Differentials

• Primary amenorrhoea:

  • Hypogonadotropic hypogonadism - abnormal functioning of the hypothalamus or pituitary gland
  • Hypergonadotropic hypogonadism - abnormal functioning of the gonads
  • Imperforate hymen or other structural pathology
• Secondary amenorrhoea:

  • Pregnancy (most common cause)
  • Menopause
  • Physiological stress e.g. excessive exercise
  • PCOS
  • Medications e.g. hormonal contraceptives
  • Premature ovarian insufficiency (menopause before 40)
  • Thyroid hormone abnormalities
  • Excessive prolactin from a prolactinoma (inhibits LH and FSH)
  • Cushing's syndrome
• Oligomenorrhea:

  • Indicates anovulation or irregular ovulation
  • Extremities of reproductive age (early periods or perimenopause)
  • PCOS
  • Physiological stress
  • Medications - progesterone only contraception, antidepressants and antipsychotics
  • Hormonal imbalances - thyroid, Cushing's syndrome and high prolactin
• Intermenstrual bleeding:

  • Red flag for cervical, endometrial and vaginal cancer
  • Hormonal contraception
  • Cervical ectropion, polyps or cancer
  • STIs
  • Endometrial polyps or cancer
  • Vaginal pathology, including cancer
  • Pregnancy
  • Ovulation can cause spotting in some women
  • Medications such as SSRIs and anticoagulants
• Dysmenorrhoea:

  • Primary dysmenorrhoea - no underlying pathology
  • Endometriosis or adenomyosis
  • Fibroids
  • PID
  • Copper coil
  • Cervical or ovarian cancer
• Menorrhagia:

  • Dysfunctional uterine bleeding - no identifiable cause
  • Extremes of reproductive age
  • Fibroids
  • Endometriosis and adenomyosis
  • PID
  • Contraceptives - particularly copper coil
  • Anticoagulants
  • Bleeding disorders e.g. von Willebrand disease
  • Endocrine disorders - diabetes and hypothyroidism
  • Connective tissue disorders
  • Endometrial hyperplasia or cancer
  • PCOS
• Postcoital bleeding:

  • Red flag for cervical, endometrial and vaginal cancer
  • Often no cause is found
  • Cervical ectropion or infection
  • Trauma
  • Atrophic vaginitis
  • Polyps
• Pelvic pain:

  • UTI
  • Dysmenorrhoea
  • IBS
  • Ovarian cysts
  • Endometriosis
  • PID
  • Ectopic pregnancy
  • Appendicitis
  • Mittelschmerz - cyclical pain during ovulation
  • Pelvic adhesions
  • Ovarian torsions
  • IBD