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The Rational Clinical Examination
David L. Simel, Drummond Rennie
Lori A. Bastian, Crystal M. Smith, Kavita Nanda

Topics Discussed: depressed mood, diagnostic process, hot flashes, hysterectomy, irritable mood, menopause, night sweats, perimenopause, smoking, urinary incontinence, women's health

Excerpt: "This evaluation can be divided into 5 basic categories: self-assessment, symptoms, family and medical history, physical signs, and laboratory tests.Clinicians can ask a woman whether she thinks she is starting menopause. Women may base their perceptions of their menopausal status on awareness of the subtle changes taking place in their bodies.10,11 In a cross-sectional study by Garamszegi et al,10 self-reported menopausal status was more correlated with symptoms than menstrual cycle characteristics.Hot flashes are sudden sensations of heat, sweating, and flushing that most often occur in the face, head, neck, and chest. Chills, clamminess, and anxiety also may accompany hot flashes. They generally last 1 to 5 minutes, though 6% of women experience hot flashes lasting longer than 6 minutes.12 Most North American, European, and Australian women report that they experience hot flashes (50%-85%)9,12-14 and that they occur periodically during a span of 1 to 5 years.15,16 There appear to be cultural differences in the reporting or experiencing of hot flashes. For example, only 10% to 20% of Indonesian women17 and 10% to 25% of Chinese women18 report experiencing them. The mechanism triggering these episodes is thought to be a combination of fluctuating estradiol levels and a narrowing of the thermoneutral zone.19Genetic factors seem to predispose women to menopause at an earlier age.44,45 Torgerson et al44 reported that women with premature (<40 years) and early (<45 years) menopause report significantly younger maternal menopausal ages than did women with normal menopausal ages. In a case-control study of women from the greater Boston area, Cramer et al45 found that women with a family history (eg, mother, sister, aunt, grandmother) of menopause before age 46 years had a higher risk of early menopause (odds ratio, 6.1; 95% confidence interval [CI], 3.9-9.4).One proposed assessment of vaginal estrogen deficiency is an evaluation of the vaginal epithelium maturation index. This procedure involves obtaining cells from the junction of the upper and middle third of the lateral vaginal wall with a brush. These cells are prepared on a slide with the Papanicolaou technique, and the percentages of parabasal, intermediate, and superficial cells are counted.66 Although the maturation index changes significantly after estrogen replacement therapy, diagnostic studies have not compared the maturation index with menstrual cycle characteristics.Measurement of FSH plasma levels has been used to try to identify perimenopausal and postmenopausal women. High FSH levels indicate that menopausal changes are occurring in the ovary. As the ovary becomes less responsive to stimulation by FSH from the pituitary gland (and produces less estrogen), the pituitary gland increases production of FSH to try to stimulate the ovary to produce more estrogen (Figure 31-1). However, some clinicians and researchers doubt the clinical value of FSH measurements in perimenopausal women because FSH levels fluctuate considerably each month, depending on whether ovulation has occurred.2,69,70..."
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