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What is the Psychiatrist to Do With Positive Pregnancy Tests in Postmenopausal Women?

TO THE EDITOR: Serum ß-hCG assays are the standard for identifying a pregnancy or for ruling out early pregnancy in patients requiring urgent but potentially teratogenic pharmaceutical or procedural exposures (such as an X-ray). In a normal pregnancy, the serum ß-hCG pregnancy test levels rise dramatically after first becoming positive 10 days after fertilization. A different pattern is sometimes observed in postmenopausal women, in which a persistently positive pregnancy test and a slight elevation in the serum ß-hCG concentration are documented. This could put the physician in a quandary about whether to start treatment or not. We are reporting two such cases encountered on our psychiatric inpatient unit.

Case Report

Case 1: A 53-year-old white woman was hospitalized during a manic episode; she had a history of bipolar disorder and hypothyroidism. She said that she was pregnant and reported recent weight gain, breast engorgement, and feeling fetal movements. These claims were unsubstantiated on physical examination. Her laboratory work-up revealed an elevated TSH level and a positive serum ß-hCG pregnancy test, at 6.2 mIU/ml. Serial quantitative ß-hCG levels over 2 consecutive days were 5.7 and 7.0 mIU/ml. This pattern of weakly-positive serum levels was compatible with postmenopausal findings. The patient was not considered to be pregnant. Psychiatric and endocrine treatments were initiated in a conventional regimen.

Case 2: A 59-year-old white woman was hospitalized with psychosis, a history of drug abuse, and hypertension. She exhibited bizarre behavior and hallucinations. Routine laboratory assessment discovered a positive serum ß-hCG pregnancy test, at 13.6mIU/ml. Repeated quantitative serum ß-hCG assays over the next 3 days posted concentrations of 15.3, 18.2, and 16.9 mIU/ml. The patient was deemed postmenopausal, and appropriate pharmaceutical treatment was initiated.

Discussion

Normal pregnancy results in exponentially increasing secretion of ß-hCG, roughly doubling every 2 to 3 days until approximately 8 weeks of gestation.¹ The levels gradually decline thereafter. This hormone is primarily secreted by the placenta. Other potential causes of elevated serum ß-hCG include ectopic pregnancy,² liver or gastrointestinal disorders,³ trophoblastic or germ-cell tumors,⁴ and certain non-trophoblastic neoplasias.⁵ These conditions are potentially treatable, and the serum ß-hCG testing is used for initial diagnosis and as a follow-up marker. Persistent slight increases in concentration of serum ß-hCG are rarely noted in nonpregnant postmenopausal women. The source is thought to be of pituitary origin,⁶ and ß-hCG concentrations tend to remain stable.

The psychiatrist treating female patients needs to know their pregnancy status as early as possible, since many have compromised history-giving ability and also because some psychotropic drugs, such as lithium and divalproex, can be teratogenic. Serial quantitative serum ß-hCG levels are important to follow in cases of a positive pregnancy test. Having sustained low levels, without doubling, rules out normal pregnancy. If an increased ß-hCG is recorded, other etiologies should then be considered, and further evaluations may be required.

Because the normal doubling time of serum ß-hCG levels is every 2 to 3 days, progressive increases in concentration have also been recognized over even shorter time intervals during pregnancy. A 30% rise in level is considered significant and may be determined within 12 to 36 hours. A slightly raised ß-hCG without a progressively increasing pattern and in absence of other pathology is consistent with menopause. More increased concentrations should prompt a careful work-up. We emphasize here the importance of quickly establishing pregnancy status. This can be done with laboratory testing often in half a day or even more definitively in 2 days.

REFERENCES

1. Dilts P: Normal pregnancy, labor, and delivery, in The Merck Manual, 17^th Edition. Edited by Beers M, Berkow R. Whitehouse Station, NJ, Merck, 1999, pp 2016-2017
2. Toth P, Jothivijayarani A: Gynecology, in The Family Practice Handbook, 3^rd Edition. Edited by Shanahan J. St Louis, MO, Mosby, 1997, pp 323-324
3. Shinde S, Adil M, Sheth A, et al: Ectopic human placental lactogen and beta-human chorionic gonadotropin in gastric fluid of patients with malignant and non-malignant conditions of the stomach. Oncology 1981; 38:277–280[CrossRef][Medline]
4. Stenman U, Alfthan H, Hotakqainen K: Human chorionic gonadotropin in cancer. Clin Biochemistry 2004; 37:549–561[CrossRef]
5. Yatsuru S, Harrara E, Nopajaroonsri C, et al: Gynecomastia attributable to human chorionic gonadotropin-secreting giant cell carcinoma of lung. Endocrine Practice 2003; 9:233–235[Medline]
6. Burger HG: The endocrinology of the menopause. J Steroid Biochem Mol Biol 1999; 69:31–35[CrossRef][Medline]

Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by BASHIR, I. Articles by LIPPMANN, S. B. Search for Related Content PubMed Citation Articles by BASHIR, I. Articles by LIPPMANN, S. B. Somatoform Disorders Syndromes Secondary to General Medical Disorders

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