Differentials

Question 1

What are the differentials of Primary Amenorrhoea?

What are the differentials of Secondary Amenorrhoea?

Answer 1

➊ Pt has never had any periods:
• Hypogonadotropic Hypogonadism – Hypothalamus/Pituitary not functioning – Anorexia, Excessive exercise or stress
• Hypergonadotrophic Hypogonadism – Gonads not functioning – Gonadal dysgenesis (43%), Mullerian agenesis (15%)
• Structural pathologies, like an imperforate hymen

➋ Pt’s periods suddenly stopped:
• Pregnancy – Most common cause
• Menopause, inc. Premature ovarian insufficiency
• Physiological stress e.g. excessive exercise, anorexia
• PCOS
• Contraceptives
• Thyroid disease
• Cushing’s syndrome
• High prolactin

Question 2

What are the differentials of Menorrhagia?

Answer 2

• No underlying pathology (Dysfunctional Uterine bleeding)
• Endometriosis
• Adenomyosis
• Fibroids
• Endometrial polyps
• PID
• IUD (e.g. cooper coil)
• Anticoagulants
• Coagulopathy

Question 3

What are the differentials of Dysmenorrhoea?

Answer 3

• No underlying pathology (Primary dysmenorrhoea)
• Endometriosis
• Adenomyosis
• Fibroids
• Endometrial polyps
• PID
• IUD (e.g. cooper coil)
• Cervical/Ovarian cancer

Question 4

What are the differentials of Post-coital bleeding?

Answer 4

• Cervical ectropion – associated with increased oestrogen e.g. younger women, pregnancy, hormonal contraception
• Endocervical and cervical polyps
• Cervicitis – often with pv discharge
• Cervical ca. – there will also be inter-menstrual bleeding, urinary symptoms and vaginal discomfort
• Atrophic vaginitis
• STI – those, like gonorrhoea and chlamydia, lead to PID (discharge, pelvic pain)

Question 5

What are the differentials of Post-menopausal bleeding?

Answer 5

• Atrophic vaginitis
• Endometrial ca.
• Endometrial hyperplasia – common after menopause due to unopposed oestrogen action, and is a premalignant condition
• HRT
• Coagulopathy

N.B. Atrophic vaginitis is the most common cause of postmenopausal bleeding, but endometrial cancer still needs to be ruled out.

Question 6

What are the differentials of PV discharge?

What are the differentials of Lower abdominal pain?

Answer 6

➊ • Bacterial vaginosis
• STI
• Vulvovaginal candidiasis

➋ • Ovarian torsion
• Ovarian cyst rupture
• PID
• GI and Urological causes