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 |
|---|---|---|---|---|
| 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？」 | ~50% |
| 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？」 | ~15% | |
| Serious Not To Miss | Pregnancy (including ectopic) | Always exclude first | 「有冇機會懷咗？上次性行為幾時？」 | ~5% |
| 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？」 | ~3% | |
| 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？」 | ~2% | |
| Androgen-secreting tumour (ovarian/adrenal) | Rapid-onset virilisation, very high testosterone | Rapidly progressive hirsutism + voice deepening | < 1% | |
| 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？」 | ~5% |
| Non-classical congenital adrenal hyperplasia (NCAH) | Mimics PCOS; ↑17-hydroxyprogesterone | Consider in hirsute patient not responding to PCOS Rx | ~2% | |
| 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？」 | < 1% | |
| Masquerades | Depression/stress as masquerade | Hypothalamic suppression from chronic stress | 「心情點呀？瞓得好唔好？」 | ~10% |
| Drug-induced hyperprolactinaemia | Antipsychotics, metoclopramide, methyldopa [5] | 「有冇食緊精神科藥物或者止嘔藥？」 | ~5% | |
| 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？」 | ~20% |
| 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？」 | ~5% |
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)
Nipple Discharge
Nipple discharge is the release of fluid from one or both nipples, which may be physiologic or pathologic, with spontaneous, unilateral, bloody, or single-duct discharge warranting evaluation for underlying conditions such as intraductal papilloma or malignancy.
Oral / Dental Lesions
Oral and dental lesions are pathological changes in the tissues of the oral cavity, including the teeth, gingiva, tongue, palate, and mucosa, arising from infectious, inflammatory, traumatic, autoimmune, or neoplastic processes.