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Most popular medical Questions
How is the diagnosis of anorexia made?Anorexia nervosa consists of a spectrum of psychological, behavioral, and medical abnormalities. The 1996 Diagnostic and Statistical Manual for Primary Care: Child and Adolescent Version criteria list five components:
Refusal to maintain body weight or BMI at or above minimal norms for age and height (less than 85% of expected weight for height or a BMI of less than 17.5 in an older adolescent)
Intense fear of gaining weight or becoming fat
Disturbances of perception of body shape and size
Denial of seriousness of weight loss or low body weight
In postmenarchal girls, amenorrhea (i.e., the absence of at least three consecutive menstrual cycles)
What are good and bad prognosticators for recovery from anorexia?
Good: Early age at onset, high educational achievement, improvement in body image after weight gain, emotionally well-adjusted, supportive family
Bad: Late age at onset, continued overestimation of body size, self-induced vomiting or bulimia, laxative abuse, family dysfunction, male
What hormonal abnormalities may be seen in anorexia nervosa?
Amenorrhea is seen in most cases due to hypothalamic/pituitary dysfunction with very low levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Twenty-five percent of affected girls experience amenorrhea before significant weight loss occurs, which suggests that there is a psychological effect on physiology. Symptoms that are suggestive of hypothyroidism-constipation, cold intolerance, dry skin, bradycardia, and hair or nail changes-are common. Thyroid studies, however, have relatively normal results, except for a low triiodothyronine (T3) and an increased reverse T3 (rT3), which is a less-active isomer.
The T3/rT3 reversal is also seen in conditions that are associated with weight loss, possibly indicating that it is a physiologic means of adapting to a lower energy state. Other abnormalities include a loss of diurnal variation in cortisol, diminished plasma catecholamine levels, normal or increased growth hormone levels, and flattened glucose tolerance curve.
What is the difference between primary and secondary amenorrhea?
Primary amenorrhea: No onset of menses by age 16 or within 3 years of onset of secondary sex characteristics or within 1 year of Tanner V breast/pubic hair development
Secondary amenorrhea: No menses for 3 months after previous establishment of regular menstrual periods
How can estrogen influence be evaluated on vaginal or cervical smears?
Vaginal smear: In patients with normal estrogen, 15-30% of cells are superficial (small pyknotic nuclei with large cytoplasm), and the remainder are intermediate (larger nuclei with visible nucleolus but still with cytoplasm predominant). If parabasal cells are noted (nuclear:cytoplasmic ratio of ?50:50), relative estrogen deficiency should be suspected.
Cervical smear: Cervical mucus is smeared onto a glass slide and allowed to dry. If a fern pattern appears, estrogen is normal (i.e., because salts crystallize only if estrogen is unopposed by progesterone). No fern pattern occurs during the second half of menses, after ovulation, because of the presence of progesterone. Absence of ferning during pregnancy is also a result of higher progesterone levels.
What is the value of a progesterone challenge test in a patient with amenorrhea?
If bleeding ensues within 2 weeks after the administration of oral medroxyprogesterone (10 mg daily for 5 days) or intramuscular progesterone in oil (50-100 mg), the test is positive. This indicates that the endometrium has been primed by estrogen and that the pituitary-hypothalamic-ovarian axis and outflow tract are functioning.
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