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Menstrual problems

Medicine > Endocrine & metabolic

Differential Diagnosis Schema 🧠

Heavy Menstrual Bleeding (Menorrhagia)

  • Fibroids (Leiomyomas): Benign uterine tumors; associated with heavy, prolonged periods, pelvic pressure, and anemia.
  • Adenomyosis: Endometrial tissue within the uterine muscle; causes heavy, painful periods, and a bulky, tender uterus.
  • Endometrial Polyps: Benign growths in the endometrium; may cause irregular or heavy bleeding, particularly intermenstrual bleeding.
  • Coagulopathies: Disorders such as von Willebrand disease; consider if there is a history of heavy bleeding since menarche or a family history of bleeding disorders.
  • Endometrial Hyperplasia or Cancer: Suspect in older women or those with risk factors (obesity, unopposed estrogen); presents with irregular, heavy, or postmenopausal bleeding.

Painful Menstrual Periods (Dysmenorrhea)

  • Primary Dysmenorrhea: Common in adolescents and young women; caused by excessive prostaglandins leading to uterine contractions; no underlying pathology.
  • Endometriosis: Ectopic endometrial tissue outside the uterus; associated with cyclic pelvic pain, dysmenorrhea, dyspareunia, and infertility.
  • Pelvic Inflammatory Disease (PID): Ascending infection of the female reproductive tract; presents with pelvic pain, dysmenorrhea, and abnormal vaginal discharge.
  • Adenomyosis: Also a cause of heavy menstrual bleeding; presents with secondary dysmenorrhea and a tender, enlarged uterus.
  • Uterine Fibroids: Can cause secondary dysmenorrhea due to pressure effects; associated with heavy menstrual bleeding.

Irregular Menstrual Bleeding

  • Polycystic Ovary Syndrome (PCOS): Common cause of oligomenorrhea or amenorrhea; associated with hyperandrogenism (hirsutism, acne), obesity, and polycystic ovaries on ultrasound.
  • Thyroid Disorders: Both hyperthyroidism and hypothyroidism can cause menstrual irregularities; symptoms may include weight changes, fatigue, and temperature intolerance.
  • Perimenopause: Irregular periods due to fluctuating hormone levels; common in women in their 40s.
  • Hyperprolactinemia: Elevated prolactin levels can cause amenorrhea or oligomenorrhea; associated with galactorrhea and may indicate a pituitary adenoma.
  • Premature Ovarian Insufficiency (POI): Amenorrhea or irregular periods before age 40; associated with symptoms of estrogen deficiency.

Key Points in History 🥼

Symptomatology

  • Onset and Duration: Determine when symptoms began and if they have changed over time; chronic versus acute onset can guide differential diagnosis.
  • Menstrual Pattern: Regularity, duration, and volume of menstrual bleeding; ask about the presence of clots, intermenstrual bleeding, and postcoital bleeding.
  • Pain Characteristics: Assess the nature, location, and timing of pain in relation to the menstrual cycle; cyclical pain suggests endometriosis or adenomyosis.
  • Associated Symptoms: Consider systemic symptoms such as fatigue, weight changes, hirsutism, and galactorrhea; these can indicate underlying endocrine disorders.
  • Impact on Daily Life: Assess how symptoms affect daily activities, work, and quality of life; this helps gauge the severity of the condition.

Background

  • Past Medical History: Ask about previous diagnoses of fibroids, endometriosis, thyroid disease, or bleeding disorders.
  • Drug History: Review use of hormonal contraception, anticoagulants, and other medications that might affect menstrual cycles.
  • Family History: Inquire about family history of menstrual disorders, polycystic ovary syndrome, thyroid disease, and gynecological cancers.
  • Social History: Consider lifestyle factors such as stress, diet, exercise, and smoking, which can influence menstrual patterns.
  • Obstetric History: Note previous pregnancies, miscarriages, and any complications, as these can impact menstrual health.

Possible Investigations 🌡️

Laboratory Tests

  • Full Blood Count: To assess for anemia due to heavy menstrual bleeding.
  • Thyroid Function Tests: To rule out thyroid dysfunction as a cause of menstrual irregularities.
  • Hormonal Profile: Assess levels of FSH, LH, prolactin, testosterone, and estradiol to evaluate for conditions like PCOS, premature ovarian insufficiency, or hyperprolactinemia.
  • Coagulation Studies: Consider in patients with a history suggestive of a bleeding disorder.
  • Sexually Transmitted Infection (STI) Screening: Important in cases of suspected PID or abnormal vaginal discharge.

Imaging and Specialist Tests

  • Pelvic Ultrasound: First-line imaging to evaluate uterine structure, detect fibroids, polyps, or ovarian cysts.
  • Transvaginal Ultrasound: More detailed view of the uterus and ovaries; useful for diagnosing adenomyosis, endometrial polyps, or small fibroids.
  • Hysteroscopy: Allows direct visualization of the uterine cavity; indicated for abnormal uterine bleeding and removal of polyps.
  • MRI Pelvis: Consider if ultrasound findings are inconclusive, particularly for adenomyosis or deep infiltrating endometriosis.
  • Endometrial Biopsy: Indicated in women over 45 with abnormal uterine bleeding to rule out endometrial hyperplasia or cancer.

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Endocrine & metabolic