- Urinalysis
- Pregnancy test
- Follicle stimulating hormone
- Estradiol
- Prolactin
- Thyroid function tests
b. An electrocardiogram may also be indicated as
some patients may develop cardiac rhythm distur-
bances, including prolongation of the QTc.
•Treatment for disordered eating requires a multidisci-
plinary team, including a physician, psychologist, and
a nutritionist.
a. Treatment includes the following: - Recognition of the problem
- Identification and resolution of psychosocial
precipitants - Stabilization of medical and nutritional condition
- Reestablishment of healthy patterns of eating
- Medication is not generally helpful in the treatment of
anorexia, but fluoxetine, a selective serotonin reup-
take inhibitor, has been approved by the U.S. Food
and Drug Administration (FDA) for the treatment
bulimia. (Hudson et al, 1988).
a. Desipramine and imipramine have also been used in
the treatment of bulimia. (Hay, Bacaltchuk, and
Bulimia, 2002) - Indications for inpatient treatment for a patient with
an eating disorder include the following:
a. Very low body weight (<75% of expected body
weight)
b. >15% loss of initial body weight
c. Rapid (>10% in 1–2 months) weight loss
d. Cardiac arrhythmias
e. Electrolyte imbalances
f.Suicidal ideation
g. Temperature <36°C
h. Pulse <45 bpm
i. Orthostatic pulse differential >30 bpm
j. Patient not responding to outpatient treatment
(Becker et al, 1999)
AMENORRHEA
- Primary amenorrhea is defined as delayed menarche,
or the absence of menses by the age of 16 (Bruckner,
Fricker, 1998). - Athletes who begin intensive training before
puberty, especially gymnasts and ballet dancers are
at risk of developing primary amenorrhea (Marshall,
1994).
•Evaluation of a patient with amenorrhea should
include a thorough history, including pubertal mile-
stones in the patient and other female relatives.
a. A lack of any pubertal development can indicate
hypothalamic, pituitary, or gonadal failure.
b. An interruption of normal pubertal development
can indicate ovarian failure, or pituitary failure, as
happens with a pituitary neoplasm.
c. Normal breast and pubic development in the
absence of menstrual periods can indicate an
abnormality of the reproductive organs.- Other history should include a training and dietary his-
tory, a thorough history of past medical problems and
treatments, medications, including over-the-counter
medications such as diuretics, laxatives, or ipecac, and
supplements such as ephedra, a thorough family history,
and psychologic screening for evidence of increased
stress, depression, anxiety, obsessive or compulsive per-
sonality traits, or symptoms of an eating disorder.
a. Athletes who associate more stress with their sport
and competition are more likely to be amenorrheic
(Marshall, 1994).
•A thorough physical should include vital signs,
height, weight, body fat, arm span, Tanner stage, any
characteristics of chromosomal anomalies, any traits
of androgen excess, fundoscopic examination and
visual field confrontation, evaluation for galactorrhea,
palpation of the thyroid, and a pelvic examination.
Imaging studies may include a computed tomography
(CT) or magnetic resonance imaging(MRI) to rule
out a pituitary adenoma if indicated. - Laboratory testing for amenorrhea is shown in Fig. 98-1.
The progestin challenge is done by giving medrox-
yprogesterone as a 10-mg daily dose for 5–10 days. This
testing is appropriate for both primary and secondary
amenorrhea. - Secondary amenorrhea is the absence of menstrual
bleeding in a woman who has previously had men-
strual cycles (Marshall, 1994). - One commonly used definition of secondary amenor-
rhea is “the absence of menstrual cycles for a length
of time equal to the total time of the three previous
menstrual cycles” (Marshall, 1994). Some other defi-
nitions are “the absence of menstrual cycles for
6 months,” and the International Olympic Committee
definition of “one period or less per year.” - In hypothalamic amenorrhea, the pulsatile gonadotropin
releasing hormone(GnRH) is abnormal. Rarely, this can
be caused by a tumor or trauma or developmental defect.
More commonly, it is thought that psychologic and/or
physical stress affects neurohormones that regulate
GnRH, leading to hypothalamic amenorrhea (Marshall,
1994).
•Exercise-related amenorrhea can be considered a
subset of hypothalamic amenorrhea, which also
includes amenorrhea related to anorexia nervosa,
weight loss, and psychologic stress. It is, however, a
576 SECTION 7 • SPECIAL POPULATIONS