Oligomenorrhoea
Oligomenorrhoea is infrequent menstruation characterized by menstrual cycles occurring at intervals greater than 35 days but less than 6 months.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Polycystic ovary syndrome (PCOS) [1] | Oligomenorrhoea + hyperandrogenism (hirsutism/acne) ± polycystic ovaries on USS | 「面上或者身上有冇多咗毛、暗瘡？有冇肥咗？」 |
| Functional hypothalamic oligo/amenorrhoea | Stress / excessive exercise / low BMI / eating disorder | 「最近壓力好大？節食或者做好多運動？」 | |
| Serious Not To Miss | Pituitary tumour (prolactinoma / non-functioning) [3][5] | Galactorrhoea + headache + visual field defect; PRL > 5000 mU/L | 「有冇乳頭出奶？頭痛？睇嘢有冇邊邊睇唔到？」 |
| Premature ovarian insufficiency (POI) [2] | Age < 40 + ↑FSH (> 25 IU/L on two occasions) + oligomenorrhoea progressing to amenorrhoea | 「有冇潮熱、出汗、陰道乾燥？」 | |
| Pregnancy (including ectopic) | Always exclude first | 「有冇機會懷咗？上次性行為幾時？」 | |
| Androgen-secreting tumour (ovarian/adrenal) | Rapid-onset virilisation, very high testosterone | Rapidly progressive hirsutism + voice deepening | |
| Pitfalls | Thyroid disease (hypo or hyper) [6] | Subtle presentation; check TFT routinely | 「有冇怕凍、便秘、皮膚乾？或者心跳快、手震？」 |
| Non-classical congenital adrenal hyperplasia (NCAH) | Mimics PCOS; ↑17-hydroxyprogesterone | Consider in hirsute patient not responding to PCOS Rx | |
| Cushing's syndrome [7] | Central obesity + purple striae + proximal myopathy | 「有冇肚腩大咗、面圓咗、身上有冇紫色紋？」 | |
| Masquerades | Drug-induced hyperprolactinaemia | Antipsychotics, metoclopramide, methyldopa [5] | 「有冇食緊精神科藥物或者止嘔藥？」 |
| Depression/stress as masquerade | Hypothalamic suppression from chronic stress | 「心情點呀？瞓得好唔好？」 | |
| Trying to Tell Me Something? | Fear of infertility / cancer / early menopause | Hidden agenda — the real RFC | 「你最擔心係咩嘢？你覺得點解會咁？」 |
| Relationship/sexual difficulties | May not disclose spontaneously | 「同伴侶嘅關係點呀？呢件事對你哋有冇影響？」 |
Oligomenorrhoea = menstrual cycles > 35 days but < 6 months apart (vs amenorrhoea = no menses ≥ 6 months) [1][2]
GC High Yield
Oligomenorrhoea is most commonly caused by PCOS in reproductive-age women. Always exclude pregnancy first. The GC lecture on menstrual disorders [1] and pituitary tumours [3] both feature oligomenorrhoea as a key presenting complaint. The clinical test will likely test your ability to differentiate PCOS from thyroid disease, hyperprolactinaemia, and hypothalamic causes.
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, set agenda | 「你好，我係X醫生，今日想了解吓你嘅情況，可唔可以先講吓你今日嚟睇醫生嘅原因？」(Hello, I'm Dr X, can you tell me why you came today?) | Friendly opening, open question, patient-centred |
| 0:30–1:30 | Chief complaint + HPI – duration, cycle length, previous pattern, LMP, amount of bleeding | 「你嘅月經幾時開始唔正常？以前幾多日嚟一次？而家幾多日先嚟一次？上一次月經幾時？」 | Establishes timeline; defines oligo vs amenorrhoea |
| 1:30–2:30 | Targeted Hx – pregnancy, sexual activity, contraception, galactorrhoea, weight change, acne/hirsutism, hot flushes, thyroid symptoms, stress, exercise, medications | 「有冇機會懷孕？有冇食避孕藥或者其他藥物？有冇留意到體重變化、面上多咗暗瘡、身上多咗毛？有冇頭痛或者眼矇？」 | Covers PCOS, thyroid, prolactinoma, hypothalamic causes |
| 2:30–3:30 | ICE + Hidden agenda – Ideas, Concerns, Expectations | 「你自己覺得係咩問題？你最擔心邊方面？你希望今日醫生可以幫到你啲咩？」 | Scores interpersonal + ICE marks directly |
| 3:30–4:30 | Red flags + PMH/FH/SH – visual field loss, headache, bleeding tendency, family PCOS/thyroid/DM; occupation, relationship, fertility wish | 「屋企人有冇甲狀腺或者糖尿病？你而家有冇計劃生BB？工作壓力大唔大？」 | Biopsychosocial; identifies serious DDx |
| 4:30–5:15 | Summarise back to patient | 「等我總結一下：你嘅月經由XX開始變得疏咗，大約XX日先嚟一次，你擔心嘅係… 我有冇漏咗啲咩？」 | Shows active listening; scores communication marks |
| 5:15–6:00 | Explain plan + safety net + close | 「我建議我哋做吓檢查，包括驗血同超聲波。如果月經完全停咗超過三個月，或者有突然劇烈頭痛同眼矇，要即刻返嚟睇。你有冇其他問題想問？」 | Safe closure; demonstrates competence |
Uncovering the hidden agenda: The patient may present with "irregular periods" but actually be worried about infertility, cancer, or early menopause. Always ask: 「你最擔心係咩嘢？」and 「你有冇嘢想講但未講到嘅？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Menstrual Hx | How many days between periods now vs before? | 「而家幾多日嚟一次M？以前正唔正常？」 | Defines oligomenorrhoea (> 35d) vs amenorrhoea (≥ 6mo) [1] | PCOS, thyroid, hypothalamic |
| LMP | When was your last period? | 「你上一次嚟M係幾時？」 | Excludes pregnancy; timeline | Pregnancy if overdue |
| Pregnancy | Any chance you could be pregnant? | 「有冇機會懷咗？」 | Must exclude pregnancy first [1][2] | Pregnancy |
| Sexual/contraception | Are you sexually active? Using contraception? | 「有冇性生活？有冇用避孕措施？」 | OCP can mask PCOS; IUD can alter bleeding | Drug-induced; pregnancy |
| Galactorrhoea | Any milky nipple discharge? | 「乳頭有冇出過奶白色嘅分泌物？」 | Hyperprolactinaemia → prolactinoma [4][5] | Prolactinoma, hypothyroidism, drugs |
| Hirsutism/acne | More facial/body hair or acne recently? | 「面上身上有冇多咗毛或者暗瘡？」 | Hyperandrogenism in PCOS [1] | PCOS, CAH, androgen-secreting tumour |
| Weight change | Any weight gain or loss? | 「體重有冇明顯變化？」 | Weight gain → PCOS/Cushing; loss → hypothalamic amenorrhoea [1] | PCOS, eating disorder, Cushing's |
| Thyroid Sx | Heat/cold intolerance, tremor, fatigue? | 「有冇特別怕凍或者怕熱？手有冇震？」 | Hypothyroidism or hyperthyroidism both cause oligomenorrhoea [6] | Thyroid disease |
| Visual/headache | Any headache or visual problems? | 「有冇頭痛或者睇嘢矇咗？」 | Pituitary macroadenoma → bitemporal hemianopia [3] | Pituitary tumour |
| Stress/exercise/diet | Under a lot of stress? Exercising heavily? Dieting? | 「最近壓力大唔大？有冇做好多運動或者節食？」 | Functional hypothalamic amenorrhoea [1] | Hypothalamic cause |
| Medications | Taking any medications? (antipsychotics, metoclopramide, OCP) | 「有冇食緊任何藥物？精神科藥？止嘔藥？」 | Drug-induced hyperprolactinaemia [5] | Drug-induced |
| PMH | Any chronic illness, surgery, chemo/radiotherapy? | 「以前有冇大病、做過手術或者電療化療？」 | Premature ovarian insufficiency; pituitary surgery | POI, Sheehan's |
| FH | Family history of PCOS, thyroid disease, DM, early menopause? | 「屋企人有冇多囊卵巢、甲狀腺或者糖尿病？」 | Genetic predisposition | PCOS, thyroid |
| Fertility wish | Are you planning to have children? | 「你有冇計劃將來生BB？」 | Determines urgency of workup & Rx | Shapes management |
| Mood/psych | How is your mood? Any low mood or anxiety? | 「心情點呀？有冇唔開心或者好大壓力？」 | Depression → hypothalamic; also biopsychosocial | Hypothalamic; psychological problem |
| Hot flushes/vaginal dryness | Any hot flushes or vaginal dryness? | 「有冇潮熱或者覺得下面好乾？」 | Premature ovarian insufficiency / perimenopause [2] | POI, menopause |
Case Report Form Answer Builder
CC: Oligomenorrhoea for _____ months/years
HPI must include: Previous menstrual pattern (age of menarche, cycle length, duration, amount) → When cycle became irregular → Current cycle length (> 35 days) → LMP → Associated symptoms (hirsutism, acne, weight gain, galactorrhoea, hot flushes, headache, visual change) → Pregnancy status → Contraception → Medications → Impact on daily life and fertility wish
Likely RFC examples:
- "Patient is worried about infertility as she has been trying to conceive for 1 year"
- "Patient is concerned her irregular periods may indicate cancer or serious disease"
- "Patient wants to know why her periods are irregular and whether treatment is needed"
How to phrase: Pick the single most important reason from ICE. e.g. "To find out the cause of irregular menstruation and its impact on future fertility."
| Component | Likely Content | Exact Wording Example |
|---|---|---|
| Ideas | "I think I might have hormonal problems" / "My friend has PCOS" | Ideas: Patient thinks her irregular periods are due to hormonal imbalance |
| Concerns | Infertility, cancer, early menopause, weight gain | Concerns: Patient is worried she may not be able to have children in the future |
| Expectations | Blood test, ultrasound, medication to regulate periods, referral | Expectations: Patient would like investigations and treatment to regulate her menstrual cycle |
Polycystic ovary syndrome (PCOS) [1]
Minimum supporting evidence (Rotterdam criteria — need 2 of 3):
- Oligo/anovulation (presented as oligomenorrhoea)
- Clinical and/or biochemical hyperandrogenism (hirsutism, acne, ↑testosterone)
- Polycystic ovaries on ultrasound (≥ 12 follicles or ovarian volume > 10 mL per ovary)
Also exclude other causes: thyroid disease, hyperprolactinaemia, CAH [1]
| DDx | Key Discriminator |
|---|---|
| 1. Hyperprolactinaemia (prolactinoma) [3][5] | Galactorrhoea, headache, visual field defect; serum PRL > 1000 mU/L |
| 2. Thyroid disease (hypothyroidism) [6] | Fatigue, cold intolerance, weight gain, constipation; ↑TSH, ↓fT4 |
| 3. Premature ovarian insufficiency (POI) [2] | Age < 40, hot flushes, vaginal dryness; ↑FSH > 25 IU/L on two occasions 4–6 weeks apart |
| Domain | Problem |
|---|---|
| Biological | Anovulatory cycles leading to potential subfertility and long-term risk of endometrial hyperplasia |
| Psychological | Anxiety about infertility or fear of serious disease; body image issues from hirsutism/acne/weight gain |
| Social | Impact on marital/partner relationship; work/school absenteeism; social embarrassment from hirsutism |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| PCOS (most likely) | Hirsutism (Ferriman-Gallwey score ≥ 4–6 in Chinese women) [1] | Inspect face (upper lip, chin), chest, abdomen, inner thigh for terminal hair; also look for acne and acanthosis nigricans | Clinical hyperandrogenism is a Rotterdam criterion; acanthosis nigricans indicates insulin resistance associated with PCOS |
| PCOS (additional) | Raised BMI / central obesity (waist circumference ≥ 80 cm in Chinese women) [8] | Measure waist circumference at level of iliac crest | > 50% of PCOS patients are overweight; central obesity worsens insulin resistance |
| Prolactinoma | Bitemporal hemianopia [3] | Confrontation visual field testing (wiggle finger in temporal fields) | Macroadenoma compresses optic chiasm; this is the classic field defect |
| Hypothyroidism | Delayed relaxation of ankle jerk; dry skin, bradycardia | Test ankle reflexes; check pulse rate | Slow-relaxing reflexes are relatively specific for hypothyroidism |
| POI | No reliable physical sign in brief FM station | Best clue: patient reports hot flushes, vaginal dryness; confirm with ↑FSH blood test | POI diagnosed biochemically, not by examination |
| Cushing's syndrome | Purple abdominal striae, proximal myopathy, moon face [7] | Inspect abdomen for wide (> 1 cm) purple striae; test proximal muscle power (stand from squat) | Specific features distinguishing Cushing's from simple obesity |
Top Traps That Lose Marks
- Forgetting to exclude pregnancy — Always ask about LMP, sexual activity, and do urine βhCG. This is the #1 pitfall in any menstrual disorder station.
- Confusing oligomenorrhoea with amenorrhoea — Oligo = cycles > 35 days; amenorrhoea = no menses ≥ 6 months (secondary) or never had menses (primary). The distinction matters for your written answer.
- Not asking about galactorrhoea — Misses prolactinoma entirely.
- Ignoring drug history — Antipsychotics and antiemetics are common causes of hyperprolactinaemia [5].
- Jumping to PCOS without excluding thyroid disease and hyperprolactinaemia — Rotterdam criteria require exclusion of other aetiologies first [1].
- Not exploring ICE — This is heavily weighted. The patient's concern may be infertility, not the period itself.
- Forgetting long-term risks of anovulation — Unopposed oestrogen → endometrial hyperplasia/cancer risk. Mention this in biopsychosocial if relevant.
Must-Not-Miss Red Flags → Urgent Referral:
- Visual field defect / severe headache → pituitary apoplexy / macroadenoma → urgent MRI + neurosurgical referral
- Rapid-onset virilisation (voice deepening, clitoromegaly, rapid hirsutism) → androgen-secreting tumour → urgent gynaecology/endocrine referral
- Positive pregnancy test + abdominal pain → ectopic pregnancy → A&E
Safety-Net Line (closing the consultation):
「如果你嘅月經完全停咗超過三個月，或者有突然劇烈頭痛、睇嘢矇咗，記得即刻返嚟睇或者去急症室。」 (If your period stops completely for > 3 months, or you get sudden severe headache or blurred vision, come back immediately or go to A&E.)
High Yield Summary
What to ASK: Pregnancy status, LMP, cycle pattern, hirsutism/acne, galactorrhoea, weight change, thyroid symptoms, visual symptoms, headache, stress/exercise/diet, drug history, fertility wish, ICE.
What to WRITE: CC = oligomenorrhoea × duration. Most likely Dx = PCOS (state Rotterdam criteria met). DDx = prolactinoma, hypothyroidism, POI. Biopsychosocial must include subfertility risk (bio), anxiety/body image (psych), relationship/occupational impact (social). Physical sign = hirsutism (Ferriman-Gallwey) or acanthosis nigricans.
What NOT to MISS: Pregnancy, pituitary tumour (ask visual fields + galactorrhoea), thyroid disease (ask TFT), drug-induced hyperprolactinaemia, and the patient's hidden agenda (usually fertility worry).
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: CFB (OG04) Menstrual Disorders.pdf [2] Lecture slides: GC 114. Climacteric symptoms menopause and related illness; amenorrhoea.pdf [3] Lecture slides: GC 067. I keep on bumping into people on my side.pdf; Senior notes: Block A - I keep on bumping into people on my side_ pituitary tumours; hypopituitarism.pdf (F/40 oligomenorrhoea case, p25) [4] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p1541 — gonadotrophin deficiency features) [5] Senior notes: Ryan Ho Endocrine.pdf (p110 — Hyperprolactinaemia causes, clinical presentation, approach) [6] Senior notes: Block A - I am losing weight and sweating all the time_ causes of severe, weight loss; thyrotoxicosis; hypothyroidism.pdf [7] Senior notes: Block A - I have fluctuating BP_ cushing syndrome; adrenal diseases and tumours; other endocrine tumours.pdf (clinical features of Cushing's) [8] Senior notes: Block A - I am overweight, doctor_ obesity; Hyperlipidaemia.pdf (waist circumference ≥ 80 cm in Chinese women)
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