Name
Purdue University Globle
NU576 NP II – Primary Care of Women’s Health
Prof. Name
Date
Irregular menstrual cycles after stopping hormonal birth control can have several causes, including changes in ovulation, thyroid disorders, pregnancy, elevated prolactin levels, structural uterine conditions, and polycystic ovary syndrome (PCOS). In a 37-year-old woman with persistent menstrual changes, fatigue, hair thinning, and a family history of diabetes, PCOS is an important diagnosis to evaluate, but it should not be assumed without appropriate testing. A comprehensive assessment that includes pregnancy testing, targeted laboratory studies, pelvic imaging when indicated, and gynecological evaluation can help identify the underlying cause and guide individualized treatment. Early recognition of PCOS and related metabolic risks is particularly important because the condition may affect fertility and increase the risk of insulin resistance, type 2 diabetes, and cardiovascular risk factors.
Patient Name: Cindy Haas
Encounter Number: 1524523
Date of Encounter: September 26, 2023
Age: 37 years
Sex: Female
The patient reports, “My periods are wacky, and I would like to figure out why.”
Cindy Haas is a 37-year-old woman presenting with abnormal menstrual patterns that have persisted for more than one year. She reports that her periods became noticeably shorter after discontinuing hormonal birth control. Her menstrual periods generally last two to three days, with approximately one to two sanitary pads used per day.
The patient experiences lower abdominal cramping during menstruation but denies persistent pelvic or abdominal pain. She also denies gastrointestinal symptoms. She has attempted to manage her symptoms with prenatal vitamins and acupuncture, but neither intervention has produced significant improvement.
Because the menstrual changes have continued for more than a year and the patient has concerns about her reproductive health, further evaluation is warranted. The clinical assessment should consider endocrine, gynecologic, reproductive, and structural causes of abnormal menstrual patterns.
The patient currently takes over-the-counter prenatal vitamins.
The patient reports an allergy to sulfa drugs, which causes a rash.
No medication intolerances are reported.
The patient denies a history of chronic medical conditions, major trauma, hospitalization, or surgical procedures.
The patient’s family history includes several metabolic and cardiovascular risk factors. Her mother has diabetes mellitus, her father has hypertension, and her sister has type 2 diabetes mellitus.
This family history is clinically relevant because a strong family history of diabetes may increase concern for metabolic risk in a patient being evaluated for PCOS. However, family history alone does not establish a diagnosis of PCOS.
Cindy has been married for 10 years and has worked as a teacher at Washington High School for approximately 15 years.
She reports no tobacco use, social alcohol consumption primarily involving wine on weekends, and no recreational drug use.
The patient denies recent weight changes but reports persistent fatigue and thinning hair. These nonspecific symptoms may occur with several endocrine or systemic conditions and therefore warrant further evaluation rather than being attributed automatically to PCOS.
The patient denies chest pain and palpitations.
She denies cough, congestion, and shortness of breath.
The patient denies bruising, rashes, or skin discoloration but reports dry skin.
She denies blurred vision or other visual changes and does not wear corrective lenses.
The patient denies nausea, vomiting, constipation, and diarrhea. Lower abdominal cramping occurs during menstruation.
The patient denies dysuria and urinary frequency. She remains sexually active with her husband and reports ongoing changes in her menstrual bleeding pattern.
She denies sinus problems, sore throat, and difficulty swallowing.
The patient denies back pain, muscle aches, and joint stiffness.
She reports no breast changes and does not routinely perform breast self-examinations.
The patient denies dizziness, weakness, and seizure activity.
The patient denies excessive thirst, excessive hunger, and a history of blood transfusions. She reports having previously undergone HIV screening during a blood donation.
The patient denies depression, anxiety, previous psychiatric treatment, or psychiatric hospitalization.
Weight: 170 lb
Height: 5 ft 5 in
Temperature: 37.1°C
Blood pressure: 120/70 mmHg
Pulse: 68 beats/minute
Respiratory rate: 20 breaths/minute
The patient appears healthy, alert, and cooperative. She answers questions appropriately and shows no signs of acute distress.
The skin is dry but intact, without lesions or bruising.
The head is normocephalic and non-tender. Pupils are equal, round, and reactive to light and accommodation. The ears are symmetrical and patent bilaterally, the nares are patent, and dentition is intact without evidence of dental caries.
The heart has a regular rate and rhythm with normal S1 and S2 sounds. No murmurs, additional heart sounds, or peripheral edema are noted.
Breath sounds are clear bilaterally. Respirations are even and unlabored.
The abdomen is soft and non-tender, with bowel sounds present in all four quadrants. The patient reports lower abdominal cramping only during menstruation.
The breasts are non-tender, with no palpable masses, nipple discharge, or skin abnormalities.
The pelvic examination demonstrates normal external and internal findings. The vulva has no lesions, the vaginal mucosa appears normal, and the cervix has no abnormal discharge. The uterus is anteverted and non-tender, and the bladder is non-distended and non-tender. Rectal tone is normal. A Pap smear was obtained during the examination.
The patient has full range of motion in all extremities without pain or functional limitation.
Speech is clear, gait is steady, posture is appropriate, and no focal neurological deficits are identified.
The patient is alert and oriented to person, place, and time. Her speech, behavior, and appearance are appropriate.
Persistent menstrual irregularity requires an evaluation directed at identifying the underlying cause. PCOS is one possibility, but pregnancy, thyroid dysfunction, hyperprolactinemia, ovarian dysfunction, and structural uterine abnormalities should also be considered.
Initial laboratory evaluation may include:
Pregnancy testing
Complete blood count (CBC)
Thyroid-stimulating hormone (TSH)
Prolactin
Ferritin when iron deficiency is suspected
Total testosterone or other androgen testing when hyperandrogenism is suspected
Metabolic testing based on clinical risk factors
A CBC can help identify anemia, while ferritin can provide additional information about iron stores. Pregnancy testing is important in reproductive-age patients with changes in menstrual bleeding. TSH and prolactin testing can help identify endocrine causes of menstrual irregularity. Androgen testing may be useful when clinical findings suggest hyperandrogenism.
Because the patient has a family history of diabetes and possible PCOS, assessment of metabolic health is also important. Depending on the clinical evaluation, clinicians may assess glucose regulation, lipid levels, blood pressure, and other cardiovascular risk factors.
Pelvic ultrasound may be appropriate when structural abnormalities are suspected or when additional evaluation of the uterus and ovaries is clinically indicated. Imaging can help identify uterine fibroids, ovarian abnormalities, or other structural causes of abnormal bleeding.
It is important to recognize that polycystic-appearing ovaries on ultrasound alone do not establish PCOS. Diagnosis should be based on the overall clinical picture and accepted diagnostic criteria.
PCOS is an important diagnostic consideration because the patient has persistent menstrual irregularity and symptoms that may be associated with endocrine dysfunction. PCOS is a common endocrine and reproductive disorder characterized by features such as ovulatory dysfunction and clinical or biochemical hyperandrogenism, with polycystic ovarian morphology potentially contributing to diagnosis depending on the diagnostic criteria used.
Common manifestations of PCOS include:
Irregular or infrequent menstrual periods
Ovulatory dysfunction
Clinical or biochemical hyperandrogenism
Acne or excess facial/body hair
Difficulty becoming pregnant
Insulin resistance or metabolic abnormalities
The patient’s family history of type 2 diabetes further supports the need to evaluate her metabolic health. However, fatigue and hair thinning are nonspecific and may also occur with thyroid disease, nutritional deficiencies, stress, or other medical conditions.
Thyroid disorders can affect menstrual regularity and may produce symptoms such as fatigue, hair changes, and changes in skin condition. Because the patient reports fatigue, thinning hair, and dry skin, thyroid dysfunction should be considered as part of the differential diagnosis. TSH testing can help determine whether thyroid abnormalities are contributing to her symptoms.
Endometriosis should also be considered, particularly if menstrual pain becomes significant or persistent. Endometriosis occurs when tissue resembling the endometrium grows outside the uterus and may cause dysmenorrhea, pelvic pain, pain during intercourse, and infertility.
The patient’s current presentation does not establish endometriosis, particularly because she reports cramping primarily during menstruation without chronic pelvic pain. Further evaluation should be guided by the severity and progression of symptoms.
Uterine fibroids are benign growths that develop in or around the uterus. Depending on their size and location, fibroids can cause abnormal uterine bleeding, pelvic pressure, pelvic pain, or reproductive problems.
Although the patient’s pelvic examination does not identify an obvious abnormality, imaging may be appropriate if symptoms or clinical findings raise concern for a structural uterine condition.
Treatment should be based on the confirmed diagnosis, severity of symptoms, reproductive goals, metabolic risk factors, and patient preferences. A diagnosis of PCOS should not be made solely from menstrual irregularity or ultrasound findings.
If PCOS or another endocrine condition is confirmed, treatment may include hormonal therapy to regulate menstrual cycles when pregnancy is not currently desired. Combined hormonal contraceptives are commonly used for menstrual regulation and management of androgen-related symptoms in appropriate patients.
Other treatments may be considered depending on the patient’s symptoms and reproductive goals. For example, antiandrogen therapy may be considered for clinically significant androgen-related symptoms, while fertility-focused treatment may be appropriate if the patient is attempting to conceive.
Medication selection should account for contraindications, potential adverse effects, pregnancy plans, and the patient’s preferences.
Lifestyle management is an important component of care for patients with PCOS or metabolic risk factors. Rather than focusing exclusively on weight loss, care should emphasize sustainable nutrition, regular physical activity, adequate sleep, and overall cardiometabolic health.
Recommended strategies include:
Following a balanced and nutrient-dense eating pattern
Engaging in regular physical activity
Maintaining or working toward a healthy weight when appropriate
Monitoring blood pressure and metabolic health
Completing recommended preventive screenings
Attending regular follow-up appointments
Lifestyle interventions can support metabolic health even when they do not result in substantial weight changes.
Patient education should explain that menstrual irregularity has multiple possible causes and that additional testing is needed before assigning a definitive diagnosis. If PCOS is confirmed, the patient should understand that it is a chronic condition that may affect reproductive, metabolic, and cardiovascular health.
Education should address:
The relationship between PCOS and ovulatory dysfunction
Potential fertility implications
Risk of insulin resistance and type 2 diabetes
Cardiovascular risk factors
Available menstrual-management options
Importance of regular follow-up
Symptoms that should prompt earlier medical evaluation
The patient should also be encouraged to track menstrual dates, bleeding duration, bleeding volume, pelvic pain, and other symptoms. This information can help clinicians identify patterns and evaluate treatment response.
Culturally responsive care is important when discussing menstrual health, fertility, contraception, and hormonal treatment. The healthcare provider should create an environment in which the patient feels comfortable discussing reproductive goals, personal beliefs, cultural expectations, and concerns about treatment.
Shared decision-making allows the patient to participate actively in selecting an appropriate treatment strategy. Patient preferences regarding hormonal contraception, fertility planning, medications, lifestyle interventions, and follow-up should be considered alongside clinical recommendations.
Preventive care should be incorporated into the patient’s overall management plan. Recommendations include routine cervical cancer screening according to current guidelines and age-appropriate breast cancer screening based on individual risk.
Because of the patient’s family history and possible PCOS, ongoing assessment of metabolic health is also appropriate. Blood pressure, glucose regulation, lipid status, and other cardiovascular risk factors should be evaluated according to current clinical recommendations.
Referral to an obstetrician-gynecologist is appropriate for continued evaluation of persistent menstrual abnormalities and interpretation of diagnostic findings. Depending on the results, additional referral to an endocrinologist may also be considered, particularly when significant endocrine or metabolic abnormalities are identified.
Follow-up should occur after laboratory and imaging results are available, with timing determined by the patient’s symptoms and clinical findings. A follow-up visit in approximately 12 weeks may be reasonable for a stable patient to:
Review laboratory and imaging results
Reassess menstrual patterns
Evaluate symptom progression
Review treatment response
Address fertility goals
Assess metabolic risk factors
Modify the treatment plan as needed
Earlier evaluation is appropriate if the patient develops severe pelvic pain, very heavy bleeding, dizziness, syncope, or other concerning symptoms.
Cindy Haas is a 37-year-old woman with more than one year of menstrual changes after discontinuing hormonal birth control. PCOS is an important consideration because of the persistent menstrual irregularity and family history of diabetes, but the available information is not sufficient to confirm the diagnosis. Thyroid dysfunction, pregnancy, hyperprolactinemia, endometriosis, uterine fibroids, and other reproductive or endocrine conditions should also be considered.
A structured evaluation that combines the patient’s history, physical examination, targeted laboratory testing, and appropriate imaging can help identify the underlying cause. Management should then be individualized according to the diagnosis, reproductive goals, metabolic health, symptoms, and patient preferences. Ongoing preventive care and follow-up are important for reducing potential long-term complications and supporting the patient’s reproductive and overall health.
American College of Obstetricians and Gynecologists. (n.d.). Polycystic ovary syndrome (PCOS). https://www.acog.org/womens-health/faqs/polycystic-ovarian-syndrome-pcos
American College of Obstetricians and Gynecologists. (n.d.). Uterine fibroids. https://www.acog.org/womens-health/faqs/uterine-fibroids
Cleveland Clinic. (2023). Polycystic ovary syndrome (PCOS). https://my.clevelandclinic.org/health/diseases/8316-polycystic-ovary-syndrome-pcos
James, A. H. (2016). Heavy menstrual bleeding: Work-up and management. Hematology: American Society of Hematology Education Program, 2016(1), 236–242. https://doi.org/10.1182/asheducation-2016.1.236
Johns Hopkins Medicine. (n.d.). Uterine fibroids. https://www.hopkinsmedicine.org/health/conditions-and-diseases/uterine-fibroids
Mayo Clinic. (2018, July 24). Endometriosis: Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/endometriosis/symptoms-causes/syc-20354656
Teede, H. J., Tay, C. T., Laven, J. J. E., Dokras, A., Moran, L. J., Piltonen, T. T., Costello, M. F., et al. (2023). Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. Human Reproduction, 38(9), 1655–1675. https://doi.org/10.1093/humrep/dead167
