The patient suffers from unstable, and at the same time, short menstruation periods. She has not had many previous GYN exam visits. The average cycle length can reach 40 days. The girl says that she leads a fickle sex life. Besides, in adolescence, she suffered from an eating disorder, the consequences of which she still cures. The patient often lost weight and then quickly gained back. She is not happy with her primary care physician, to whom she was sent by her mother. SM is studying in college and seeking out her own healthcare needs. She is not too afraid of having fickle sexual relations. However, her infrequent periods made her consider going to the GYN to make sure that she is alright. The patient has been suffering from acne since adolescence.
Current Medications: Accutane, Dose: 60 mg per day
Allergies: Food allergy to animal protein. She does not eat eggs and milk, because of them, dryness and severe irritation appear on the bends of the arms and legs and between the fingers. The patient says that she rarely takes antihistamines, as she tries not to use allergens in food.
PMHx: No past surgeries or hospitalizations
SM was a vaginal birth at the local hospital
Soc & Substance Hx: Social drinker-visits bars with friends on weekends. Can afford a glass of wine or beer during the week. She does not smoke regularly; however, she can have a cigarette when out with friends. No substance use or vape use. College student living in the dorm works as part-time waitress in the afternoon. Due to having late working hours, sleeps 5-6 hours per night. Often wakes up feeling tired, about 3-4 days out of the week. Irregular exercise, patient tried going to the gym each month, but after a couple of visits stops, due to an inconsistent schedule and studying.
Fam Hx: Mother – 45 y.o, alive, HTN, DM, Hypothyroidism,
- Father – 52 y.o, HTN
- Maternal grandmother – 69 y.o, alive, HTN, Hypothyroidism, “cholesterol”
- Maternal grandfather – Deceased – “car accident”
- Paternal grandmother – 75 y.o – Deceased – “heart attack”
- Paternal grandfather – 72 y.o – alive – early dementia – HTN
- Brother – 15 y.o – twin- no health issues
- Sister – 15 y.o -twin-acne-takes tetracycline for acne
Surgical Hx: No prior surgical procedures.
Mental Hx: Denies having any history of self-harm practices and suicidal or homicidal ideation.
The patient says that sometimes she feels tides of negative and sad emotions but denies the presence of depression.
PHQ-9 completed – score – 5 – Mild symptoms of depression. Patient should contact a specialist.
Violence Hx: No concerns for safety. Feels safe at the college dorm and while out in town. She has taken no self-defense classes.
Reproductive Hx: Menses started at age 14, used to be regular, once every 28-30 days. Now occurs every 2 to 3 months, with minor bleeding at times. The patient uses 3-4 tampons per day, changing them every 6-7 hours. Menses usually lasts three days, with one day of relatively heavy bleeding. She denies having any clots. There is a pulling feeling in the lower part a few days before menstruation. Has no pain during menstruation. She will at times have an increased “nauseated feeling” before her menses.
- LMP was two months ago.
- Admits to being sexually active – uses condoms each time.
- The patient denies the possibility of pregnancy; her last sexual activity was before her last period.
- Denies any history of STI
- Heterosexual – has had ten male sexual partners in the last year. Oral and vaginal types of intercourse.
ROS:
- GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT:
- Eyes: No visual loss, blurred vision, double vision, or yellow sclerae.
- Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
- Hair: Occasional thick hair on the upper lip area, which she plucks regularly. Acknowledges some hair loss when showering.
SKIN: No rash or itching, only after shaving in the lower region. Relatively thick leg hair, shaves rather frequently, sometimes twice a week.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No signs of palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. No pregnancy. LMP: 07/15/2021.
NEUROLOGICAL: Does not experience headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities.
There is no change in bowel or bladder control.
MUSCULOSKELETAL: Does not experience muscle pain, back pain, or stiffness. Experiences joint pain in her knees when working out.
HEMATOLOGIC: Does not heve anemia, bleeding. States that easily gets bruised.
LYMPHATICS: No signs of enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Has no history of depression or anxiety.
ENDOCRINOLOGIC: Does not experience sweating or cold or heat intolerance. Does not have polyuria or polydipsia.
REPRODUCTIVE: The patient is not pregnant and is not pregnant. No complaints of vaginal or penile discharge. Sexually active.
ALLERGIES: Infrequent eczema due to allergy.
Physical exam:
- HEAD: Healthy, average weight female in good health.
HEENT:
- Eyes: clear sclera.
- Ears, Nose, Throat: Tympanic membrane grey, throat moist with no exudate, no lesions noted
- Deep voice noted – more bass tones
- Scalp – no thinning or alopecia noted
SKIN: Few thin hairs and a few coarse hairs noted on the upper lip.
Multiple areas of acne on the face, most prominent on the cheek area. Few small scars noted on cheeks and forehead.
Male hair pattern on the lower abdomen – reports shaving lower belly. Few coarse hairs noted on her upper lip – she says she usually plucks them – light hair on forearms
She was noted with thick and coarse hair on the legs.
CARDIOVASCULAR: S1, S2, No S3 or S4 noted, Regular rate and rhythm
RESPIRATORY: Lungs clear to auscultation
ABDOMEN: Soft, bowel sounds positive to all quads. Ovaries are palpable and tender to the right and left lower quadrants. Liver margins are palpable
BREAST: Symmetrical, no masses, dimpling, redness or discharge, no adenopathy,
GASTROINTESTINAL: Bowel sounds positive and regular in all quads and no herniations
MUSCULOSKELETAL: ROM good to all extremities. Reflexes +1
REPRODUCTIVE: Not pregnant and no recent pregnancy. Denies vaginal pain or discharge. Sexually active.
VVBSU: WNL, cervix – pink and moist
CERVIX: Moist, no drainage or bleeding noted
UTERUS: Mid mobile, non-tender
ADNEXA: No masses or tenderness
PERINEUM: No redness or swelling
RECTUM: Good tone
PSYCHOSOCIAL: Noted to avoid eye contact on many questions. Looks at the floor as she answers questions.
Diagnostic results: None on record
Assessment
Diagnoses
Oligomenorrhea – Menstrual function is impaired, characterized by a reduction in the duration of menstruation, less than three days, and an increase in the interval between cycles of more than 40 days. The menstrual flow was normal before oligomenorrhea development (Riaz, Y., & Parekh, 2020).
Endometriosis – Described by heavy bleeding on the first day of the period. However, the patient does not have any abdominal pain or other symptoms. Because of the lack of follow-up in the past, the patient should undergo some testing to conclude any additional causative factors. If not diagnosed in time, the disease can cause associated pain, infertility, decreased quality of life (Agarwal et al., 2019).
Amenorrhea – Menstruation suddenly stops and is absent for more than two to three months, there were menstruations before, but now they are missing (Klein et al., 2019). The causes of this condition can be stress associated with work and study and severe violations of average body weight. In addition, significant psychological injuries can affect. Additional signs are increased fatigue, indifference to oneself, anxiety, and a tendency to depression, sleep disorder.
Plan
The plan includes an extensive workup to determine if there is an underlying endocrine disorder or metabolic disorder.
LABS:Â Urine pregnancy test, thyroid studies, free testosterone, progesterone level, CBC, Basic metabolic panel, Liver function test, Cholesterol, FSH, LH. The labs need to be completed fasting due to the possibility of an underlying metabolic process such as diabetes.
DIAGNOSTICS: Transvaginal Ultrasound of both ovaries (Campbell, S., & Gentry-Maharaj , 2018)
MEDICATIONS: General restorative therapy plays a vital role in the treatment. It should include normalization of nutrition, vitamin intake, immunostimulation, physiotherapy, acupuncture.
In patients with oligomenorrhea, gestagens are used from the 16th to the 25th day of the cycle.
Duphaston 10 mg 2 times a day orally or Crinone 8% 100 mg 2 times a day vaginally.
The course of treatment is 3-6 months.
HEALTH PROMOTION: With oligomenorrhea, a consultation with a psychologist or psychotherapist is optional, but still desirable. It is obvious that this pathology with all its manifestations has an extremely negative effect on the patient’s morale.
Weight regulatory diet
With oligomenorrhea, a consultation with a psychologist or psychotherapist is optional but still desirable. Obviously, this pathology, with all its manifestations, has a highly negative effect on the patient’s morale.
Encourage continued activity – Continue track and field at college or other sport.
Sunscreen daily and reapply frequently.
Increase sleeping hours as much as possible.
Use a seatbelt, and no texting and driving.
Monitor for signs of a blood clot and notify the office immediately – redness, color changes to extremities, pain.
Monitor for side effects of Yasmin such as nausea, vomiting, bloating, cramps. All of which may improve the longer you are on the medication.
Do not share your medications. Taking birth control is a personal decision, and you do not need to share the information with others.
REFERRAL: Pending the results of the laboratory test. SM may need a referral to endocrinology.
My concern for SM is the possibility later in life to stop the hormones and antiandrogens, which can return the symptoms. Besides, I am afraid that changing the lifestyle would be almost impossible for the patient as she pays for her expenses and college. It is important to note that doctors need to be aware of all the possibilities and long-term effects of treatments and educate their clients about them. In addition, late diagnosis and treatment of diseases related to the reproductive system can cause infertility.
References
Agarwal, S. K., Chapron, C., Giudice, L. C., Laufer, M. R., Leyland, N., Missmer, S. A., Sukhbir, S., & Taylor, H. S. (2019). Clinical diagnosis of endometriosis: a call to action. American journal of obstetrics and gynecology, 220(4). Web.
Campbell, S., & Gentry-Maharaj, A. (2018). The role of transvaginal ultrasound in screening for ovarian cancer. Climacteric, 21(3), 221-226. Web.
Klein, D. A., Paradise, S. L., & Reeder, R. M. (2019). Amenorrhea: a systematic approach to diagnosis and management. American family physician, 100(1), 39-48.
Riaz, Y., & Parekh, U. (2020). Oligomenorrhea. StatPearls.