I Almost Ordered the Pelvic Ultrasound First: Reflecting on a Simulated Case of Secondary Amenorrhea in a 24-Year-Old Distance Runner and the Cognitive Error I Caught
[Student Name]
University of Phoenix
NRP/563: Management of Women's Health Issues
Week 3 Assignment
[Instructor Name]
[Date]
The simulated patient is a composite written for a model paper, resembling the virtual patient cases used in many sections.
The simulated patient was a 24-year-old graduate student and competitive distance runner who had not had a period for seven months. My task was to take a history, examine her, choose tests, reach a diagnosis and reflect on my reasoning. This paper describes what I did and what I learned.
The First Impression
Her chief concern was "no period since last spring." My first thought, before the history was complete, was polycystic ovary syndrome, the condition I had studied most recently. I began planning a pelvic ultrasound and androgen levels. This early fixation is what Croskerry (2003) calls anchoring: locking on to salient features of a presentation too early and failing to adjust the impression in light of later information.
The History That Should Have Moved Me
As the history continued, the details did not fit my anchor. She runs 70 miles a week, increased from 40 a year ago when she began training for a marathon. She has lost 6 kg over the year and describes eating "clean," avoiding fats. She has had two stress fractures in her feet. She has no acne, hair growth or weight gain. Her periods were regular before her training increased. She is not sexually active and denies pregnancy, but a pregnancy test is still required.
Recognizing the Error
When the simulation prompted me to state my differential, I listed polycystic ovary syndrome first, followed by pregnancy, thyroid disease and hyperprolactinemia. Reviewing my notes, I realized I had not listed functional hypothalamic amenorrhea at all, despite high training volume, weight loss, restrictive eating and stress fractures. Croskerry (2003) describes strategies to reduce such errors, including metacognition, stepping back to reflect on one's own thinking, and deliberately considering alternatives. I stopped, rewrote the differential and asked what finding would distinguish each option.
The stress fractures were in the history from the start; my attention was not.
The Revised Differential and Testing
The Endocrine Society guideline states that functional hypothalamic amenorrhea is a diagnosis of exclusion and recommends ruling out pregnancy, thyroid disease, hyperprolactinemia and other causes, with evaluation of estradiol, luteinizing hormone and follicle-stimulating hormone (Gordon et al., 2017). I ordered a pregnancy test, thyroid-stimulating hormone, prolactin, luteinizing and follicle-stimulating hormones, estradiol and, given her stress fractures, a bone density scan. The simulated results showed a negative pregnancy test, normal thyroid and prolactin levels, low-normal gonadotropins and a low estradiol, a pattern consistent with hypothalamic suppression rather than polycystic ovary syndrome, in which luteinizing hormone is often relatively high and estradiol normal. Her bone density was below the expected range for age.
The Female Athlete Triad
The Female Athlete Triad links three problems that feed one another: too little energy for the training load, sometimes with disordered eating; disrupted menstrual cycles; and weakened bones (De Souza et al., 2014). The simulated patient has all three. The consensus statement recommends a multidisciplinary team, with the primary goal of increasing energy availability through increased intake and reduced energy expenditure, and it provides a risk stratification to guide return-to-play decisions.
The Plan I Chose
Following the guideline, the first-line treatment is correcting energy deficit through nutrition and, if needed, reducing exercise, with psychological support for stress and eating behaviors (Gordon et al., 2017). I referred her to a sports dietitian and a counselor experienced with athletes, recommended reducing mileage and planned follow-up bone density monitoring. The guideline advises against using combined oral contraceptives solely to restore menses or protect bone, because withdrawal bleeding masks the underlying problem without correcting it; short-term transdermal estradiol with cyclic progestin is considered if recovery does not occur with nutritional change.
Why Estrogen Matters for Her Bones
In hypothalamic amenorrhea, low estrogen reduces bone formation and increases bone loss at an age when bone mass should be peaking. Her stress fractures and low bone density show that the energy deficit has already affected her skeleton. Restoring menses through adequate nutrition is the most effective way to protect bone, which is why the guideline puts energy availability first (Gordon et al., 2017).
Screening for Disordered Eating
The simulation offered a screening questionnaire for disordered eating, which I used only after recognizing my error. Her answers showed restrictive eating driven by concern about performance and weight. Identifying this matters because treatment requires addressing eating behaviors with appropriate expertise, not only telling her to eat more.
What I Would Say to Her
In the simulated counseling portion, I explained that her body had lowered reproductive hormones to conserve energy, that this protects her in the short term but weakens her bones, and that eating more and training somewhat less could restore her cycles and protect her running career. Framing the plan around her goal, to keep running, made it more likely she would accept it.
What the Simulation Showed Me
The simulation scored my history as thorough but my initial differential as incomplete. That matched my own reflection. I gathered the right data but did not use it because I had already decided.
Why Polycystic Ovary Syndrome Did Not Fit
Polycystic ovary syndrome usually presents with irregular rather than absent periods from adolescence, signs of androgen excess such as acne or hair growth and often weight gain. Her regular cycles before her training increased, her weight loss and her lack of androgen signs argued against it. The hormone pattern confirmed that her ovaries were not being stimulated, rather than being stimulated abnormally.
The Role of Stress
Graduate school deadlines added psychological stress to her physical training load. Stress can suppress the hypothalamic signals that drive the menstrual cycle, and the guideline recommends addressing it, for example with cognitive behavioral therapy, as part of treatment (Gordon et al., 2017). In the simulation, I had skipped questions about stress; that was a second gap I noted.
Return to Running
Using the consensus risk stratification, her two stress fractures and low bone density place her at moderate to high risk, which argues for a supervised return to training (De Souza et al., 2014).
What I Will Do Differently
First, I will write my differential only after completing the history, and will force myself to list at least one diagnosis that fits the most unusual finding, here the stress fractures. Second, when a condition I have recently studied comes to mind first, I will treat that as a warning of availability bias. Third, I will ask, before ordering tests, what result would change my plan; the ultrasound I nearly ordered would not have.
Conclusion
In a simulated case of secondary amenorrhea in a distance runner, my first impression anchored on polycystic ovary syndrome despite high training volume, weight loss and stress fractures. Recognizing the error with Croskerry's framework, I revised the differential, tested according to the Endocrine Society guideline and reached functional hypothalamic amenorrhea within the Female Athlete Triad. The reflection gave me three specific habits to prevent the same error with real patients.
References
Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78(8), 775-780. https://doi.org/10.1097/00001888-200308000-00003
De Souza, M. J., Nattiv, A., Joy, E., Misra, M., Williams, N. I., Mallinson, R. J., Gibbs, J. C., Olmsted, M., Goolsby, M., & Matheson, G. (2014). 2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad. British Journal of Sports Medicine, 48(4), 289. https://doi.org/10.1136/bjsports-2013-093218
Gordon, C. M., Ackerman, K. E., Berga, S. L., Kaplan, J. R., Mastorakos, G., Misra, M., Murad, M. H., Santoro, N. F., & Warren, M. P. (2017). Functional hypothalamic amenorrhea: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 102(5), 1413-1439. https://doi.org/10.1210/jc.2017-00131
How this NRP 563 Week 3 example is structured
The NRP/563 Week 3 work usually centers on a simulated patient case followed by a reflection on clinical reasoning. This paper narrates the reasoning step by step, identifies where it went wrong using a published framework of cognitive errors and states what will change in the author's practice. Students search this week as NRP 563 Week 3, NRP563 Wk 3 or NRP/563 Wk 3; all three are the same assignment.
NRP/563 Week 3 questions, answered
What does NRP/563 Week 3 usually ask for?
Many sections use a simulated patient case in which students gather a history, examine, order tests and diagnose, followed by a written reflection on their clinical reasoning.
What is functional hypothalamic amenorrhea?
Absence of periods caused by suppression of the hypothalamic signals to the ovaries, usually from low energy availability, excessive exercise, weight loss or stress, diagnosed after excluding other causes.
What is anchoring bias?
A cognitive error in which a clinician fixes on an early impression and fails to adjust when new information arrives.
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