Low estrogen, testosterone

* High FSH/LH

* FSH
* LH

* Done to rule out any pituitary cause

* Genetic tests (karyotype)
* Measurement of total and free testosterone and 17-hydroxyprogesterone concentrations

Hypoprolactinemia  | Chronic  | \-  | \+  | \-  |

* Infertility
* Subfertility

* Puerperal agalactogenesis

* No workup is necessary

* Decreased prolactin levels

* Done to rule out any pituitary cause

* Prolactin assay in 3rd trimester

* LH, FSH

* Thyrotropin and free thyroxine

Panhypopituitarism | Chronic  | \-  | \+  | Oligo/amenorrhea |

* Polyuria

* Polydipsia
* Features of hypothyroidism and hypoadrenalism

* Growth failure

* B/L hemianopsia

* Papilledema

* All pituitary hormones decreased

* MRI

* Done to rule out any pituitary cause

* Left hand and wrist radiograph for bone age

Primary adrenal insufficiency/Addison's disease | Chronic  | \-  | \-  | \-  |

* Hypoglycemia

* Hypotension

* Dehydration

* Hyperpigmentation

* loss of pubic and axillary hair

* Hyponatremia with/without hyperkalemia

* Plasma renin activity to aldosterone ratio

* Abdominal CT

* Abdominal CT

* Serum cortisol testing

* Serum ACTH testing

* Anti-adrenal Ab testing

Menopause | Chronic  | \-  | +/-  | Oligo/amenorrhea |

* Hot flashes
* Insomnia
* Weight gain and bloating
* Mood changes

* Vaginal atrophy
* Loss of pelvic muscle tone

* ↑ FSH
* ↓ Estradiol and inhibin

* FSH > LH

| Normal  |

* Endometrial biopsy

## References[edit | edit source]

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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