Can someone please explain the workup, differential for secondary amenorrhea and also the workup, differential for irregular/dysfunction uterine bleeding? For whatever reason, I get these straight in my head for a short time, then I can't ever remember if the DUB is caused by too much estrogen or too much progestin or whatever. Help!
Firstly, rest-assured that you're not alone. Even those of us in practice have to brush-up once in awhile to refresh our approach. I will start by saying Gyne isn't medicine's most fascinating branch, and textbooks often make these topics even harder to understand.
Here's Mike59's real-world GYNE summary:
DISCLAIMER: This is not a complete differential and I am no expert in women's health, BUT my patients are happy and no one has been sued
😉
CC: Female c/o vaginal bleeding
- Always always always get a Urine Preg test in a female with any gyne/abdo complaint, common sense. If positive, the differential includes ectopic vs. aborting pregnancy vs. normal pregnancy with implantation bleed. Use serial serum B-HCG and U/S to help differentiate.
- If Beta is negative, you have to then distinguish between "ovulatory" vs. "Anovulatory" bleeding.
The history will help here:
"Ovulatory" usually means the bleeding is in predictable cycles, she is having periods and they are heavy (menorrhagia, DDx is usually a structural issue that "acts up" during menses such as a cervical polyp, endometrial polyp, adenomyosis, leiomyoma, rare clotting problem).
Anovulatory means she has not had regular cycles, the bleeding is all over the map at irregular intervals. This is where "DUB" comes in, 90% of this Anovulatory category occurs because of an underlying endocrine problem that is not detectable with bloodwork. Anovulatory bleeding is often summarized as "Hypothalamic amenorrhea", as weight changes, stress, and other psychosocial/physical problems wreck the normal menstrual pattern. You should consider PCOS , Hypothyroidism and Prolactinoma in this anovulatory umbrella as well.
Putting it all together:
Female c/o vaginal bleeding,
- Take Hx, could she be pregnant (Preg DDx) ? is she having regular cycles, or is the heavy bleeding at random times? (Ovulatory vs. Anovulatory)
- Physical to exclude a cervical change, bleeding source or obvious tumor
- Office tests: B-HCG, there's more work to do if it's positive (serum BHCG, U/S)
- Consider workup for Ovulation/Anovulation: TSH, PRL, DHEA-S/FSH/LH (PCOS), Pelvic U/S to exclude fibroids/endometrial change, CBC/Ferritin if you think they may be iron deficient
- Regardless of etiology, these Ovulation vs. Anovulation cases usually respond well to a Contraceptive pill
If the patient is at extremes of age, the DDx is slightly different, the adolescents can have a coag problem, or congenital/anatomical issue.. the older ones need to be considered for CA anywhere in the gyne tract.
Hope that helps! I will shoot off an Amenorrhea approach if you find this useful.
