Causes of a Missed Period beyond Normal Pregnancy

Case Study: Juanita

Patient Information: Juanita Morales is a 47-year-old G5P5LC6 Hispanic female. She presents with symptoms of lower abdominal cramping, urinary leakage, and cessation of menses for 8-12 months. She is well developed and well nourished but obese (BMI 45.89). She has a negative social history for alcohol, tobacco, and recreational drugs. Her last medical exam was several years ago.

Subjective

CC (chief complaint): Lower abdominal cramping and urinary leakage, along with fatigue, for the past day.

HPI: Juanita reports the abdominal cramping started several hours ago, is sharp, intermittent, and is increasing in frequency and intensity. She tried Motrin but it provided no relief. Her menses ceased 8-12 months ago. She also reports constipation, increased gas over the past several months, and a possible vaginal spotting several days ago.

Current Medications: None reported.

Allergies: No known drug allergies.

PMH: No past medical or surgical history reported.

Soc Hx: Negative for alcohol, tobacco, and recreational drugs.

Fam Hx: Not provided.

Surgical Hx: No history of prior surgical procedures.

Reproductive Hx: G5P5LC6, her menopause was "easy", last menses 8-12 months ago. Was using NFP for contraception before stopping her period.

Objective

Physical exam: Well developed, well-nourished obese Hispanic female in no apparent distress. There is potential for an abdominal mass, but this is difficult to assess due to her body habitus. The abdomen is otherwise soft and non-tender. Fungal dermatitis is observed under pannus.

Breasts: Pendulous, with bilateral white/yellow nipple discharge.

Abdomen: Obese, possible mass in the abdomen but difficult to assess due to body habitus, otherwise soft and non-tender. Fungal dermatitis under pannus.

CVA: No cva tenderness.

VVBSU: WNL, some watery d/c noted, nitrazine positive. Vagina with pink with rugae present. Good pelvic support, no cystocele or rectocele noted.

Cervix: Soft, smooth without CMT, os parous, slightly open.

Uterus: Difficult to assess due to body habitus, however, feels enlarged by bimanual exam.

Adnexa: Not palpated.

Diagnostic results: Urine dipstick showed SG 1.010, trace blood, neg nitrates, neg leukocytes, negative glucose, 3+ protein.

Assessment Based on the patient's age, clinical presentation, physical examination findings, and initial laboratory results, a few possible diagnoses come to mind.

Primary Diagnosis: Uterine Fibroids—Uterine fibroids are a common cause of enlarged uterus and can cause abdominal pain, urinary problems, and irregular vaginal bleeding (Ahmad et al., 2023).

Differential Diagnoses:

1. Ovarian Cancer: The patient's abdominal discomfort, urinary symptoms, and fatigue could be symptoms of ovarian cancer (Martin et al., 2020).

2. Urinary Tract Infection (UTI): While her dipstick urine analysis was negative for nitrates and leukocytes, her symptom of urinary leakage and abdominal discomfort could still suggest a UTI (Vitale & Lockwood, 2020).

3. Pregnancy: Given the history of urinary leakage, abdominal pain, and enlarged uterus, we cannot rule out an ectopic pregnancy or a normal pregnancy despite her age and her report of menopause. This would be considered a low possibility given her age and history but still should be ruled out (Dubbewar et al., 2022).

The priority diagnosis at this point would be uterine fibroids, given the high prevalence in women around her age and her symptoms.

Plan

Further diagnostic tests including a complete blood count (to evaluate for anemia), transvaginal ultrasound (to evaluate for fibroids or ovarian cancer), and a urine culture (to rule out UTI) are recommended. Additionally, a pregnancy test should be performed to rule out pregnancy.

Treatment and management would depend on the definitive diagnosis. If uterine fibroids are confirmed, non-pharmacologic treatment includes watchful waiting if they are asymptomatic or causing only mild symptoms. Pharmacologic treatments include medications like GnRH agonists, which can help shrink fibroids (Dubbewar et al., 2022). Surgical options are available for severe cases. Follow-up parameters would include monitoring for any changes in symptoms or condition.

Reflection

This case was particularly challenging given the patient's obesity, which complicates physical assessment, and her multiple symptoms, which could be indicative of various health conditions. While I agree with the preceptor's initial handling of the case, considering the symptoms, I would have recommended imaging studies sooner, especially given the difficulty of physical examination due to the patient's body habitus.

Learning from this case, I understand the importance of comprehensive patient evaluation, including a detailed history and thorough physical examination, even when it is challenging due to factors like obesity. In a similar future case, I would also consider the need for early imaging and more immediate interventions due to the patient's weight and the potential for more complex conditions (Ahmad et al., 2023).

In terms of health promotion and disease prevention, this case highlighted the need for regular health check-ups, especially in the perimenopausal and postmenopausal age group. It also reinforced the importance of weight management and maintaining a healthy lifestyle to prevent complications associated with obesity. Considering the patient's Hispanic ethnicity, understanding the potential cultural and social barriers to health care access and promoting culturally appropriate interventions is crucial. Addressing diet and lifestyle modifications, including regular exercise, can also be beneficial in managing her current symptoms and reducing her risk for other health conditions related to obesity.