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Respond to the 2 following discussion posts separately with separate reference lists.
1. [Onpaneeya Pataky] A 21-year-old female patient presents to the office for an annual exam. She has had normal, regular menstrual cycles since she was 14 but she has not had a menstrual cycle in over 6 months. A pregnancy test is negative. The FNP wants to order blood work to determine the cause of her secondary amenorrhea (SE). When the patient hears that if all is normal the treatment will be giving progestins to initiate a menstrual cycle, she tells the FNP that she cannot do that because she does not believe in birth control pills. The FNP tries to advise the patient that it is not birth control pills, but a hormone to assist in regulating her periods and the patient leaves the office crying. What does the FNP do now to help this patient?
It appears that this patient history interview went awry due to the lack of correct, detailed questioning of the patient by the FNP, which should have included 1) is the patient significantly underweight (BMI under 18.5) and/or does she have anorexia or bulimia (causes 10% of SE cases), 2) does the patient have a significantly abnormally high amount of stress, especially perfectionism (causes 10% of all SE cases), and 3) does the patient practice a severely strenuous amount of exercise, since all of these lifestyle issues can lead to excessively low body fat and cause this patient’s secondary amenorrhea (Arthur & Collins, 2021). Since the patient appears overly emotional and impulsive, due to her leaving the office crying, 2) above should be suspected at least. If these issues are confirmed, they should be addressed before further testing occurs, with the exception of a serum human chorionic gonadotropin (HCG) pregnancy test, if the only test done was a urine test (Arthur & Collins, 2021). History and exam should also have included detection of galactorrhea, headaches, or visual field disturbances, which could indicate hypothalamic or pituitary disease, as well as medication or substance use, as well as persistent acne and hirsuitism, which could indicate hyperandrogenism, as well as night sweats and hot flashes, which could indicate primary ovarian insufficiency, as well as normal breast size, which indicates circulating estrogen (Klein et al., 2019). The FNP should also create a safe, welcoming environment to discuss the sensitive issues of reproductive health, establishing confidentiality, building rapport, and making enough time to discuss all options in a non-rushed manner (Klein et al., 2019).
If these issues are normal or resolved and the condition persists, then further lab testing would include 1) thyroid-stimulating hormone (TSH) to rule out thyroid dysfunction such as hypothyroidism (10% of all SE cases), 2) prolactin to rule out hyperprolactinemia (values above 20 ng/mL, 3) follicle stimulating hormone (FSH) to rule out ovarian failure (values greater than 40 IU/mL, 4) pelvic ultrasound to rule out tumors or masses (Arthur & Collins, 2021). If all of these issues test normal, the next step would be to complete a progesterone challenge, which attempts to induce vaginal withdrawal bleeding within 14 days by administering medroxyprogesterone acetate (MPA or Provera) 10mg per day for 10 days or 200 mg IM once; if bleeding occurs, this indicates intact pituitary-gonad function and that amenorrhea is likely the result of anovulation caused by neuroendocrine dysfunction, which is called hypothalamic amenorrhea, the most popular cause of SE in 28% of cases (Gould et al., 2019). In the case of hypothalamic amenorrhea, the normal pulsatile release of gonadotrophin releasing hormone (GnRH) is impaired, which can be caused by many factors, including stress, weight loss, severe exercise, nutritional deficiencies, CNS lesions such as hypothalamic tumors or sarcoidosis, rare pituitary tumors which cause prolactinemia (20% of all cases of SE), and genetic causes (Gould et al., 2019). Additional testing can include 17-hydroxyprogesterone to rule out late-onset congenital adrenal hyperplasia (high), serum free and total testosterone to rule out hyperandrogenism (high), estradiol to rule out ovarian insufficiency (low), karyotype to rule out Turner Syndrome (abnormal), MRIs of the brain and adrenals to rule out adrenal and microadenoma tumors, and anti-Mullerian hormone to confirm hypothalamic amenorrhea (high) vs. ovarian insufficiency (low) (Gould et al., 2019).
Each cause if/when found should be treated appropriately, and referrals to appropriate specialists may need to be made, including endocrinologists and gynecologists. Treatment for hypothalamic amenorrhea typically involves giving the same drug that was used to perform the progesterone challenge, MPA or Provera, 10 mg per day for 10 days per month to reestablish menses (Arthur & Collins, 2021; Gould et al., 2019). Birth control pills, though helpful to regulate the patient’s menstrual cycle, are not required if the patient is not wanting contraception (and this patient may not have understood that) (Gould et al., 2019). The patient should also be informed that if she does not agree to progesterone therapy to reestablish her menses, her chances of developing endometrial cancer are greatly increased (Arthur & Collins, 2021).
References
Arthur, R. & Collins, M. (2021). Gynecological guidelines. In Cash, J. C., Glass, C. A., & Mullen, J. (2021). Family practice guidelines (5th ed, pp. 475-526). Springer Publishing Company.
Gould, K. R., Thomas, D. J. & Porter, B. O. (2019). Vaginal, uterine, and ovarian disorders. In L. M. Dunphy, J. E. Winland-Brown, B. O. Porter & D. J. Thomas (Eds.), Primary care: The art and science of advanced practice nursing – an interprofessional approach (5th ed., pp. 704-747). F. A Davis Company.
Klein, D. A., Paradise, S. L., & Reeder, R. M. (2019). Amenorrhea: A Systematic Approach to Diagnosis and Management. American Family Physician, 100(1), 39–48. https://www.aafp.org/pubs/afp/issues/2019/0701/p39.html
2. [Crystal Loveland-Davis] The key findings in this case study to help guide care are the patient’s age, the age of menarche onset, the duration of amenorrhea, the presence of a negative pregnancy test, personal preference not to want birth control, and patient crying. The essential items to diagnose and manage secondary amenorrhea not presented in this case study are the patient’s current lifestyle factors, vitals, weight, exercise status, nutritional status, relationship status, and sexual activity (Klein et al., 2019). Assume the case study included patient information that she was of the catholic faith, just married her high school sweetheart ten months ago, and they were trying to conceive. Would her tearful response hold additional significance to you?
Patient crying should always be clinically noted as its occurrence is significant and typically stems from emotions surrounding personal loss, interpersonal conflict, or personal failure (Bylsma et al., 2021). In the case study, as it is written, it is likely that the patient’s tears stem from interpersonal conflict as she weighs her personal anti-birth control beliefs against what her trusted clinician is presenting as a care plan. As the FNP, I would ensure that I contacted this patient to check in on her later that day or the next day, depending on the visit time. Bylsma et al. highlight that in most clinical experiences, patient crying should be viewed as an emotional response within the therapeutic relationship that signals intake and processing of presented information and is associated with improved patient psychological outcomes (2021).
As the FNP, when checking on her, I would remind her of the office education presented and encourage her to have her labs drawn and return for a follow-up visit to review them together. I would also ensure that the patient knew I was willing to listen to her and develop a plan that met her physiological and psychological needs. Pending normal lab results, if my patient remained resistant to hormone replacement, I would encourage lifestyle modifications to include proper nutrition, hydration, exercise, rest, and stress management to naturally regulate hormones (Klein et al., 2019).
References
Bylsma, L. M., Gračanin, A., & Vingerhoets, A. M. (2021). A clinical practice review of crying research. Psychotherapy, 58(1), 133–149. https://doi.org/10.1037/pst0000342
Klein, D., Paradise, S., & Reeder, R. (2019). Amenorrhea: a systematic approach to diagnosis and management. American Family Physician, 100(1), 39–48. https://www.aafp.org/pubs/afp/issues/2019/0701/p39.html