MKSAP Quiz: Last menstrual period more than 12 months ago
A 48-year-old woman is evaluated during a routine examination. She reports that her last menstrual period was more than 12 months ago. She states she has occasional hot flushes. Following a physical exam and pregnancy test, what is the most appropriate management?
A 48-year-old woman is evaluated during a routine examination. She reports that her last menstrual period was more than 12 months ago. She states she has occasional hot flushes. She has no genitourinary symptoms. Medical history is unremarkable, and she takes no medications.
Physical examination findings, including vital signs, are normal.
A pregnancy test result is negative.
Which of the following is the most appropriate management?
A. Obtain serum follicle-stimulating hormone level
B. Obtain serum prolactin level
C. Obtain serum thyroid-stimulating hormone level
D. No further evaluation
MKSAP Answer and Critique
The correct answer is D. No further evaluation. This content is available to MKSAP 19 subscribers as Question 68 in the General Internal Medicine II section. More information about MKSAP is available online.
The most appropriate management is no further evaluation (Option D). Menopause is a clinical diagnosis made retrospectively when a woman has not experienced a menstrual period for 12 months. Menopause occurring in women older than 40 years, such as this patient, requires no additional laboratory or diagnostic evaluation. Menopause occurring in women younger than 40 years should be evaluated for premature ovarian insufficiency and other disorders by obtaining follicle-stimulating hormone (FSH), serum thyroid-stimulating hormone (TSH), and prolactin levels; on the basis of results of these studies, additional evaluation may be required. Symptoms of menopause include vasomotor symptoms (hot flushes, night sweats). Hot flushes generally start in the perimenopausal period and can last for a few years to lifelong. Women may experience other symptoms, such as depression, anxiety, and irritability, but it is unclear whether these symptoms can be attributed to menopause. Genitourinary syndrome of menopause results from estrogen deficiency and is characterized by vaginal symptoms, such as burning or irritation; sexual symptoms, such as dyspareunia or sexual dysfunction; or urinary symptoms, such as dysuria or recurrent urinary infections.
Although serum FSH levels (Option A) are elevated in menopausal woman, measurement of FSH levels is not required to diagnosis menopause in this patient. In a woman older than 40 years who has not had a menstrual period in more than 1 year and has a negative result on pregnancy test, the clinical diagnosis of menopause can be made without additional laboratory evaluation.
A serum prolactin level (Option B) is appropriate management in the evaluation of early menopause and amenorrhea, but it is not required to diagnose menopause in a patient older than 40 years.
Obtaining a serum TSH level (Option C) can be helpful in evaluating a woman younger than 40 years with absent menses or a woman presenting with abnormal uterine bleeding, but it is not required for the routine diagnosis of menopause.
Key Points
- Menopause is a clinical diagnosis made retrospectively when a woman has not experienced a menstrual period for 12 months, and routine laboratory testing for the diagnosis is not recommended.
- Patients with possible early menopause (age <40 years) should have pregnancy excluded and undergo measurement of follicle-stimulating hormone, thyroid-stimulating hormone, and prolactin.