Menstrual Irregularity

Age: ‍ years old

Gender: female



HISTORY:

Presents with a ‍-‍monthyear history of irregular periods

Menstrual cycle: ‍ days

Onset was ‍gradualsuddensince menarche, occurred after ‍ ‍weight gain

Pattern ‍persistentintermittent

Menstrual flow: ‍lightnormalheavy, ‍with smallwith largewithout clots



Associated symptoms: *Try using right-click for negatives*

‍pelvic pain

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍weight gain, ‍ ‍lbskg over ‍ ‍weeksmonths

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

‍hot flashes

‍night sweats

‍vaginal dryness

‍fertility issues

‍irritability

‍fatigue

‍hair loss



Gynecological history:

Menarche: ‍ years old

Contraception: ‍yesno ‍oral contraceptives, ‍compliantfrequently misses pills

Condom use: ‍alwayssometimesnever

G‍01234 P‍01234 A‍01234

Menopausal status: ‍premenopausalperimenopausalmenopausal



Contributing factors:

‍genetics

‍obesity

‍stress

‍high-performance athletics

‍low body weight

‍smoking

‍high alcohol consumption

no history of: ‍thyroid disease, ‍PCOS, ‍diabetes, ‍hormonal imbalances, ‍eating disorders

no use of: ‍hormone therapy, ‍steroids





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Breasts: ‍normal, ‍mass, ‍axillary adenopathy

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Pelvic: external genitalia ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍cervical motion tenderness





ASSESSMENT:

‍Polycystic ovary syndrome ‍likelysuspectedpossible

DDx: polycystic ovary syndrome, hypothyroidism, hyperprolactinemia, eating disorders, chronic illness, stress, excessive exercise, obesity, significant weight loss or gain, anovulation, perimenopause, contraceptive use, hormonal imbalance, premature ovarian failure, pituitary adenoma, Cushing syndrome, adrenal hyperplasia, thyroid disease, prolactinoma, androgen-secreting tumors, medication side effect (e.g., antipsychotics, chemotherapy, antidepressants)





PLAN:

Investigations:

- Blood work: ‍CBC, ‍TSH, ‍prolactin, ‍FSH, ‍LH, ‍estradiol, ‍progesterone, ‍β-hCG, ‍testosterone on day 3 of cycle, ‍DHEAS, ‍17-OH progesterone, ‍cortisol

- Pelvic ultrasound

- Pelvic MRI

- Progestin challenge test: Medroxyprogesterone 10mg po for 10 days (if bleeding occurs, anovulation is confirmed)

- Endometrial biopsy

Treatments:

- Lifestyle modifications: ‍weigh loss, ‍avoid thinness, ‍healthy diet, ‍regular exercise, ‍avoid overtraining, ‍stress management

- ‍Oral contraceptives

- ‍Progestin therapy

- ‍Metformin

Further care:

- Referral to gynecologist

- Referral to endocrinologist

- Follow-up in ‍ ‍weeksmonths

- Return if menstrual irregularity persists, if new symptoms develop such as heavy bleeding or pelvic pain, or if symptoms do not improve with treatment

- Referral to ER if severe abdominal pain or heavy bleeding occurs