Sex and Gender Womens Health Collaborative Fostering a Sex & Gender Approach to Medical Education Mon, 04 Dec 2017 20:43:52 +0000 en-US hourly 1 Sex and Gender Differences in Psychogenic Non-epileptic Seizures Tue, 12 Sep 2017 00:38:53 +0000 In This Case: Sex and Gender Differences in Psychogenic Non-epileptic Seizures 

Author:  Sigrid Young

Co-Editor:  Dr. Rebecca Baron

Case Overview (*Case created as an illustrative example)

Psychogenic non-epileptic seizures (PNES) are paroxysmal events that resemble epileptic seizures but are not associated with changes in cortical activity. The etiology of PNES is not well understood, and its diagnosis and treatment remain a clinical challenge.

Patient Profile

Chief Complaint: “I keep having these staring spells.”

History of Present Illness:

Mrs. K is a 36-year-old female who presents today with new onset of seizures. These episodes began two weeks ago in the context of starting a new job at a corporate law firm and subsequent stress with adjusting to her new 90-hour work schedule. According to family members, the episodes consist of staring spells that last for several minutes with mild shaking in her right arm. She has no recollection of these events and states that stress and exhaustion increase her seizure frequency. On average, she is experiencing 5-10 episodes daily. She claims that the seizures are interfering with her job and expresses concern that she will become unemployed if she does not gain control over her seizures. She lives with her 6-year-old daughter and husband, who is currently unemployed.

Past Medical History:

PMH: Generalized Anxiety Disorder (GAD), Post-traumatic Stress Disorder (PTSD)

Prior surgeries: None

Prior hospitalizations: None

Medications: Sertraline (50 mg)

Family History:

Mother: 60-years-old – depression diagnosed 10 years ago

Brother: 32-years-old – ADHD diagnosed 20 years ago

Father: 65-years-old – no significant history

Social History:

Past Trauma/Abuse: Sexual, verbal, and emotional abuse from past partner in college

Tobacco use: none

Alcohol: none

Physical Exam:

General Appearance: Patient is well-nourished and looks stated age. Appears comfortable and is no acute distress.

Neurological Exam: Cranial nerves II-XII symmetric and intact bilaterally. 5/5 strength in all 4 extremities. Sensation intact to light touch throughout. Cerebellar exam reveals normal finger to nose, rapid alternating movements, and heel to shin. Gait evaluation reveals toe, heel, and tandem walk within normal limits. Reflexes are 2+ and symmetric in the biceps, triceps, brachioradialis, patellar, and Achilles tendons. Down-going Babinski, no clonus bilaterally. Negative pronator drift and Romberg.

Diagnosis: Psychogenic non-epileptic seizures (PNES)

Treatment: The patient was counseled on sleep hygiene and referred to outpatient cognitive behavioral therapy (CBT). Further work-up with video-EEG will be conducted to confirm diagnosis.


Psychogenic non-epileptic seizures (PNES) occur more frequently in women than in men, accounting for approximately 80% of all cases.1 Several factors may explain this trend – first, PNES often occur with comorbid psychiatric disorders, typically depression, anxiety, post-traumatic stress disorder (PTSD), and personality disorders, which are more commonly diagnosed in women.2 Trauma history, including sexual, physical, verbal, and emotional abuse, is also a major risk factor for PNES. Not only are these adverse events more prevalent among women, but they are also more likely to be reported by women compared to men. Recent neurobiological research suggests that women with a past trauma history are more likely to experience abnormal connectivity between brain areas involved in emotional processing, cognitive integration systems, and motor/pre-motor regions, which may explain an underlying vulnerability to PNES for women compared to men.3

Because men are less likely to utilize healthcare services, diagnosing PNES in this population may be particularly challenging. The gold standard for diagnosing PNES is with video-EEG. When video-EEG reveals no epileptiform activity before, during, or after ictus, a diagnosis of PNES can be made definitively. 1 It has been postulated that PNES may in fact be underdiagnosed in men. One study found that video-EEG confirmed PNES was accurately predicted in 86% women versus 61% men.4 Another study comparing male veterans with PNES to those with epilepsy found that ~40% of male veterans with seizure symptoms were diagnosed with PNES – a larger percentage than is currently recognized in the clinical community.5 Although rates of PNES differ between men and women, recent literature suggests that seizure semiology is similar, with both groups experiencing similar rates of major motor, minor motor, and non-motor seizure episodes.6 The fact that men experience similar seizure severity and symptoms as women with PNES warrants particular emphasis, especially since PNES are more challenging to diagnose in men.

In addition to diagnosis, treatment for PNES also poses a current clinical challenge. Successful treatment often includes both pharmaceutical and behavioral interventions, namely therapeutic doses of sertraline, a selective serotonin reuptake inhibitor, and cognitive behavioral therapy (CBT). In a randomized clinical trial, it was found that 60% of patients who received both CBT and sertraline interventions experienced a decrease in seizure severity and frequency, compared to 50% of patients who received CBT-only treatment. Patients receiving only sertraline for treatment showed no reduction in seizures.7 Male patients are less likely to seek behavioral and mental health interventions, perhaps due to traditional gender norms of masculinity.8 The fact that psychotherapy plays such a significant role in treating PNES suggests that female patients are more likely to seek CBT and experience improvement of their seizure symptoms compared to men.

The etiology of PNES currently remains unknown, and similar to the historical diagnosis of hysteria, unexplained symptoms in women often become relegated to the psychiatric realm until further clinical knowledge is uncovered to explain these symptoms.9 Although PNES is traditionally thought of as a “female diagnosis,” it is important to recognize that PNES are underdiagnosed and undertreated in men. Understanding this discrepancy will yield better clinical care, reduce health care costs, and ultimately improve knowledge of how neuropsychiatric conditions can manifest across the sex and gender spectra.


1. Devinsky O, Gazzola D, LaFrance WC Jr. Differentiating between nonepileptic and epileptic seizures. Nat Rev Neurol. 2011 Apr;7(4):210-20. doi: 10.1038/nrneurol.2011.24. Epub 2011 Mar 8. Review.

2. Shen, W., Bowman, E.S. & Markand, O.N. Presenting the diagnosis of pseudoseizure. Neurology 40, 756-759 (1990).

3. Asadi-Pooya AA. Psychogenic nonepileptic seizures are predominantly seen in women: potential neurobiological reasons. Neurol Sci. 2016 Jun;37(6):851-5. doi: 10.1007/s10072-016-2481-5. Epub 2016 Jan 21. Review.

4. Noe KH, et al. Confirming psychogenic nonepileptic seizures with video-EEG: sex matter. Epilepsy Behav. 2012 Mar;23(3):220-3. doi: 10.1016/j.yebeh.2011.12.015. Epub 2012 Feb 15.

5. Dworetzky, B.A., et al. Characteristics of male veterans with psychogenic nonepileptic seizures. Epilepsia. 4, 1418-1422 (2005). Epilepsy Behav. 2013 Nov;29(2):295-7. doi: 10.1016/j.yebeh.2013.08.006. Epub 2013 Sep 8.

6. Thomas AA, et al. Diagnosis of probable psychogenic nonepileptic seizures in the outpatient clinic: does gender matter?

7. LaFrance WC Jr, et al. Multicenter pilot treatment for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA Psychiatry. 2014 Sep;71(9):997-1005. doi: 10.1001/jamapsychiatry.2014.817.

8. Good GE, Thomson DA, Brathwaite AD. Men and therapy: Critical concepts, theoretical frameworks, and research recommendations. Journal of Clinical Psychology. 2005;61(6):699–711.

9. Goetz, CG. Charcot, hysteria, and simulated disorders. Handbook of Clinical Neurology. 2016;139: 11-23. doi: 10.1016/B978-0-12-801772-2.00002-3.

Pregnancy During Transition Tue, 12 Sep 2017 00:34:23 +0000 In This Case: A Transgender Male’s Decision to Conceive

Author: Jon Spiegel

Co-Editor: Dr. Rebecca Barron

This is a fictional case study meant to represent the medical need of an underserved and often slighted population of patients.

Case Overview

H.G. is a transgender man wishing to have a child after 36 months on masculinizing hormone treatment.

Patient Profile

Initials: H.G.

Age: 28

Sex/Gender: Transgender man

Gravida: 0

Occupation: Starbucks barista

Living situation/marital status: unmarried committed relationship

Substance use (e.g. smoking, alcohol, street drugs): smokes one pack of cigarettes per week and drinks 5-7 drinks per week, typically beer

Medical History

H.G. is a transitioning transgender man. In affirming his gender identity, he has undergone the following procedures: masculinizing hormone treatment, subcutaneous mastectomy and pectoral implants (“top-surgery”), rhinoplasty, and genitoplasty.

In addition to these, H.G. has suffered from migraines since age 12. He was in a car accident at age 22 during which he broke several ribs and his tibia. He has suffered from depression for most of his life and has taken 25mg of Paroxetine (Paxil) for the past 4 years without any major side effects.

Presenting Complaint

H.G. began medical treatments to guide in his transition approximately 36 months ago. He has remained on testosterone treatment and has undergone masculinizing facial surgery and “top-surgery”.

H.G. has a sperm producing partner and they would like to now have a child together. They would strongly prefer for H.G. to carry this child rather than using a surrogate or pursuing adoption.

Evaluation and Diagnosis

Movement off of masculinizing hormones can be associated with painful return of menses as well as considerable mental and social morbidity. We therefore first offered and provided a gynecological evaluation to assess if there are any major structural anomalies or pathophysiological entities that would be expected to complicate the pregnancy.

All evidence indicated good gynecological health suggesting reasonable chance of fertilization, implantation, and fetal growth.


Cessation of hormone treatment was recommended. It was important to remind H.G. that return of menses can take six months or longer following cessation of hormones but that he can get pregnant prior to its return1.

The primary concern of H.G. and his partner surrounded risk of congenital defects in their child as a result of his testosterone use. Past work has shown high (endogenous) androgen levels to be associated with lower birth weight2,3 and lower infant weight gain3, though work to date has not examined risk specifically in transgender men (who receive exogenous androgens). Some work indicates hyperandrogenism may lead to epigenetic changes in the oocyte leading to increased incidence of glucose metabolism disorder in offspring4, though more work is needed. In light of the lack of work to support negative consequences from H.G.’s testosterone treatment, we supported their decision to conceive but advised that they wait to try to have children until H.G.’s testosterone levels return to normal female physiological range to minimize risk of reduced birth weight.


Some transgender men still want to have children after having begun transitioning. Masculinizing hormone treatments can complicate this process (as they do in this case) and surgeries can complicate or preclude it. In light of these complications, providers should discuss with patients whether they have any future interest in having offspring and provide options such as cryofreezing eggs prior to providing such care. Cryofreezing could enable the patient to avoid cessation of hormones if they wished to use assisted reproductive technologies at a future time5. Additionally, the strong gender associations present in our society linking pregnancy and femininity can complicate the self-image of a trans man as the carrier of their own child.

This violation of typical gender roles surrounding pregnancy can make pregnant parents feel isolated, and interviewed parents have reported the “lack of clear role models of what a positive, well integrated, gender-variant parental role might look like,” to be especially difficult6. The importance of the physician to provide a supporting and accepting environment is stressed. This can begin with asking the patient for their preferred name and pronouns7.

The entire medical team should also be familiarized with what it means to be transgender and similarly play an integral role in providing a supportive environment for the parent-to-be. Particular attention has been paid toward the importance of knowledgeable nursing staff around transgender men’s identities and their post-partum needs, particularly surrounding lactation8. Obstetric care and delivery do not appear to differ in pregnancies of non-gender conforming and transgender patients and cisgender patients’ pregnancies. In light of the increased incidence of depression and suicidal ideation amongst transgender individuals,9,10 care focusing on prevention, detection, and treatment of post-partum depression may be warranted.

While transitioned and transitioning parents do present some clinical challenges, they are more like to other obstetric patients than different: they require a careful history with care adjusting accordingly, an accepting medical environment, and standard obstetric monitoring. By providing these patients with the care they need, we can help to ensure both their safety and the safety of their future children.


1. Light, Alexis D., et al. “Transgender men who experienced pregnancy after female-to-male gender transitioning.” Obstetrics & Gynecology 124.6 (2014): 1120-1127.

2. Carlsen, S. M., G. Jacobsen, and P. Romundstad. “Maternal testosterone levels during pregnancy are associated with offspring size at birth.” European Journal of Endocrinology 155.2 (2006): 365-370.

3. Voegtline, K. M., et al. “Sex-specific associations of maternal prenatal testosterone levels with birth weight and weight gain in infancy.” Journal of developmental origins of health and disease 4.04 (2013): 280-284.

4. Tian, Shen, et al. “Prevalence of Prediabetes Risk in Offspring Born to Mothers with Hyperandrogenism.” EBioMedicine (2017).

5. Maxwell, Susan, et al. “Pregnancy Outcomes After Fertility Preservation in Transgender Men.” Obstetrics & Gynecology (2017).

6. Ellis, Simon Adriane, Danuta M. Wojnar, and Maria Pettinato. “Conception, pregnancy, and birth experiences of male and gender variant gestational parents: it’s how we could have a family.” Journal of Midwifery & Women’s Health 60.1 (2015): 62-69.

7. Makadon HJ, Mayer K, Potter J, et al. Fenway guide to lesbian, gay, bisexual, and transgender health, 2nd ed. Philadelphia: American College of Physicians, 2015

8. Wolfe-Roubatis, Emily, and Diane L. Spatz. “Transgender men and lactation: what nurses need to know.” MCN: The American Journal of Maternal/Child Nursing 40.1 (2015): 32-38.

9. Hepp, U., et al. “Psychiatric comorbidity in gender identity disorder.” Journal of psychosomatic research 58.3 (2005): 259-261.

10. Clements-Nolle, Kristen, Rani Marx, and Mitchell Katz. “Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization.” Journal of homosexuality 51.3 (2006): 53-69.

Postural Orthostatic Tachycardia Syndrome Tue, 12 Sep 2017 00:02:31 +0000 In This Case: Postural Orthostatic Tachycardia Syndrome (POTS)

Author: Janice Werbinski, MD, FACOG

Case Overview: POTS is a little known condition affecting the autonomic nervous system, and 80-85% of those affected are female, with usual onset at puberty.

Presenting Complaint: LM is a 17-year old adolescent female in Pennsylvania whose parents sought medical care at age of 12 after a week of tiredness and headaches which persisted and did not respond to home interventions. LM first displayed symptoms at age 12, and these consisted of extreme fatigue, heart palpitations, sleeping 15 to 17 hours a day, headaches, dizziness, and inability to attend school without feeling sleepy.

Patient Profile:

Name: LM

Age: 17

Sex: Female

Social Status: Single adolescent living at home with parents and an older sister.

Occupation/Lifestyle: Student-12th grade, not working currently. The main limitation is not being able to stand up for long periods of time. At school she has a plan that allows her to start the school day later and modified PE class. Additionally, she has water and salty snacks available at all times as well as extra time to complete work when absent from school for more than a week.

Medical History: Patient has been diagnosed with: POTS (Postural Orthostatic Tachycardia Syndrome), IBS (Irritable Bowel Syndrome), GERD (Gastro-Esophageal Reflux Disease), Dysmenorrhea, Hypersomnia, and Overactive Bladder. Patient suffers from fatigue, heat intolerance, tachycardia, low blood pressure, low blood volume, blood pooling, dizziness/light-headedness, abdominal pain, and flushing.

Family History: No history of neurologic or hypotensive or autonomic disorders.

Interventions: Florinef, Midodrine, Seasonique, Amitriptyline, Ritalin, Dicyclomine, and Omeprazole.

Non-pharmaceutical treatments; melatonin, physical therapy, yoga, acupuncture, vegan diet, weight-lifting, salt tablets, bed risers, increased salt and water intake, compression stockings, probiotics, and recumbent bike.

Assessment: Patient has been evaluated by pediatrics, cardiology, neurology, gynecology, nutritionist, physical therapists, rheumatology, urology, pediatric gastroenterology, and adolescent medicine.

Blood work: Mononucleosis screen, Lyme Disease screen, Complete Blood Count, Comprehensive Metabolic Screen, Phosphorus, Ferritin, Epstein-Barr Antibody, RBC SED Rate, Insulin, Glucose, Blood Ventilation/Perfusion Ratio, Thyroid, Thyroxine.

Other Testing: Echocardiogram, Head CT scan, Poor Man’s tilt-table, Sleep study, Transthoracic Echogram, Tilt-table test, QSART (Sweat test), Endoscopy, Esophageal pH Probe test, Renal ultrasound scan, and Urinalysis.

Pediatrics initially diagnosed a post viral syndrome but blood work did not confirm so other tests were required and patient was referred to a cadre of specialists.

· Cardiology specialist diagnosed POTS.

· Neurologist made a secondary diagnosis of mild Neurogenic orthostatic hypotension with neurogenic POTS.

· Pediatric gastroenterologisy diagnosed with IBS and GERD.

Diagnosis: Postural Orthostatic Tachycardia Syndrome (POTS). A little known, yet fairly common Dysautonomia Syndrome. (describing various medical conditions causing malfunction of the autonomic nervous system) For more information, see:

Evaluation/Treatment: Initially, two different pediatricians were not able to determine a diagnosis. One of them suspected an anxiety disorder or school aversion. After several visits, and numerous blood tests, patient was referred to a cardiologist and a rheumatologist. The cardiologist was the first one to evaluate for, and diagnose POTS. Patient’s fatigue and change in sleep cycle were not addressed by this diagnosis. A rheumatologist confirmed the diagnosis and referred patient to a sleep clinic. A sleep study result was normal.

Patient was started on fludrocortisone, increased fluids, and salt. The fludrocortisone helped initially, but improvement did not persist.

A second Cardiologist started midrodine, an alpha receptor agonist.

Due to dysmenorrhea, gynecology prescribed Seasonique, (Levonorgestrel/Ethinyl Estradiol – extended cycle). The patient states it is her “magic” pill. Very effective for the dysmenorrhea

Patient was unable to attend school for nearly a year and was bed ridden. After ~ 6 months patient saw a neurologist in Florida. The neurologist diagnosed Mild Neurogenic orthostatic hypotension with neurogenic POTS. neurologist suggested compression stockings, raised head of bed, salt tablets, and resistance training for deconditioning. Ultimately, she saw a cardiologist in Ohio who specializes in treating POTS. He prescribed methylphenidate which only helped the symptoms for a week. She experienced side effects of appetite suppression and abdominal pain.

Some non-pharmacologic treatments were recommended: physical therapy, salt tablets. Physical therapy was difficult due to deconditioning and low blood pressure which limited this modality.

Because of persistence of abdominal pain, referral was made to gastroenterology. Additional tests: Endoscopy and Ph probe were normal. Patient was prescribed dicyclomine (Bentyl), and omeprazole. The omeprazole didn’t give any relief of GI symptoms, and initially dicyclomine at 10 mg. was no help.

Adolescent Medicine Referral suggested amitriptyline (Elavil), 20 mg. for the abdominal pain, but not much improvement. When this was increased to a higher dose (35 mg.), the abdominal pain subsided somewhat.  An additional increase of the dose to 50 mg. has helped remarkably.  Again, the patient dubs these her “life savers.”


The presentation and course of this adolescent female with POTS is likely typical, as it is a complex disorder with symptoms which require expertise from many disciplines of medicine, as many syndromes do. This girl presented with multiple symptoms, and faced the skepticism that many women experience when their symptoms don’t fit a particular known diagnostic pattern. As many women have experienced, when symptoms aren’t standard, a diagnosis of anxiety or other psychologic spectrum is often assumed, and, indeed, counseling was recommended for this patient, but wasn’t particularly helpful

Since her symptoms spanned gyn, GI, neurology, cardiology, and urology, it was hard for the parents to decide where to start, and they needed to persist in researching symptoms, consulting support groups, and finding the proper diagnostician. And even then, several treatment options needed to be tried before finding any that were helpful. POTS often presents in adolescence, and is much more prevalent in girls (5:1, female:male) and since much of the diagnostic testing and symptomatology lies within the purview of cardiology, the consultation in that field turned out to be the most helpful. In fact, the parents were able to find an expert cardiologist in Ohio who specializes in these cases. Unfortunately, the etiology is still largely unknown, but it seems to be associated with an immune-mediated neuropathy, with studies showing autoantibodies to alpha3 acetyl choline receptors of the peripheral autonomic ganglia. This would likely explain the preponderance of diagnosis in females, as many autoimmune diseases seem to be more common in women.




Panic Disorder and Cardiac Arrhythmias Mon, 11 Sep 2017 22:49:56 +0000 In This Case: Panic Disorder and Cardiac Arrhythmias in Women

Author: Kaitlyn McLeod

Co-Editor:  Dr. Rebecca Barron

Analogous symptoms in panic disorder and cardiac arrhythmias can lead to diagnostic uncertainty for clinicians and hesitation to seek care for patients. Given that the prevalence of panic disorder is higher in women than men, women are poised to interact with this uncertainty more frequently [1,2].

Patient Profile (Based on true patient, but some details are fabricated)

Initials: Mrs. M

Age: 35

Sex: Female

Occupation: Teacher

Living situation/marital status: Long-term relationship; currently lives with boyfriend

Substance use: smokes cigarettes (1 pack/day for 15 years); smokes marijuana on occasion, denies other recreational drug use; alcohol <7 drinks per week on average

Past Medical History: 5-year history of panic disorder. No current medications or prior surgeries or current medications. No relevant family history.

Patient presented to the ED via EMS after sudden onset of racing heart approximately 45 minutes prior to arrival. She has associated shortness of breath and fatigue. Patient was outside of her apartment smoking a cigarette when her symptoms started. Patient notes that initially she thought she might be having a panic attack and tried to slow her breathing, sit down, and relax. However, her heart continued to race, so she called EMS.

Evaluation: On physical exam, patient appears anxious and uncomfortable. HR: tachycardic at 180 with regular rhythm. Troponin: negative. EKG shows SVT Supraventricular Tachycardia. CXR: negative. Toxicology screen: negative.

Diagnosis: new onset SVT

ED Course: Vagal maneuvers were performed, but did not improve patient’s tachycardia. Adenosine was administered. Patient’s heart rate decreased to 80BPM and returned to sinus rhythm without any arrests or bradycardia.


The lifetime prevalence of anxiety disorders—including panic disorder, agoraphobia, social anxiety disorder, and generalized anxiety disorder—is higher in women than men, and these disorders are more likely to be disabling in women than men [1]. It should be acknowledged that a higher prevalence of psychiatric disorders could be explained by cultural norms dictating female acceptance of psychopathology and willingness to report symptoms. Regardless, past medical history of anxiety disorder poises women to be at greater risk of diagnostic error in the context of cardiac symptoms due to provider anchor biasing. This type of cognitive bias occurs when a provider fails to consider a broad differential diagnosis for new symptoms because they can be explained by a past diagnosis. Anchoring bias has been identified as a key reason for delayed diagnosis in the context of other anxiety disorders such as PTSD [3].

Anxiety and stress can cause decreased vagal tone and increased sympathetic activation leading to somatic symptoms, specifically palpitations and shortness of breath [4]. When a patient presents to an emergency department with these symptoms and has a prior history of panic disorder,

concluding that a panic attack is the root cause can be logical. It could be an example of anchoring bias, however, because palpitations and shortness of breath are also consistent with a host of cardiac problems including Postural Orthostatic Tachycardia Syndrome (POTS) and SVT. For instance, Dr. Beauregard, a cardiologist who specializes in cardiac arrhythmias, in an article entitled “Cardiac Arrhythmia Management: Why Women are different than Men,” explores how panic disorder and POTS are often confused [5]. Thus, relationship between anxiety and cardiac health is complex, and considering a broad differential diagnosis is necessary to optimize treatment.

Anchoring bias not only affects the provider, but it also affects the patient. Mrs. M noted that she delayed seeking care because she thought she was having a panic attack. This begs the question: does past medical history of panic disorder, a condition more prevalent in women, delay care for cardiac events? This is a factor that should be considered when educating patients and studying cardiac disease through a gendered lens.

Overall, Mrs. M seemed to receive appropriate treatment, but there was lacking explicit recognition and education that her panic disorder and heart health are interconnected. Sympathetic activation can lead to increased heart stress and the development or exacerbation of cardiac disease and arrhythmias [4]. Therefore, patients should be encouraged to have a lower, not higher, threshold to seek emergency care for cardiac symptoms in the context of pre-existing panic disorder.


1. McLean CP, Asnaani A, Litz BT, Hofmann SG. Gender Differences in Anxiety Disorders: Prevalence, Course of Illness, Comorbidity and Burden of Illness. Journal of psychiatric research. 2011;45(8):1027-1035. doi:10.1016/j.jpsychires.2011.03.006

2. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen H, Kendler KS. Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric Disorders in the United StatesResults From the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51(1):8-19. doi:10.1001/archpsyc.1994.03950010008002

3. Daya SK, Paulus AO, Braxton EE Jr, Vroman PJ, Mathis DA, Lin R, True MW. Delayed Diagnosis of TSH-Secreting Adenoma Attributed to Worsening Post-Traumatic Stress Disorder Symptoms in a Military Veteran Because of Provider Anchoring Bias. Military Medicine. 2017 Mar;182(3):e1849-e1853. doi: 10.7205/MILMED-D-16-00241.

4. Hocaoglu C, H.Yeloglu C, Polat S, undefined undefined undefined. Cardiac Diseases and Anxiety Disorders. In: Cardiac Diseases and Anxiety Disorders. INTECH Open Access Publisher; 2011.

5. Beauregard L-A. Cardiac Arrhythmia Management: Why Women are Different from Men. Cardiac Arrhythmias. Accessed May 14, 2017.

ACL Tears in Female Athletes Mon, 11 Sep 2017 22:43:31 +0000 In this Case: ACL Tears in Female Athletes

By: Alicia Hersey

Co-Editor:  Dr. Rebecca Barron

Case Overview:

Female athletes experience ACL tears at a higher rate than their male counterparts. Elucidating the most pertinent factors that contribute to this discrepancy is important for designing effective prevention and intervention for female athletes to reduce, and thereby equalize, injury rate.

Patient Profile

Initials: CR

Age: 16

Sex: Female

Medical History: No pertinent positives; no prior knee or lower extremity injury.

Surgical History: None

Social History: Patient is in 10th grade. She lives at home with her parents. She plays soccer (since age 6) and softball (since age 10). She denies use of alcohol, tobacco, or illicit drugs.

Prescribed Medication: None

Presenting Complaint

CR presents to the Emergency Department with pain and swelling in the right knee. Patient reports immediate pain, followed by swelling, after another player slid into her right shin during her soccer game, approximately 1 hour prior to arrival. She notes that it felt like her knee “shifted”. Patient reports the pain was initially 9/10 in severity, but is currently a 5/10. She reports difficulty bearing weight on her right leg. Patient denies other trauma, numbness, or paresthesias.


Physical Exam:

Vital signs: BP 110/60, HR 90, RR 16, Temp 37° C, pO2 100% on room air

On exam, CR is awake, alert, and appearing in mild painful distress. Right knee markedly swollen compared to left, moderately tender to palpation at joint lines. Active flexion limited secondary to pain. (+) Lachman test, (+) hemarthrosis. Left knee exhibits full active range of motion without swelling, tenderness, or deformity. Full active range of motion of hips, ankles, and toes bilaterally without swelling, tenderness, or deformity. DP and PT pulses intact bilaterally. Sensation to light touch intact proximally and distally.

Right knee X-ray: (-) fracture

Hospital Course

MRI confirmed complete ACL rupture. CR underwent ACL graft reconstruction 2 weeks later without complications. Rehabilitation therapy arranged upon discharge.


Female athletes exhibit higher rates of anterior cruciate ligament (ACL) tears compared to male athletes. There appears to be a significant role in knee biomechanics that may attribute to this discrepancy, and specifically the higher rate at which female athletes experience noncontact ACL tears compared to male athletes.1 Two important properties that appear to increase the rate of ACL tears is knee abduction, as well as knee extension. Females exhibit greater knee abduction and greater knee extension during running.2 In sports such as basketball and volleyball, females exhibit greater knee abduction during double-leg stop jump (deceleration followed by rapid acceleration in the form of a jump, which mimics movement in basketball or volleyball3 and greater knee extension during side-cutting at and above 90-degrees.4

Differences in biomechanics are thought to, in part, be due to proximal control, in that females favor use of knee extensors greater than hip extensors during landing, while males exhibit a more-equal distribution.5 With this in mind, there have been numerous training programs centered on enforcing proper landing and appropriate neuromuscular activity, which have significantly decreased the incidence of ACL injury in female athletes.6 There is also potential for biomechanical properties being used to identify those at-risk for ACL tears.

While it is encouraging to see initiatives that seek to address modifiable factors of sex differences in ACL tears, there also appears to be a role of normal maturation and physiology underlying the discrepancy. The divergence in ACL tears between male and female athletes seems to appear after puberty, in high school and collegiate athletes.7 Peak height velocity is defined as the period when adolescents are at approximately 91% of adult height, and maturation is defined as >92% of adult height. It has been shown that both of these stages are associated with greater knee abduction moment and angle during drop vertical jump (which resembles taking a rebound shot in basketball, or blocking or spiking in volleyball in female athletes, but not their male counterparts.8

It is not clear what role hormonal changes, and specifically estrogen, play in mediating ligament function and failure. Studies have found that there is no acute difference in ligamentous laxity throughout three phases of the menstrual cycle9, while other studies have found increased laxity during ovulation due to decreased fiber crosslinking.10,11 Changes in ligamentous laxity may contribute to female athletes adopting compensatory activity in leg muscles, leading to the observed differences in knee biomechanics mentioned above.

Intrinsic differences in ACL properties and structure may predispose female athletes to ACL tears over male athletes. Studies have suggested that female ACLs have lower strain at failure, lower strain-energy density, and lower modulus of elasticity, after accounting for differences in ACL size, length, and age.12 Female ACLs also exhibit lower fibril concentration compared to males, which is significantly correlated with stiffness and modulus of elasticity.13

Sex differences in ACL tears extend beyond the moment of failure, to differences in outcomes after ACL reconstruction. Following reconstruction, women report more frequent and intense pain.14 They also exhibit significantly greater deficiency in extensor strength and range of motion.14,15 This may contribute to female patients being less likely to return to pre-injury activity level, and more likely to experience repeat failure following reconstruction.14


This case highlights the complexity that underlies sex differences in ACL tears. Current literature highlights the roles of anatomy, injury mechanism, and neuromuscular activity. The latter two have been recognized as modifiable risk factors, and initiatives have been taken to raise awareness and properly train athletes to avoid injury. However, wide differences in rates of ACL injury between female and male athletes still exist. Building consensus in attributable factors and identifying persistent differences will continue to be important for designing targeted prevention.


1. Boden BP, Dean GS, Feagin JA, Garrett WE. Mechanisms of Anterior Cruciate Ligament

Injury. Orthopedics. 2000;23:573-578. doi:10.3928/0147-7447-20000601-15.

2. Sinclair J, Selfe J. Sex differences in knee loading in recreational runners. J Biomech. 2015;48(10):2171-2175. doi:10.1016/j.jbiomech.2015.05.016.

3. Carson DW, Ford KR. Sex differences in knee abduction during landing: A systematic review. Sport Heal A Multidiscip Approach. 2011;3(4):373-382. doi:10.1177/1941738111410180.

4. Sheu CL, Gray AM, Brown D, Smith BA. Sex Differences in Knee Flexion Angle During a Rapid Change of Direction While Running. Orthop J Sport Med. 2015;3(12):2325967115617932. doi:10.1177/2325967115617932.

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Abdominal pain and Diarrhea in an Adolescent Indian Girl Mon, 11 Sep 2017 22:38:01 +0000 In This Case: Abdominal pain and Diarrhea in an Adolescent Indian Girl

Author: Shreya Ramayya

Co-Editor: Dr. Rebecca Barron

Case Overview

AT, a 13-year-old girl with abdominal and pelvic pain, and diarrhea for two months duration, that started during her first menstrual cycle and gradually got worse. She now has several episodes of diarrhea per day associated with blood and mucous. Symptoms are worse during her menstrual cycles.

Patient Profile

Name: A.T.

Age: 13

Sex: Female

Marital Status: Single

Living Conditions: Lives with her father and two brothers in a remote village in India.

Socioeconomic Status:

Father and brothers work in the fields, and they are poor and uneducated. They have deep-rooted cultural and religious beliefs and are superstitious. They live in a mud hut padded with cow dung. There’s no source of running water at home. The only source of water is the nearby lake where all the villagers (mostly women) bathe, wash, and collect water for cooking and other household use. The lack of toilets in the community results in open defecation typically by the lake. AT uses the water from this same lake for cooking and typically keeps the leftover boiled water for drinking for her family members. For the most part she drinks the water directly from the lake and her father and her brothers drink the water from a well situated in the field where they work. AT has been thirstier lately and drinking more water at the lake.

Social History: No history of smoking, drinking, or chewing tobacco.

Past Medical History: None. Never immunized.

Family History:

Mother died of unknown causes six months ago. She had abdominal pains, nausea, diarrhea and fevers off and on and had lost a lot of weight and appeared very sick before her death, as per history from the family. Never got any medical care.

Chief Complaint:

AT is a 13 year old, single girl presenting with abdominal and pelvic pain and diarrhea for two months duration. The problem started during her first menstrual period two months ago. Since then she has continued to have abdominal and pelvic pains along with diarrhea off and on, but the symptoms seem worse during her menstruation. Her diarrhea now accounts for 6-8 bowel movements per day associated with abdominal cramping, bloating, weight loss, and recently blood and mucous in the stool. Noticing blood in her stool while not on her menstrual cycle finally made her complain about her problems to her father who brought her to the primary health center (PHC) located 50 kilometers away from her home. Other family members have no GI symptoms.

Presenting Complaint

Patient complains of pain in the abdomen and pelvic areas along with bloating. Also complains of nausea off and on. She has poor appetite and states that her clothes are falling off her waist. Admits to feeling lightheaded and dizzy. She has passed out two times while doing household chores. The last episode was two days prior to arrival at the PHC and was witnessed by her father, which prompted a conversation about her health between them. Complains of excessive thirst, chills, and fatigue. She feels warm but is unsure of fevers. She has headaches off and on. Upon further questioning she admits to heavy cycles requiring her to change and wash her cloth sanitary napkin several times a day for seven days during each of her past three cycles. She has to go to the lake to urinate and do the washing at all times of the day and night. Her urinary output is less but she’s unaware of it, as she doesn’t understand what is normal. Does admit to drinking water from the lake while doing her chores of washing, bathing, and after defecation/urination, especially lately because of thirst. Her visit to the lake has increased since her menarche as she needs to go there to clean herself and change the menstrual cloth pads and wash them. Her visit to the lake has gradually increased over the past six to nine months as she was helping her mother with her chores before she died and has taken over all the chores since her mother’s death.

Her living situation makes it difficult for her to seek medical attention and care from her community. In rural India symptoms pertaining to bowel and bladder problems are not openly communicated. Additionally in many parts of India, menstruation is seen as taboo, so it is neither discussed nor addressed with appropriate resources to help girls during their cycles.


Patient is a young girl who looks frail and slightly older than her age. She is severely underweight and malnourished. She is in moderate distress due to abdominal pain. She appears dehydrated with dry oral mucosa and poor skin turgor. Her blood pressure is 85/50 and her pulse rate is 110, with positive orthostatics. Her temperature is 101.1. Her conjunctiva are pale. Her bowel sounds are hyperactive. Her abdomen is bloated and tender. There are no masses. She had an urge to defecate during the exam. Since she was at the PHC, the doctor ordered the patient to use the toilet to defecate and encouraged her to collect a stool sample, which was bloody and filled with mucous. It was also foul smelling. Because of her ill appearance and degree of dehydration she was admitted to the local government hospital where she was treated with IV fluids.


Laboratory results showed severe microcytic anemia. The stool evaluation showed parasites consistent with entamoeba histolytica leading to a diagnosis of amoebiasis.


She was given IV hydration initially followed by instructions for oral rehydration, to treat diarrhea-induced dehydration. The importance of boiling lake water before consumption was stressed. It was recommended that she locate alternative sources of water, as the water in the lake was likely contaminated by human and cattle feces. The option of fetching water from the well in the fields where her father worked was discussed, but she was still encouraged to boil and cool it before consumption. She was treated with Metronidazole to eradicate her amoeba infection and instructions about hygiene were discussed. She was also started on iron supplements to help resolve the anemia, which was due to amoebiasis as well as heavy menstruation. It was unclear if AT would follow through with the instructions and the treatment plan because of underlying financial restraints, lack of education and resources, and cultural beliefs including negative perceptions of medications. A visiting health worker was assigned to AT’s village to not only follow up on AT but also to evaluate and assess the disease burden of amoebiasis, dehydration and anemia in that community.


This patient demonstrated symptoms during her first menstrual cycle making it difficult to discern whether the pain was due to her menstrual cramps or something else. Since there was no reason to suspect any other medical problems she ignored her pain and then the diarrhea. As her symptoms worsened she came to the attention of healthcare providers who could fortunately diagnose and treat her accurately.

Given the overall unwillingness of women to talk about their health and menstruation in particular and lack of resources to address their symptoms and treat their problems, anemia often becomes fatal. Additionally in most rural areas in India, menstruation is considered a curse and a woman untouchable during that time frame. Even if there had been other water sources in this case, a menstruating woman is kept out of the house in a cow shed and asked to use an outside body of water for her personal needs. Healthcare workers do not have access to or are not entertained in rural areas because of their cultural and social beliefs and lack of trust in modern medicine. People instead rely on traditional remedies. Consequently, the healthcare workers are also not well trained in dealing with rural women’s health issues.

AT was more vulnerable than her male family members to this infection because her responsibilities of household chores, as a woman, required her to use lake water. Additionally her exposure to contaminated lake water also increased because of menstruation and personal hygiene needs and lack of sanitation and menstrual supplies to rural women who are ‘cursed’ and undergoing menstruation. Anemia and menstruation further reduced her immunity making her more vulnerable to infections, dehydration, and weight loss. It is likely that AT’s mother had been dealing with similar health issues, and with earlier diagnosis and treatment would have had a better chance at survival.

With increased awareness of the potential health risks inherent in the roles typically designated for women in the community, the overall wellbeing of women can be promoted while ensuring the establishment of an appropriate healthcare infrastructure for women and men alike.


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