Irregular Or Frequent Cycles
Menstrual cycle irregularity refers to variations in cycle length (oligomenorrhea > 35 days, polymenorrhea < 21 days) or unpredictable timing of menses, often reflecting underlying ovulatory dysfunction or hormonal imbalance.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Polycystic Ovarian Syndrome (PCOS) [3] | Oligo/amenorrhoea + hyperandrogenism (hirsutism/acne) ± PCOS on US; accounts for ~90% of oligomenorrhoea [3] | 「有冇多咗體毛或者暗瘡？月經係咪由十幾歲開始就唔規則？」 | ~40% |
| Physiological (perimenarchal / perimenopausal) | Age < 2 years post-menarche or > 40 with vasomotor symptoms | 「你幾歲開始嚟M？有冇潮熱或者夜晚標汗？」 | ~20% | |
| Serious Not To Miss | Ectopic pregnancy / pregnancy complications | Missed period + acute pelvic pain + vaginal bleeding | 「月經有冇遲咗？有冇肚痛？有冇可能有咗？」 | ~5% |
| Endometrial hyperplasia / carcinoma | Prolonged unopposed oestrogen, age > 35, obesity, postmenopausal bleeding | 「經期之間有冇出血？有冇停咗M之後又出血？」 | ~2% | |
| Coagulopathy | Easy bruising, heavy periods since menarche, FHx | 「你係咪好容易瘀？由細到大M都好多？」 | ~2% | |
| Cervical carcinoma | Postcoital bleeding, irregular IMB | 「親密之後有冇流血？上次做子宮頸抹片幾時？」 | < 1% | |
| Pitfalls | Thyroid dysfunction (hypo > hyper) | Fatigue, weight change, cold/heat intolerance, constipation/diarrhoea | 「有冇成日攰、怕凍、便秘、或者體重升咗？」 | ~5% |
| Hyperprolactinaemia | Galactorrhoea, headache, visual field defect | 「乳頭有冇出水？有冇頭痛或者睇嘢模糊？」 | ~3% | |
| Premature ovarian insufficiency | Age < 40, hot flushes, ↑FSH | 「你未夠40歲但有冇潮熱？有冇覺得陰道乾？」 | ~2% | |
| Masquerades | Drugs (OCP, antipsychotics, valproate) | Temporal relationship with drug start | 「最近有冇開始食新藥？」 | ~10% |
| Depression / stress | Low mood, anhedonia, sleep disturbance → hypothalamic suppression | 「最近心情點？有冇瞓得差或者對嘢冇興趣？」 | ~10% | |
| Eating disorder / excessive exercise | Low BMI, amenorrhoea, stress fractures | 「你有冇刻意減肥或者做好多運動？」 | ~5% | |
| Trying to Tell Me Something? | Fertility anxiety | Patient asks about getting pregnant; partner pressure | 「你係咪擔心將來生唔到BB？」 | ~20% |
| Fear of cancer | FHx of gynaecological cancer; health anxiety | 「你係咪擔心自己有咩嚴重嘅病？」 | ~10% | |
| Relationship / sexual concern | Dyspareunia, body image, partner conflict | 「呢個問題有冇影響你同伴侶嘅關係？」 | ~5% |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好！我係X醫生，今日想同你傾下你嚟嘅原因。方唔方便你簡單講下咩事？」(Hello, I'm Dr X, I'd like to chat about why you came today.) | Interpersonal marks: greeting, open-ended start |
| 0:30–2:00 | HPI – symptom analysis | 「你嘅月經幾時開始唔正常？隔幾耐嚟一次？每次嚟幾多日？量多唔多？有冇經期之間出血？」 | Captures chief complaint, onset, cycle length, duration, volume, IMB |
| 2:00–3:00 | Red flags & targeted systems review | 「有冇頭暈或者好攰？有冇體重變化？有冇出多咗毛或者暗瘡？有冇性生活？有冇可能有咗？」 | Screens PCOS, thyroid, pregnancy, anaemia |
| 3:00–4:00 | PMH, drug Hx, FHx, social Hx | 「你之前有冇乜嘢病？食緊咩藥？屋企人有冇類似問題？你做咩工作？壓力大唔大？」 | Completeness of history; identifies masquerades (drugs, stress) |
| 4:00–5:00 | ICE – uncover hidden agenda | 「你自己覺得呢個問題係咩原因？最擔心嘅係咩嘢？你今日嚟最想醫生幫你做啲咩？」 | Directly scores ICE marks; reveals hidden agenda |
| 5:00–5:30 | Summarise & check understanding | 「等我總結下：你月經大約X個月先嚟一次，已經持續咗X個月，你最擔心嘅係……係咪咁？」 | Shows active listening, accuracy |
| 5:30–6:00 | Signpost plan, safety-net, close | 「我建議幫你做個簡單檢查同抽血睇下荷爾蒙。如果你之後突然大量出血或者好暈，要即刻去急症。多謝你今日嚟！」 | Safe closure, safety-net, professional ending |
Uncovering the hidden agenda: The patient may present with "irregular periods" but the real reason could be:
- Wanting to get pregnant (fertility concern)
- Fear of cancer / serious illness
- Relationship or sexual concern
- Weight/body image issues
- Side effects of contraception Ask: 「點解揀咗今日嚟睇？係咪有啲特別嘅嘢令你擔心？」(Why did you choose to come today? Is there something specific worrying you?)
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Cycle frequency | How often do your periods come? | 「你月經隔幾耐嚟一次？」 | FIGO defines frequent < 24d, infrequent > 38d [1] | Polymenorrhoea (luteal defect) vs oligomenorrhoea (PCOS) |
| Regularity | Are your cycles regular or do they vary a lot? | 「每次隔嘅日子差唔多定差好遠？」 | Irregular variation ≥ 8-10d [1] | Anovulatory cycles, PCOS |
| Duration & volume | How many days do you bleed? Is it heavy? | 「每次嚟幾多日？量多唔多？要唔要成日換M巾？」 | Differentiates HMB from normal; anaemia risk | Fibroid, coagulopathy, endometrial pathology |
| Intermenstrual bleeding | Any bleeding between periods? | 「經期之間有冇出血？」 | Red flag for cervical/endometrial pathology | Polyp, cervical ca, endometrial ca |
| Postcoital bleeding | Any bleeding after sex? | 「親密之後有冇出血？」 | Cervical pathology red flag | Cervical ectropion, cervical ca |
| LMP & pregnancy | When was your last period? Could you be pregnant? | 「你上次月經幾時嚟？有冇可能有咗BB？」 | Must exclude pregnancy first | Pregnancy, ectopic |
| Sexual activity & contraception | Are you sexually active? Using contraception? | 「你有冇性生活？有冇用避孕方法？」 | OCP/IUD can cause irregular bleeding; fertility concern | Iatrogenic (COEIN-I), pregnancy |
| Hyperandrogenism | Excess hair growth, acne, hair thinning? | 「有冇多咗體毛、暗瘡、或者甩頭髮？」 | Clinical hyperandrogenism = PCOS criterion | PCOS (Rotterdam: ≥2 of oligo/anovulation, hyperandrogenism, PCOS on US) [3] |
| Weight change | Any weight gain or difficulty losing weight? | 「體重有冇變化？係咪好難減肥？」 | Obesity + insulin resistance in PCOS; also thyroid | PCOS, hypothyroidism |
| Thyroid symptoms | Heat/cold intolerance? Tremor? Fatigue? Constipation? | 「有冇怕凍或者怕熱？有冇手震、便秘、成日攰？」 | Thyroid disorder is a masquerade & needs TFT [2] | Hypothyroidism, hyperthyroidism |
| Galactorrhoea | Any milky discharge from nipples? | 「乳頭有冇出奶或者分泌物？」 | Hyperprolactinaemia | Prolactinoma, drug-induced |
| Stress / psych | Are you under a lot of stress? Low mood? | 「最近壓力大唔大？心情點？有冇唔開心？」 | Functional hypothalamic amenorrhoea; hidden agenda | Stress, depression, eating disorder |
| Exercise & diet | Do you exercise a lot? Any dieting? | 「你做唔做好多運動？有冇刻意節食？」 | Excessive exercise/low BMI → hypothalamic cause | Functional hypothalamic amenorrhoea |
| Drug history | Any medications? Especially hormones, valproate, antipsychotics? | 「你食緊咩藥？有冇食荷爾蒙藥、抗癲癇藥或者精神科藥？」 | Valproic acid is a risk factor for PCOS [3]; antipsychotics → ↑prolactin | Iatrogenic, drug-induced hyperprolactinaemia |
| PMH | Any previous gynaecological problems or surgery? | 「之前有冇婦科問題或者做過手術？」 | Pelvic surgery → adhesions; known endometriosis | Endometriosis, Asherman syndrome |
| FHx | Family history of similar problems or PCOS? | 「屋企人有冇月經問題或者多囊卵巢？」 | 1st degree FHx of PCOS is a risk factor [3] | PCOS |
| Fertility desire | Are you trying to get pregnant? | 「你有冇想生BB？」 | Changes urgency and management; may be the real RFC | Infertility workup |
| Functional impact | How does this affect your daily life? | 「呢個問題對你日常生活有冇影響？」 | Biopsychosocial; scores interpersonal marks | QoL impairment |
Case Report Form Answer Builder
Chief Complaint: Irregular menstrual cycles for [duration]
HPI high-yield points to capture:
- Age of menarche, previous cycle pattern, onset of irregularity
- Current cycle frequency (e.g. q6–8 weeks), duration, volume
- Associated symptoms: hirsutism, acne, weight gain, galactorrhoea, hot flushes
- LMP, sexual activity, contraception use
- Red flags: IMB, PCB, postmenopausal bleeding
- Impact on daily life, fertility concerns
| Likely RFC | How to Phrase |
|---|---|
| Fertility concern | "Patient is concerned about her ability to conceive in the future due to irregular cycles" |
| Worried about serious disease | "Patient is worried her irregular periods may indicate cancer or hormonal disease" |
| Wants investigation/treatment | "Patient wants to find out the cause of her irregular periods and get treatment" |
| Contraception-related concern | "Patient noticed irregular bleeding after starting a new contraceptive and wants reassurance" |
Pick ONE. Write: "The main reason for consultation is [patient's own words about why she came today]."
| Component | Example Wording |
|---|---|
| Ideas | "Patient thinks her irregular periods may be due to hormonal imbalance / stress / PCOS" |
| Concerns | "Patient is worried she may not be able to get pregnant / worried about cancer" |
| Expectations | "Patient wants blood tests to check hormones / wants medication to regulate periods / wants referral to gynaecologist" |
PCOS (Polycystic Ovarian Syndrome) — if the patient is a reproductive-age woman with oligomenorrhoea + features of hyperandrogenism (hirsutism, acne) ± obesity.
Minimum supporting evidence: [3]
- Oligomenorrhoea (cycles > 35 days or < 6 menses/year)
- Clinical or biochemical hyperandrogenism
- Rotterdam criteria: ≥2 of (1) oligo/anovulation, (2) hyperandrogenism, (3) PCOS morphology on US [3]
- Exclusion of other causes (thyroid, prolactin, CAH)
High Yield – GC Lecture Slide
| DDx | Key Discriminator |
|---|---|
| Thyroid dysfunction (hypothyroidism) | Fatigue, weight gain, cold intolerance, constipation; abnormal TFT |
| Hyperprolactinaemia | Galactorrhoea, headache, visual field defect; elevated serum prolactin |
| Functional hypothalamic amenorrhoea | Stress, excessive exercise, low BMI, eating disorder; diagnosis of exclusion |
If scenario suggests perimenopausal woman, swap in perimenopause (vasomotor symptoms, age > 40, ↑FSH). If IMB/PCB present, consider endometrial pathology or cervical pathology.
| Domain | Problem |
|---|---|
| Biological | Anovulatory cycles → risk of iron-deficiency anaemia (if HMB) and long-term risk of endometrial hyperplasia/carcinoma from unopposed oestrogen [3] |
| Psychological | Anxiety about fertility / fear of serious disease / low self-esteem related to hirsutism or weight gain |
| Social | Impact on work/school attendance due to unpredictable bleeding; strain on intimate relationships |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| PCOS (most likely) | Hirsutism (modified Ferriman-Gallwey score ≥ 4-6) | Inspect face (upper lip, chin), chest, abdomen, thighs for terminal hair | Clinical evidence of hyperandrogenism – one of the Rotterdam criteria [3] |
| PCOS | Acanthosis nigricans | Inspect posterior neck, axillae for velvety hyperpigmented patches | Indicates insulin resistance, common in PCOS |
| PCOS | Central obesity / raised BMI | Measure BMI, waist circumference | ~obesity & insulin resistance are metabolic features of PCOS [3] |
| Thyroid dysfunction | Thyroid enlargement / bradycardia / delayed ankle jerk relaxation | Palpate thyroid from behind; check HR; test ankle jerk | Hypothyroidism causing oligomenorrhoea |
| Hyperprolactinaemia | Visual field defect (bitemporal hemianopia) | Confrontation visual field testing | Suggests pituitary macroadenoma compressing optic chiasm |
| Functional hypothalamic amenorrhoea | Low BMI (< 18.5) | Measure height & weight, calculate BMI | Energy deficit → hypothalamic suppression of GnRH |
For the exam, if PCOS is your most likely diagnosis, write: "Hirsutism on face/body – evidence of clinical hyperandrogenism supporting PCOS."
Exam Discriminators and Traps
Top Traps That Lose Marks
- Forgetting to exclude pregnancy — always ask LMP and sexual activity first, regardless of the presenting complaint.
- Confusing terminology — polymenorrhoea (frequent, < 24 days) vs oligomenorrhoea (infrequent, > 35-38 days): know the FIGO definitions [1].
- Writing "hormonal imbalance" as a diagnosis — this is not a diagnosis. Write a specific entity (PCOS, hypothyroidism, etc.).
- Not asking about drugs — OCP, depot medroxyprogesterone, levonorgestrel IUS, antipsychotics, and valproic acid [3] all cause menstrual irregularity.
- Forgetting endometrial cancer risk — prolonged anovulation → chronic unopposed oestrogen → endometrial hyperplasia/carcinoma [3]. Always ask about IMB and consider referral if age > 35 with irregular cycles [5].
- Not exploring ICE — the hidden agenda (fertility, cancer fear) is often the main reason for consultation and carries significant marks.
- Skipping biopsychosocial — always identify at least one psychological and one social problem.
| Red Flag | Think Of | Action |
|---|---|---|
| Postmenopausal bleeding | Endometrial carcinoma | Urgent gynaecology referral + TVUS |
| Severe virilisation (rapid onset hirsutism, voice deepening, clitoromegaly) | Androgen-secreting tumour | Urgent referral; testosterone rarely > 150 ng/dL in PCOS [3] |
| Visual field defect + galactorrhoea | Pituitary macroadenoma | Urgent MRI pituitary |
| Acute heavy bleeding with haemodynamic instability | Haemorrhage (structural or coagulopathy) | A&E |
| Age > 35 with irregular long cycles [5] | Endometrial pathology; reduced fertility | Early referral for fertility and endometrial assessment |
「如果你之後突然大量出血、頭暈企唔穩、或者驗到有咗要即刻返嚟睇。我哋會安排抽血同超聲波，結果出咗之後會再同你跟進。」 (If you have sudden heavy bleeding, dizziness, or find out you're pregnant, come back immediately. We'll arrange bloods and ultrasound and follow up with results.)
High Yield Summary
What to ASK: LMP, pregnancy possibility, cycle frequency/regularity/duration/volume, hyperandrogenism (hirsutism/acne), weight change, thyroid symptoms, galactorrhoea, stress/exercise/diet, drugs (OCP, valproate, antipsychotics), sexual activity, contraception, fertility desire, FHx of PCOS, and ICE.
What to WRITE: Chief complaint with FIGO terminology. Most likely Dx = PCOS if young woman with oligo/anovulation + hyperandrogenism. DDx = thyroid dysfunction, hyperprolactinaemia, functional hypothalamic amenorrhoea. Physical sign = hirsutism. Biopsychosocial must include endometrial hyperplasia risk (bio), fertility anxiety (psych), impact on relationships/work (social).
What NOT to MISS: Exclude pregnancy. Screen for endometrial cancer risk (age > 35, prolonged anovulation). Ask about drugs. Explore ICE and hidden agenda (fertility, cancer fear). Use FIGO definitions correctly. For irregular cycles: check FSH, prolactin, TFT, US ovarian morphology — NOT mid-luteal progesterone (that is for regular cycles only). [2][4]
Active Recall - Family Medicine Clinical Test
[1] CFB (OG04) Menstrual Disorders.pdf (p7, p61) — FIGO definitions of normal menstruation, terminology for frequency disturbances [2] GC 117. I want to have a baby male and female infertility.pdf (p24) — Investigations for ovulation in irregular vs regular cycles [3] Adrian Lui Gynecology Notes.pdf (p40-41) — PCOS epidemiology, Rotterdam criteria, pathogenesis, clinical manifestations, risk factors including valproic acid [4] Adrian Lui Gynecology Notes.pdf (p156) — Workup for anovulation: irregular cycles → FSH, prolactin, TFT; regular cycles → mid-luteal progesterone [5] MBBS_SRH_2025.8.10.pdf (p41) — Early referral criteria for female infertility including age > 35 and irregular long cycles
Intermenstrual Bleeding
Intermenstrual bleeding is vaginal bleeding that occurs between expected menstrual periods, indicating possible cervical pathology, hormonal imbalance, infection, or structural uterine abnormalities.
Jaundice
Jaundice is the yellowish discoloration of the skin, sclera, and mucous membranes resulting from elevated serum bilirubin levels (hyperbilirubinemia) exceeding approximately 2–3 mg/dL.