Evaluation of Menstrual Disorders

History Taking - Symptom Sleuth Secrets

• Menstrual Profile (LMP: dd/mm/yy):
  • Menarche age. Cycle: interval (21-35 days), regularity.
  • Flow: duration (2-7 days), volume (pads/clots; >80mL or >7 days = HMB).
  • Associated: Dysmenorrhea, Intermenstrual Bleeding (IMB), Postcoital Bleeding (PCB), PMS/PMDD.
• Focused Inquiry:
  • OB Hx: GPAL (Gravida, Para, Abortions, Living children), delivery details.
  • Gynae Hx: Past issues, STIs, contraception (type, duration), Pap smear hx.
  • Medical Hx: Thyroid disorders, PCOS (hirsutism, acne), bleeding disorders (e.g., von Willebrand), Diabetes Mellitus (DM).
  • Medications: Hormones, anticoagulants, antipsychotics.
  • Family Hx: Gynae cancers, coagulopathies.

⭐ Postmenopausal bleeding (PMB: any vaginal bleeding >1 year after cessation of menses) mandates urgent evaluation to rule out endometrial cancer.

Physical Examination - Clinical Clue Collection

• General Examination:
  • BMI: ↑ in PCOS, ↓ in hypothalamic amenorrhea.
  • Vital signs: Orthostatic hypotension (severe blood loss).
  • Thyroid: Goiter, thyromegaly (thyroid dysfunction).
  • Skin: Hirsutism, acne, acanthosis nigricans (PCOS, hyperandrogenism); pallor (anemia); striae, bruising (Cushing's).
  • Breasts: Galactorrhea (hyperprolactinemia).
• Pelvic Examination (Bimanual & Speculum):
  • External genitalia: Clitoromegaly (hyperandrogenism).
  • Vagina & Cervix: Atrophy, lesions, discharge, cervical motion tenderness (PID).
  • Uterus: Size, shape, mobility, tenderness (fibroids, adenomyosis, pregnancy).
  • Adnexa: Masses, tenderness (ovarian cysts, tumors, ectopic pregnancy).

⭐ Acanthosis nigricans is a common skin finding in PCOS, indicating insulin resistance; often seen on the neck and axillae.

• Systemic Signs:
  • Visual field defects (pituitary tumor).

Investigations - Lab & Lens Logic

• Core Labs (Guided by History & Exam):
  • β-hCG: Crucial first step to exclude pregnancy.
  • CBC: Assess anemia in Heavy Menstrual Bleeding (HMB).
  • TSH, Prolactin: Screen for common endocrine causes.
  • Targeted Hormones: FSH, LH, Estradiol, Progesterone, Androgens (as clinically indicated).
  • Coagulation screen (PT, aPTT, vWF): For HMB or suspected bleeding disorders.
• Imaging ("The Lens"):
  • Transvaginal Ultrasound (TVS): Initial imaging for structural issues (fibroids, polyps, adenomyosis). Measures Endometrial Thickness (ET).
    • Postmenopausal ET >4-5mm with bleeding needs biopsy.
  • Saline Infusion Sonohysterography (SIS): Enhanced view of endometrial cavity.
  • Hysteroscopy: Gold standard for direct visualization, biopsy, and treating intrauterine lesions.
  • MRI: Problem-solving for complex cases, or deep infiltrating endometriosis.

⭐ In AUB, TVS is the initial imaging of choice to assess for structural abnormalities like fibroids or polyps.

Classification (PALM-COEIN) - Disorder Decoder Ring

PALM-COEIN: FIGO's system for classifying causes of Abnormal Uterine Bleeding (AUB) in non-pregnant women. Helps systematic evaluation.

📌 PALM-COEIN: "Palm" for structural, "Coin" for non-structural.

• PALM (Structural Causes):
  • Polyp (Endometrial/Cervical)
  • Adenomyosis
  • Leiomyoma (Fibroid)
    • Submucosal (AUB-LSM)
    • Other (AUB-LO)
  • Malignancy & Hyperplasia
• COEIN (Non-structural Causes):
  • Coagulopathy (e.g., von Willebrand disease)
  • Ovulatory dysfunction (e.g., PCOS, thyroid disorders)
  • Endometrial causes (e.g., infection, inflammation)
  • Iatrogenic (e.g., IUDs, anticoagulants, hormonal contraception)
  • Not Yet Classified (Rare causes or unknown)

⭐ Ovulatory dysfunction (AUB-O) is the most common cause of AUB in adolescents.

High‑Yield Points - ⚡ Biggest Takeaways

• Thorough history (menstrual pattern, LMP, symptoms) is key.
• Pelvic examination (bimanual, speculum) detects structural issues.
• Initial labs: CBC, TSH, β-hCG are essential first-line tests.
• Transvaginal sonography (TVS) is primary imaging for uterine/ovarian pathology.
• Endometrial biopsy if AUB in women >45 yrs or with cancer risk factors.
• Hormonal assays (FSH, LH, prolactin) for ovulatory dysfunction or endocrinopathy.
• Consider coagulation screen for HMB in adolescents, especially from menarche.