Case Report: Amenorrhea with a dramatic course

A young woman comes to the gynecological practice for the first time because of secondary amenorrhea. A long odyssey begins, during which the patient ends up in the intensive care unit.

At the age of 17, a young woman presented to the gynecological practice for the first time. She reported on a conscious vegan diet since she was 14 years old. She is also very careful regarding her weight, does a lot of sport and takes dietary supplements with B12, iron and iodine. The laboratory values ​​at the doctor’s were in the normal range. The menarche was at the age of 14, since then there had been no more bleeding.

course of the investigations

Physical examination revealed delayed breast development Tanner-Stadium 3-4 and a forehead acne. Of the BMI was borderline with 19 kg/m². A gynecological examination was refused. In the hormone lab Estradiol (26 pg/ml) at low levels that Gonadotropins (FSH 7.5 U/l, LH 2.9 U/l) in the lower to middle reference range of the fertile phase of life. Prolactin and Androgens were inconspicuous TSH spoke for one euthyroid function.

The patient was prescribed a classic combined contraceptive with an antiandrogenic component. The aim was to create a normal menstrual cycle, stabilize bone density and have an additional effect on the skin of the face. At a follow-up appointment every six months, the patient stated that she had not taken the hormones and was critical of hormone therapy. She finally agreed to an alternative prescription with a bioidentical hormone replacement therapy. She wanted regular medical care.

reintroduction following two years

Further check-up appointments were not kept and the patient only returned to the gynecological consultation following two years. Between the ages of 17 and 18 she gained some weight (BMI 21.5 kg/m²) and had some menstrual bleeding. In the last 6 months she has lost 12 kg, on the one hand through a conscious diet and on the other hand through excessive weight training. She has never taken hormones – on the one hand she does not want to take them, on the other hand she is concerned whether the missed periods and delayed breast development would be good for her health.

make up for lost time

“Can I make up for lost time with hormone therapy?” was the young woman’s repeated, almost panicky question. Already striking at first glance are the severe underweight (BMI 16.8 kg/m²), a pale, yellowish discoloration of the face and an overall reduced general condition. During the physical examination there is hardly any body fat left, the skin is very dry and scratched and the breast development is underdeveloped for the age.

The abdominal ultrasound shows the Uterus normal, the ovaries cannot be visualized. Vaginal or rectal ultrasound examination is rejected. Of the Pap smear gives a very low degree of proliferation. Thanks to the involvement of the family doctor, the patient is now undergoing psychological therapy. She doesn’t want to give up a reduced diet and excessive weight training, nor does she want to gain weight, just have her period and normal breasts. She looks tense.

An intensive situation analysis

A long discussion regarding the situation ensues. “Your body cannot compensate for the deficiency in the long run. Being severely underweight has a negative effect on metabolism, bone density and the hormonal situation. Without gaining weight, hormone therapy and psychological help, the collapse occurs,” is the urgent appeal to the patient. Eventually she agrees to come to the endocrine clinic at a university women’s clinic because she wants a second opinion on hormone therapy. She also agrees to a bone density determination and an outpatient appointment with a specialist in psychiatry and psychotherapy. She had given up psychological support.

Inpatient admission to a psychotherapeutic clinic for young adults with eating disorders was repeatedly recommended to her. The patient refuses.

Worrying results

The findings of the co-treating colleagues confirm a significantly reduced general condition, with an now threatening eating disorder. The years Orthorexiethe pathological desire to eat as “properly” as possible leads to a suspected diagnosis Anorexia nervosa.

In the laboratory, a pronounced hypogonadotropic hypogonadism with a gonadotropin level below the limit of detection. The estradiol level is greatly reduced. Androgens are in the normal range. Other laboratory abnormalities are a clear lack of protein, Hyponatremia, hypocalcemia, Hypervitaminose B12 and elevated transaminases.

In osteodensitometry, a pronounced Osteopenia, which equates to a postmenopausal status, is diagnosed. There is an osteocatabolic metabolic situation. The colleagues advise the patient to undergo hormone replacement therapy, reduce excessive strength training and receive specialist treatment for the eating disorder.

The situation is coming to a head

The results of the second opinion are discussed once more with the patient and necessary therapeutic measures are repeatedly recommended. She then cancels the agreed check-up appointments, as well as with the specialist in psychiatry and psychotherapy. Telephone calls with colleagues who were also treated, which the patient approved, confirm the young woman’s attitude of resistance to advice. A briefing because of self-endangerment is the last resort.

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Thanks to the committed action of the relatives, the patient finally consented to being admitted to the clinic. A few days later, the patient was transferred to the intensive care unit because of internal complications. After many conversations, discontinued therapy and admission to the hospital just in time, the young woman is now on the mend.

My conclusion

The prevalence of anorexia is 0.5–2% across Europe, with a peak between the ages of 13 and 18 years. Girls and young women represent a high-risk group for developing eating disorders. The prevalence is in comparison compared to boys and young men of the same age increased up to 10-fold. If the BMI falls below 16 kg/m², a hospital admission should take place. Lifelong consequential damage is feared. The pronounced cachexia can be life-threatening, and suicidality is increased. In German clinics in 2020 A total of 7,355 cases of anorexia nervosa were diagnosed, the disease claimed 46 lives (read more here).

In the gynecological practice, a special closeness and basis of trust develops with individual patients. In the case of a serious illness such as anorexia nervosa, it is crucial that contact with the patient is maintained. A network of colleagues from other disciplines is particularly important in order to assess the extent of the disease and to convince the patient of the need for inpatient therapy. Committed relatives often make the decisive contribution so that help can be provided in good time.

Image source: Krzysztof Kowalik, Unsplash