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This patient presents with dyspareunia, vasomotor symptoms (hot flashes), mood changes, a distant last menstrual period, and vulvovaginal atrophy, indicative of menopause. The laboratory findings associated with menopause are increased FSH and LH, decreased estrogen and testosterone, and normal TSH and T4. Menopause is characterized by depletion of ovarian follicle units, which occurs naturally throughout the reproductive life, resulting in decreased estrogen production by the ovaries. This releases the anterior pituitary gland from feedback inhibition, leading to an increase in FSH and LH levels. Menopause typically begins in women around the age of 50 years, although peri-menopausal symptoms may begin several years earlier. These symptoms include irregular menstrual cycles, vasomotor symptoms (e.g., hot flashes), mood disturbances, and vulvovaginal atrophy due to loss of the estrogenic drive. The diagnosis of menopause is made clinically in a woman with typical symptoms and amenorrhea for at least 12 months who are over the age of 45 years. Women with severe vasomotor symptoms without contraindications (e.g., history of breast cancer, previous venous thromboembolism, active liver disease) can be treated with menopausal hormone therapy, usually consisting of estrogen and progestin. Vulvovaginal dryness is treated first with nonhormonal vaginal moisturizers and lubricants; vaginal estrogen therapy is used as second-line. Roberts and Hickey review the management of various menopausal symptoms. They note the role of menopausal hormone therapy for the treatment of vasomotor symptoms. Incorrect Answers: Answer 1: Increased FSH, LH, estrogen, and testosterone with normal TSH and T4 is indicative of a pituitary gonadotroph adenoma. In middle-aged individuals, the slight excess of FSH and LH produced by gonadotroph adenomas do not result in any clinical symptoms; in younger women, oligomenorrhea or vaginal bleeding due to a thickened endometrium may be seen. Sellar masses typically present with visual disturbances and/or headaches. Answer 3: Decreased FSH, LH, estrogen, and testosterone with normal TSH and T4 is indicative of central underproduction of gonadotropins, which can be seen with a prolactinoma. Overproduction of prolactin results in suppression of FSH and LH production. This results in symptoms of estrogen and testosterone deficiency, including oligomenorrhea, infertility, decreased libido, and/or galactorrhea. This patient has a normal prolactin level. Answer 4: Normal FSH, LH, estrogen, and testosterone with decreased TSH and increased T4 is indicative of hyperthyroidism, such as from a toxic thyroid adenoma. Hyperthyroidism can present with menstrual cycle irregularities and heat intolerance along with palpitations, unintentional weight loss, and anxiety, but would not explain this patient’s vulvovaginal atrophy which is due to decreased estrogen. Answer 5: Decreased FSH, LH, estrogen, and testosterone with increased TSH and decreased T4 is indicative of hypothyroidism. Hypothyroidism results in increased release of thyrotropin-releasing hormone, which increases production of both TSH and prolactin. The increased prolactin then suppresses FSH and LH release, leading to decreased estrogen and testosterone. Patients with hypothyroidism present with fatigue, weight gain, cold intolerance, and constipation. Bullet Summary: Menopause presents with increased levels of follicle-stimulating hormone and luteinizing hormone, decreased levels of estrogen and testosterone, and normal thyroid function.
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