Patient Evaluation. History of the Present Illness

Patient Evaluation

History of the Present Illness

The history establishes the woman’s baseline menstrual cycle pattern and characterizes in detail the changes that led to the current consultation. The latter should include when the abnormal bleeding began; the characteristics of the new bleeding pattern; and the presence of additional symptoms such as pain, fever, or other systemic complaints. Historic features that suggest pregnancy should be elicited. The medical history should focus on current medications, birth control method, past surgery, and other gynecologic diagnoses.

Certain problems are more likely to occur in specific age groups. For example, pregnancy and infection are more common among women under age 30 years; cancer, leiomyomas, and endometrial polyps tend to cluster in women older than age 40 years. Clotting abnormalities are most common among teenage girls with heavy menstrual bleeding. However, overreliance should not be placed on risk by age because any diagnoses may occur in any menstruating woman.

Once a pregnancy-associated problem is eliminated, the clinician should be able to use the historic information to focus on one of the categories of the differential diagnosis. The remaining evaluation should be based on this classification.

Anovulatory Bleeding

Anovulatory episodes are commonly associated with normal events in a woman’s reproductive life cycle. After menarche, girls may not establish regular ovulatory cycles for several months. At the other end of the spectrum, some women develop anovulatory cycles as their ovarian function declines with the approach of menopause. Reestablishment of ovulation after interrupting events such as use of hormonal contraception and pregnancy is usually prompt except in two situations. Women who breastfeed will resume ovulation unpredictably; the timing is probably related to the frequency of breastfeeding. Depot medroxyprogesterone acetate, now commonly used as a contraceptive method, does not clear from the system immediately after it is discontinued, and menstruation may not resume until several months after the last injection.
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Chronic anovulation is more likely attributable to an endogenous disorder like polycystic ovary syndrome or other androgen disorders. Acute anovulation can be caused by stress, intercurrent illness, medication use (eg, spironolactone), or endocrine disturbances (eg, prolactinoma, adrenal hormone excess, thyroid hormone problems).

The major focus of the patient evaluation should be to identify any underlying cause of the ovulatory dysfunction. This will involve the measurement of various hormones (eg, gonadotropins, androgens, adrenal and thyroid hormones), with the specific selection depending on the clinical presentation. In addition, women with longstanding anovulation should be assessed for endometrial hyperpla-sia and anemia.

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