Menopause

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Rahmah Al-Edresi, M.D.[2]

Menopause is the permanent cessation of the menstrual cycle in women without any pathological causes because of physiological deficiency of estrogen hormone production in women. Menopause happens in women between 49 to 52 of age at the average. A woman is considered in menopause after amenorrhea for 12 months and she becomes suffering from the menopausal symptoms. Menopause is passes gradually through 3 stages until it reaches the permanent cessation of the menstrual cycle. These stages include premenopause, Perimenopause, and postmenopause. Premenopause is a word used to describe the years leading up to the last period even when the levels of reproductive hormones are already becoming lower and more erratic, and symptoms of hormone withdrawal may be present. Perimenopause or “menopause transition” means the menopause transition years, the years before and after the last period ever, when the majority of women find that they undergo at least some symptoms of hormonal change and fluctuation. Postmenopause, a woman has considered in post-menopause after amenorrhea more than 12 months. Several risk factors accelerate early menopause such as family history and cigarette smoking has been found to decrease the age at menopause by as much as one year and women who smoke have early menopause before non-smoking women. Menopause should be differentiated from other diseases presenting with menstrual irregularities (oligomenorrhea/amenorrhea). The prevalence of menopause is estimated to be about 50 million cases worldwide annually. The common symptoms of menopause include hot flashes, night sweats, headach, palpitation, dyspareunia, stress incontinence, urgency, frequency, dysuria, anxiety, sleep disturbance, depression. Left untreated women, increased the risk of hypertension, atherosclerosis, and hyperlipidemia. Common complications of menopause include cardiovascular disease, stroke, osteoporosis. Generally, the prognosis of menopause is good with treatment and a healthy lifestyle include stop smoking, a healthy diet, and exercise. An elevated serum of Follicle Stimulating Hormone (FSH) greater than 40 mIU/mL is diagnostic of menopause. Medical treatments of severe menopausal symptoms include Hormone therapy(HT), non-hormonal therapy, and complementary or alternative therapies. Hormonal therapy (HT) provides the best relief, but it increases the relative risks of uterine cancer, ovarian cancer, breast cancer, thromboembolism, and coronary heart disease, especially in women who start HT after menopause. A woman and her doctor should carefully review her symptoms and relative risk before determining whether the benefits of HT or other therapies outweigh the risks.

In 1821, a French physician named the cessation of the menstrual cycle as a term of menopause.The medical interest in menopause started in the mid-19th century, and was treated by estrogen replacement therapy in the 1970s. The Grandmother hypothesis considers that the menopause may have been selected for in human evolution. Unlike humans, other mammals rarely experience menopause, but some of the other few mammal species that experience menstrual cycles, such as rhesus monkeys and some cetaceans.

Menopause is classified according to causes into three types including natural menopause, premature menopause/early menopause, and induced menopause. Natural menopause, does not happen suddenly, but it passes through 3 stages include perimenopause, premenopause, and postmenopause. Premature menopause because of premature ovarian failure and several medical diseases. Induced menopause because of bilateral oophorectomy, salpingo-oophorectomy, and hysterectomy. In addition to complication of chemotherapy and radiotherapy.

Menopause is natural amenorrhea that is happened without any pathological causes, but premature menopause/early menopause is caused by pathological diseases in ovaries and other organs such as premature ovarian failure (Primary ovarian insufficiency, POI), Adrenal insufficiency, type1 diabetes mellitus, autoimmune thyroid disease, Fanconi’s anemia, and Congenital adrenal hyperplasia. Cardiovascular disease and osteoporosis are most important conditions associated with menopause. Women who had genetic disorders ( Fragile X syndrome, Turner’s syndrome) more prone able to early menopause. The histopathological analysis include ovaries‘s cortex becomes thinner and it has fewer follicles and the medulla develops fibrosis and scars. Decrease of ciliated cells of Fallopian tubes and Uterus. And atrophy of vaginal mucosal layer.

menopause is caused by the increased age of women. But the common causes of premature menopause include Premature ovarian failure, chemotherapy, and radiotherapy and bilateral oophorectomy, salpingo-oophorectomy, and hysterectomy. Less common causes include Autoimmune diseases, diabetes mellitus, Thyroid disease. chronic fatigue syndrome. Genetic causes include Fragile X Syndrome and Turner’s syndrome.

Menopause should be differentiated from other diseases presenting with menstrual irregularities (oligomenorrhea/amenorrhea) that are include Sheehan’s syndrome, Lymphocytic hypophysitis, Pituitary apoplexy, Empty sella syndrome, Pituitary cachexia, Hypothyroidism, Hypogonadotropic hypogonadism, Hypoprolactinemia, Primary adrenal insufficiency/Addison’s disease.

The prevalence of menopause is estimated to be about 50 million cases annually. Menopause naturally occurs in women between 49 to 52 of age the average. The fatality cases were 345 cases per 3191 women aged between 50-86 years in the United States. There is no racial predilection to Menopause, but African American women had experienced the largest number of menopausal symptoms compared with other ethnic groups.

There are several risk factors that accelerate menopause onset. Common risk factors include women’s age, age at menarche, age at first gestation, number of pregnancies, oral contraceptives, irregular menses, unilateral oophorectomy, body mass index, smoking, tobacco, and alcohol, high physical activity, high serum lead level, high intake of fat.

If left untreated, women with menopause may progress to develop hypertension, hyperlipidemia, and atherosclerosis. Common complications of menopause includecardiovascular disease, osteoporosis, Stroke. The complication that is happened with hormonal replacement therapy includes ovarian cancer, breast cancer, and endometrial cancer. Generally, the prognosis of menopause is good with treatment and a healthy lifestyle. In the late postmenopause stage, most menopausal symptoms relieved in most women. but untreated menopausal symptoms are poor prognosis in women who have high-risk factors to develop complications of menopause.

The hallmark of menopause is amenorrhea. The most common symptoms of menopause include hot flashes, night sweats, headach, palpitations, dyspareunia, stress incontinence, urgency, frequency, dysuria, anxiety, sleep disturbance, depression. Less common symptoms of menopause include loss of concentration, and loss of self confidence.

Women with menopause are usually well-appearing. Common physical examination of women with menopause include elevated blood pressure, hot flushes, weight gain, change of breast size, vaginal atrophy, external genital organs become thinner. In premature menopause, Signs of Turner syndrome, and Signs of Fragil X syndrome.

Laboratory findings consistent with the diagnosis of menopause include an elevated Follicle Stimulating Hormone > 40 mIU/mL, decreased estradiol level <20 pg/ml, and decreased serum of the Anti-Mullerian Hormone level below 0.20 ng/ml. In addition to other blood tests that are related to premature menopause such as positive karyotype test of FMR1 in Fragile X syndrome and decrease of Thyroid-stimulating hormone.

On pelvic ultrasound, menopause is characterized by small uterus and an endometrial thickness between 5-8 mm. Small ovaries with either a few follicles or no, and normal or non-visible adnexa. Transvaginal ultrasound is helpful for intitial evaluation of postmenopausal bleeding women, if endometrial thickness is 4mm or less, women more prone able for endometrial cancer. Endometrial biopsy is indicated in recurrent postmenopausal bleeding cases.

While perimenopause is a natural stage of life when the symptoms are severe, this may be alleviated through medical treatments that include Hormone therapy(HT), non-hormonal therapy, and complementary or alternative therapies.Hormonal therapy (HT) provides the best relief, but hormone therapy should only be used for a short duration and the lowest effective dose, as it increases the relative risk of uterine cancer, ovarian cancer, breast cancer, thromboembolism, and coronary heart disease, especially in women who start HT after menopause. Some other drugs afford limited relief from hot flashes. A woman and her doctor should carefully review her symptoms and relative risk before determining whether the benefits of HT or other therapies outweigh the risks.

Menopause is not preventable. Early menopause are preventable with the following strategie such as stop smoking, healthy food, regular exercies. Secondary prevention of menopause include HRT, followup of associated medical diseases and postmenopausal bleeding. Early determination of these conditions is very important in terms of morbidity/mortality and cost of the treatment.

Given the morbidity associated with menopause, and the high cost of  HRT and non- hormonal therapy, current pharmacotherapy to treat menopause are cost-effective.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Rahmah Al-Edresi, M.D.[2]

In 1821, a French physician named the cessation of the menstrual cycle as a term of menopause.The medical interest in menopause started in the mid-19th century, and was treated by estrogen replacement therapy in the 1970s. The Grandmother hypothesis considers that the menopause may have been selected for in human evolution. Unlike humans, other mammals rarely experience menopause, but some of the other few mammal species that experience menstrual cycles, such as rhesus monkeys and some cetaceans.

• In the past, the studies on cessation of the menstrual cycle after 40 years of age in women were very rare, a French physician named the cessation of the menstrual cycle as a term of menopause in 1821.

• The medical interest in menopause started in the mid-19th century and therefore knew the menopause symptoms because of deficiency of estrogen hormone and was treated of menopause symptoms by estrogen replacement therapy in the 1970s and had been developed in 1938.
• International Menopause Society was founded in the 1970s and the first international conference on menopause was organized in Paris, France in 1976.
• Overall, women in western countries viewed menopause negatively contrasted with the positive outlook of women in developing countries like India.^[1]

• The Grandmother hypothesis considers that the menopause may have been selected for in human evolution, because later life infertility could have conferred an evolutionary advantage by allowing older women to spend more time helping with the survival of their existing children and grandchildren.

• Unlike humans, other mammals rarely experience menopause, but it does exist in some of the other few mammal species that experience menstrual cycles, such as rhesus monkeys^[2] and some cetaceans.^[3]

• However, menopause exists in some other animals, many of which do not have monthly menstruation in this case, the term means a natural end to fertility.^[4]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Rahmah Al-Edresi, M.D.[2]

Menopause is classified according to causes into three types including natural menopause, premature menopause/early menopause, and induced menopause. Natural menopause, does not happen suddenly, but it passes through 3 stages include perimenopause, premenopause, and postmenopause. Premature menopause because of premature ovarian failure and several medical diseases. Induced menopause because of bilateral oophorectomy, salpingo-oophorectomy, and hysterectomy. in addition to complication of chemotherapy and radiotherapy.

Menopause is classified according to causes into three types :

• Natural menopause
• Premature Menopause/Early menopause
• Surgical/Induced Menopause

Physiological menopause is amenorrhea, it passes gradually through 3 stages until it reaches the permanent cessation of the menstrual cycle

• Premenopause is a word used to describe the years leading up to the last period ever when the levels of reproductive hormones are already becoming lower and more erratic, and symptoms of hormone withdrawal may be present.
• Perimenopause or “menopause transition”means the menopause transition years, the years before and after the last period ever, when the majority of women find that they undergo at least some symptoms of hormonal change and fluctuation, such as hot flashes, mood changes, insomnia, fatigue, irregular menses. During perimenopause, the production of most of the reproductive hormones, including estrogens and progestin, diminishes and becomes more irregular, often with wide and unpredictable fluctuations in levels. During this period, fertility diminishes. Symptoms of perimenopause can begin as early as age 35, although most women become aware of them about 10 years later than this. Perimenopause can last for a few years, or ten years or even longer.
• Postmenopause, a woman has considered in post-menopause after amenorrhea more than 12 months, not even any spotting. When she reaches that point, she is one year into post-menopause. The reason for this delay in declaring a woman post-menopausal is because periods become very erratic at this time of life, and therefore a reasonably long period is necessary to be sure that the cycling has ceased. A woman’s reproductive hormone levels continue to drop and fluctuate for some time into post-menopause, so any hormone withdrawal symptoms that a woman may be experiencing do not necessarily stop right away but may take quite some time, even several years, to disappear completely.^[1]

• Premature menopause is the permanent cessation of the menstrual cycle under 40 of age and early menopause (between ages 40 and 45 years).^[2]
• It is because of premature ovarian failure and several medical diseases.^[3]

• Induced menopause is the permanent cessation of the menstrual cycle because of complication of medical treatment such as chemotherapy, and radiotherapy for treatment of cancer and surgery such as bilateral oophorectomy, salpingo-oophorectomy, and hysterectomy.
• The causes of menopause after these surgery are the sudden quickly drop in hormone levels after oophorectomy and decrease in the mechanism of feedback after Hysterectomy although ovarian hormones are still produced .The surgical menopausal symptoms may be more severe like hot flushes.^[4]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Rahmah Al-Edresi, M.D.[2]

Menopause is natural amenorrhea that is happened without any pathological causes, but premature menopause/early menopause is caused by pathological diseases in ovaries and other organs such as premature ovarian failure (Primary ovarian insufficiency, POI), Adrenal insufficiency, type1 diabetes mellitus, autoimmune thyroid disease, Fanconi’s anemia, and Congenital adrenal hyperplasia. Cardiovascular disease and osteoporosis are most important conditions associated with menopause. Women who had genetic disorders ( Fragile X syndrome, Turner’s syndrome) more prone able to early menopause. The histopathological analysis include ovaries‘s cortex becomes thinner and it has fewer follicles and the medulla develops fibrosis and scars. Decrease of ciliated cells of Fallopian tubes and Uterus. And atrophy of vaginal mucosal layer .

• Menopause happens normally as women age and the main cause of the menopause is the natural shortage of the primordial follicles (oocytes) that stored in the ovaries and the decrease of the response of ovaries to anterior pituitary gonads hormones that include Follicle Stimulating Hormone (FSH) and Luteinizing Hormone(LH).
• These hormones stimulate the ovaries to produce estrogen and progesterone hormones in a cyclic method under the control of the hypothalamus that produces the gonadotropin-releasing hormones which stimulate anterior pituitary gonads hormone secretion and inhibin-B that plays role in the feedback mechanism.
• The anterior pituitary gonads hormones is decreased during the menopause transition result from decreased ovarian feedback of inhibin and are manifested primarily as elevations in follicle-stimulating hormone (FSH).^[1]

Premature menopause/early menopause is caused by several pathological diseases include:

• Pathological disease in ovaries include premature ovarian failure termed as primary ovarian insufficiency (POI). It is the loss of ovarian function lead to amenorrhea because of ovarian failure to respond for gonads hormone ( FSH, LH) and deficiency production of estrogen and progesterone hormone.
• Pathological disease in other organs such as Adrenal insufficiency, type1 Diabetes mellitus, Autoimmune thyroid disease, Fanconi’s anemia, Congenital adrenal hyperplasia due to 17α-hydroxylase deficiency.^[2][3]

There are genetic disorders involved in the premature menopause/early menopause include:

• Fragile X syndrome is a genetic disorder characterized by reduction of ovarian function, women that have Fragile X Syndrome go through early menopause an average 5 years early than other women.^[4]
• Turner’s syndrome: women born with missing X chromosome can go through menopause early, due to their ovaries do not form normally at birth.^[5]

The most important Conditions associated with Menopause include:

• Cardiovascular disease: during menopause, estrogen deficiency causes vasoconstriction of the vessel wall. menopause is linked to the increased risk of cardiovascular disease.

• Osteoporosis is a disease of the bones that causes bones to become weak and break easily. During menopause, estrogen deficiency increases osteoclastic activity.^[6]

On microscopic histopathological analysis of menopause include:

• Ovaries: the ovaries’s structure are change, the difference between the cortex and medulla is less evident. The cortex becomes thinner, it has fewer follicles. And there are invaginations of the surface epithelium of the cortex.The medulla develops fibrosis and scars, also undergoes the hyalinization of vessel walls.
• Fallopian tubes and Uterus: both endometrial and tubal mucosa demonstrated a gradual decrease in the number of ciliated cells and the non ciliated cells of the uterus.

• Vagina: the mucosa layer begins to atrophy due to decreased estrogen that causes this layer to become drier and thinner.^[7][8]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Rahmah Al-Edresi, M.D.[2]

menopause is caused by the increased age of women. But the common causes of premature menopause include Premature ovarian failure, chemotherapy, and radiotherapy and bilateral oophorectomy, salpingo-oophorectomy, and hysterectomy. Less common causes include Autoimmune diseases, diabetes mellitus, Thyroid disease. chronic fatigue syndrome. Genetic causes include Fragile X Syndrome and Turner’s syndrome

Natural menopause is caused by age, but premature menopause is caused by several causes include

• Premature ovarian failure/Primary ovarian insufficiency^[1]
• Complication of Chemotherapy or radiotherapy.
• Surgical causes: bilateral oophorectomy, salpingo-oophorectomy, and hysterectomy.^[2]

Certain health conditions include:

• Autoimmune diseases
• Diabetes Mellitus
• Thyroid disease
• Chronic fatigue syndrome^[3]

• Fragile X Syndrome.
• Missing X chromosomes (Turner’s syndrome)^[4]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Rahmah Al-Edresi, M.D.[2]

Menopause should be differentiated from other diseases presenting with menstrual irregularities (oligomenorrhea/amenorrhea) that are include Sheehan’s syndrome, Lymphocytic hypophysitis, Pituitary apoplexy, Empty sella syndrome, Pituitary cachexia, Hypothyroidism, Hypogonadotropic hypogonadism, Hypoprolactinemia, Primary adrenal insufficiency/Addison’s disease.

^{[1][2][3][4][5][6][7]}

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Rahmah Al-Edresi, M.D.[2]

The prevalence of menopause is estimated to be about 50 million cases annually. Menopause naturally occurs in women between 49 to 52 of age the average. The fatality cases were 345 cases per 3191 women aged between 50-86 years in the United States. There is no racial predilection to Menopause, but African American women had experienced the largest number of menopausal symptoms compared with other ethnic groups.

• The prevalence of menopause is estimated to be about 50 million cases worldwide will go into menopause annually.^[1]

• In 1990 there were 467 million postmenopausal women in the world, by 2030, menopausal women are projected to increase to 1.2 billion worldwide.^[2]
• The prevalence of menopausal symptoms differ in women according to areas and countries that they live them, the menopausal symptoms ranges from 74% of women in Europe, 36-50% in North America, 45-69% in Latin America and 22-63% in Asia.^[3]
• The prevalence of menopausal symptoms among women prescribed hormone therapy (HT), the mean age of patients was 54 years. The most common menopausal symptoms were: hot flushes (40 %), night sweats (17 %), insomnia (16 %), vaginal dryness (13 %), mood disorders (12 %), and weight gain (12 %).
• 85 % of postmenopausal women have experienced a menopausal symptom in their lifetime, and the prevalence of vasomotor symptoms( hot flushes and/or night sweats) alone is estimated at approximately 40 to 50 million women in the United States.^[4]

• The onset age of menopause between the ages of 50-53 in Europe.
• In North America, the onset age of menopause from 50-51years.
• In Latin America, the onset age of menopause from 44- 53 years.
• In Asia, the onset age of menopause from 42-49 years.^[3]

• In 1997, the fatality cases were 345 cases per 3191 women aged between 50-86 years in the United States over a mean follow-up time of 4.0 years.
• The mortality rate ratio (MRR) was 1.50% for women with menopause at age < 40, and the MRR of women with menopause at age 40-44 was 1.04%. While the MRR for women with menopause at age 45-49 was 0.96%.^[5]

• The prevalence of menopause does not vary by race.
• The ethnic differences in the symptoms experienced during the menopausal transition were noted. Asian women had experienced the smallest number of menopausal symptoms compared with all other ethnic groups, but African American women had experienced the largest number of menopausal symptoms compared with other ethnic groups.^[6]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Rahmah Al-Edresi, M.D.[2]

There are several risk factors that accelerate menopause onset. Common risk factors include women’s age, age at menarche, age at first gestation, number of pregnancies, oral contraceptives, irregular menses, unilateral oophorectomy, body mass index, smoking, tobacco, and alcohol, high physical activity, high serum lead level, high intake of fat.

There are several risk factors affecting the age of menopause onset include:^[1]

• Women’s age at onset menopause
• The age of women at menarche: Women who had early age at menarche, are more prone able for early menopause.^[2]
• Age at first gestation.
• A number of pregnancies: a multipara women less prone able for early menopause than an nulliparous women.
• Oral contraceptives: The use of high dose oral contraceptive accelerate the onset of menopause.^[3]
• Irregular menses.^[4]
• Unilateral oophorectomy.^[5]
• Body mass index: underweight women more prone able for early menopause than overweight women.^[6]
• Smoking, tobacco, and alcohol.^[7][8]
• High physical activity.^[9]
• High consumption of polyunsaturated fat.^[10]
• High serum lead levels.^[11]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Rahmah Al-Edresi, M.D.[2]

If left untreated, women with menopause may progress to develop hypertension, hyperlipidemia, and atherosclerosis. Common complications of menopause includecardiovascular disease, osteoporosis, Stroke. The complication that is happened with hormonal replacement therapy includes ovarian cancer, breast cancer, and endometrial cancer. Generally, the prognosis of menopause is good with treatment and a healthy lifestyle. In the late postmenopause stage, most menopausal symptoms relieved in most women. but untreated menopausal symptoms are poor prognosis in women who have high-risk factors to develop complications of menopause.

• The symptoms of menopause usually develop in the menopausal transition years (perimenopause) and start with irregular mense and vasomotor symptoms such as hot flashes, night sweats, palpitations, and headache. These symptoms continued until reach to postmenopause, in this stage a woman has amenorrhea for on year and vasomotor symptoms in addition to other symptoms such as vaginal atrophy, decreased libido, stress incontinence, frequency, depression and sleep disturbance.^[1]
• Without treatment, the patient will develop symptoms of hypertension, atherosclerosis, and hyperlipidemia which  may eventually lead to cardiovascular disease and coronary heart disease and osteoporosis.^[2]

Complications that can develop as a result of menopause include:^[2][3][4][5]

• Cardiovascular Disease, because of estrogen deficiency has an effect on cardiovascular system due to hyperlipidemia, hypertension, increased sympathetic activity.
• Osteoporosis is a disease of the bones that causes bones to become weak and break easily, estrogen deficiency increases osteoclastic activity
• Stroke, the risk of stroke increased in women after 10 years post menopause and associated with hormonal replacement therapy.^[6]
• Obesity
• Urinary incontinence

Complications that can develop as a result of the treatment of menopause by hormone replacement therapy include^[7]

• Breast cancer
• Ovarian cancer
• Endometrial cancer

• Generally, the prognosis of menopause is good with treatment and healthy lifestyle include stop smoking and a healthy diet and exercise. In the late post-menopause stage, most menopausal symptoms relieved in most women. But untreated menopausal symptoms are a poor prognosis among women who have high-risk factors to develop complications that are associated with menopause.^[8]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Sumanth Khadke, MD[2]

In general, diagnosis (plural diagnoses) has two distinct dictionary definitions. The first definition is “the recognition of a disease or condition by its outward signs and symptoms”, while the second definition is “the analysis of the underlying physiological/biochemical cause(s) of a disease or condition”.

Diagnosis covers a broad spectrum, or spectra, of testing in some form of analysis; collective reasoning using such tests is called the method of diagnostics, leading then to the results of those tests by ideal (ethics) would then be considered a diagnosis, but not necessarily the correct one.

In medicine, diagnosis or diagnostics is the process of identifying a medical condition or disease by its signs, symptoms, and from the results of various diagnostic procedures. The conclusion reached through this process is called a diagnosis. The term “diagnostic criteria” designates the combination of symptoms which allows the doctor to ascertain the diagnosis of the respective disease.

Typically, someone with abnormal symptoms will consult a physician, who will then obtain a history of the patient‘s illness and examine him for signs of disease. The physician will formulate a hypothesis of likely diagnoses and in many cases will obtain further testing to confirm or clarify the diagnosis before providing treatment.

Medical tests commonly performed are measuring blood pressure, checking the pulse rate, listening to the heart with a stethoscope, urine tests, fecal tests, saliva tests, blood tests, medical imaging, electrocardiogram, hydrogen breath test and occasionally biopsy.

The word diagnosis is derived from the Greek words dia which means “by”, and gnosis which means “knowledge”. The verb is diagnose and a person diagnosing could be considered a diagnostician.

A physician‘s job is to know the human body and its functions in terms of normality (homeostasis). The four cornerstones of diagnostic medicine, each essential for understanding homeostasis, are: anatomy (the structure of the human body), physiology (how the body works), pathology (what can go wrong with the anatomy and physiology) and psychology (thought and behavior). Once the doctor knows what is normal and can measure the patient’s current condition against those norms, she or he can then determine the patient’s particular departure from homeostasis and the degree of departure. This is called the diagnosis. Once a diagnosis has been reached, the doctor is able to propose a management plan, which will include treatment as well as plans for follow-up. From this point on, in addition to treating the patient’s condition, the doctor educates the patient about the causes, progression, outcomes, and possible treatments of his ailments, as well as providing advice for maintaining health.

It should be noted however, that medical diagnosis in psychology or psychiatry is problematic. Apart from the fact that there are differing theoretical views toward mental conditions and that there are few “lab” tests available for various major disorders (e.g., clinical depression), a causal analysis with respect to symptomatology and disorder/disease is not always possible. As a result, most if not all mental conditions, function as both symptoms as well as disorders. There are often functional descriptions provided for psychological disorders and these are vulnerable to circular reasoning due to the etiological fuzziness inherent of these diagnostic categories. (BDG, 2006)

Diagnosis is a fluid process in which the physician responds to information garnered from the patient and others, from a physical examination of the patient, and from medical tests performed upon the patient.

The doctor should consider the patient in his ‘well’ context rather than simply as a walking medical condition. This entails assessing the socio-political context of the patient (family, work, stress, beliefs), in addition to the patient’s physical body, as this often offers vital clues to the patient’s condition and its management.

The process of diagnosis begins when the patient consults the doctor and presents a set of complaints (the symptoms). If the patient is unconscious, this condition is the de facto complaint. The doctor then obtains further information from the patient himself (and from those who know him, if present) about the patient’s symptoms, his previous state of health, living conditions, and so forth.

Rather than consider the myriad diseases that could afflict the patient, the physician narrows down the possibilities to the illnesses likely to account for the apparent symptoms, making a list of only those conditions that could account for what is wrong with the patient. These are generally ranked in order of probability.

The doctor then conducts a physical examination of the patient, studies the patient’s medical record, and asks further questions as he goes, in an effort to rule out as many of the potential conditions as possible. When the list is narrowed down to a single condition, this is called the differential diagnosis, and provides the basis for a hypothesis of what is ailing the patient.

Unless the physician is certain of the condition present, further medical tests are performed or scheduled (such as medical imaging), in part to confirm or disprove the diagnosis but also to document the patient’s status to keep the patient’s medical history up to date. Consultations with other physicians and specialists in the field may be sought. If unexpected findings are made during this process, the initial hypothesis may be ruled out and the physician must then consider other hypotheses.

Despite all of these complexities, most patient consultations are relatively brief, because many diseases are obvious, or the physician’s experience may enable him to recognize the condition quickly. Another factor is that the decision trees used for most diagnostic hypothesis testing are relatively short.

Once the physician has completed the diagnosis, he explains the prognosis to the patient and proposes a treatment plan which includes therapy and follow-up (further consultations and tests to monitor the condition and the progress of the treatment, if needed), usually according to the guideline provided by the medical field on the treatment of the particular illness.

Treatment itself may indicate a need for review of the diagnosis if there is a failure to respond to treatments that would normally work.

The history of medical diagnosis began in earnest from the enlightened days of Hippocrates in ancient Greece but is far from perfect despite the enormous bounty of information made available by medical research including the sequencing of the human genome. The practice of diagnosis continues to be dominated by theories set down in the early 1900s.

Over two thousand years ago, Hippocrates recorded the association between disease and heredity. In similar fashion, Pythagoras noted the association between metabolism and heredity (allergy to Fava beans). The medical community, however, has only recently acknowledged the importance of genetics and its relevance to mainstream medicine.

The ideals of William Osler who transformed the practice of medicine in the early 1900s were based on the principles of the diagnosis and treatment of disease. According to Osler, the functions of a physician were to be able to identify disease and its manifestations, understand its mechanisms, how it may be prevented and how it may be cured. For his medical students he believed that the best textbook was the patient himself – analysis of morbid anatomy and pathology were the keys. The Oslerian ideal continues today, as the basis of the Doctor’s strategy is, “What disease does this patient have and what is the best way for treatment?” The emphasis is on the classification of the disease in order to use the remedies available for its effects to be reversed or ameliorated. The human being in question is representative of a class of people with this type of disease whereas the biological individuality of this person is not given any great weight.

The successor to William Osler as Regius Professor at Oxford was Archibald Garrod. Garrod echoed the observations of his Greek counterparts of two millennia ago, …our chemical individualities are due to our chemical merits as well as our chemical shortcomings; and it is more nearly true to say that the factors which confer upon us our predispositions to and immunities from various mishaps which are spoken of as diseases, are inherent in our very chemical structure; and even in the molecular groupings which confer upon us our individualities, and which went into the making of the chromosomes from which we sprang. Considering that the time that he formulated these ideas were the early 1900’s, and the knowledge of DNA encoding genes that in turn encoded proteins responsible for bodily structure and functions not being discovered until some fifty years later it took some time before medicine could fully appreciate the fundamental importance of his concept of diagnosis.

Whereas Osler laid the founding principles by which medicine should be practiced, Garrod placed these principles in a greater context of a chemical individuality that is inherited and is subject to the mechanisms of evolutionary selection. The Oslerian ideal of medical practice continues to dominate medical philosophy today. The patient is a collective of symptoms to be characterized and analyzed algorithmically in order to draw a diagnosis and subsequently produce a strategy of treatment. Medicine is about problems based solutions. In keeping with this philosophy, today’s pathology reports provide a momentary snapshot of the patient’s biochemical profile, highlighting the end result of the disease process.

Garrod’s conception of biological individuality was confirmed with the advent of the sequencing of the human genome. Finally the subtle relationship between inheritance, individuality and environment became apparent via the variations detected in DNA. In each patient’s DNA lies a script for how their bodies will change and become ill as well as how they will handle the assaults of the environment from the beginning of their life to its end. It is hoped that by knowing a patient’s genes that the biological strengths and weaknesses in respect to these assaults will be revealed and disease processes can be predicted before they have the opportunity to manifest. Although knowledge in this area is far from complete, there are already medical interventions based on this. More importantly, the physician, forewarned with this knowledge can guide the patient towards appropriate lifestyle changes to anticipate and mitigate disease processes.

• GPnotebook web site GPnotebook is a British medical database for GPs that provides an immediate reference resource for clinicians worldwide. The database consists of over 30,000 pages of information.
• Free 24/7 DRG & ICD-9-CM lookup powered by Flash Code at icd9coding.com
• Differential Diagnosis
• Merck Manual of Diagnosis and Therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Sumanth Khadke, MD[2], Ogechukwu Hannah Nnabude, MD

Compliance with avoidance is important. The key to avoidance is proper evaluation and detection of causative allergen. Wear appropriate clothing to protect against irritants at home and in a work environment. ^{[1] [2]}

High-potency topical corticosteroids, e.g. clobetasol propionate 0.05% cream, may be used to reduce the inflammation. ^[3] As a general rule, high-potency corticosteroids should not be used on thin skin, e.g. face, genitals, intertriginous areas, to avoid the risk of skin atrophy. Antihistamines such as hydroxyzine and cetirizine are recommended to control pruritus. Systemic steroids are advised in severe cases but should be tapered gradually to prevent recurrences. Friction should be avoided as well as the use of soaps, perfumes, and dyes. Emollients are used for hydrating the skin. Tacrolimus ointment and pimecrolimus cream are immunomodulating drugs that inhibit calcineurin and are helpful in allergic contact dermatitis.