What is the appropriate management for a 27-year-old female with irregular menstrual periods, dysmenorrhea, acne, and migraines, who is not sexually active and not on any medications or birth control, with a family history of irregular periods, and who is interested in starting Blisovi (ethinyl estradiol and norethindrone)?

Differential Diagnosis for Gabriela

• Single most likely diagnosis
  • Polycystic Ovary Syndrome (PCOS): This is the most likely diagnosis given Gabriela's history of irregular menstrual periods, acne, and emotional symptoms that worsen premenstrually. Her sister's similar symptoms and improvement with hormonal treatment (Blisovi) also support this diagnosis.
• Other Likely diagnoses
  • Premenstrual Dysphoric Disorder (PMDD): Gabriela's symptoms of depression, sadness, and worsening emotions premenstrually are consistent with PMDD. However, her irregular periods and other symptoms suggest that PCOS may be a more comprehensive diagnosis.
  • Dysmenorrhea: Gabriela's severe cramping and migraines associated with her periods are consistent with dysmenorrhea. While this could be a separate diagnosis, it may also be a symptom of her underlying condition (e.g., PCOS).
  • Irregular Ovulation: Gabriela's irregular periods and symptoms could be due to irregular ovulation, which may be related to PCOS or other hormonal imbalances.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Pregnancy: Although Gabriela denies being sexually active, pregnancy should always be considered in the differential diagnosis for irregular periods.
  • Thyroid Disorders: Hypothyroidism or hyperthyroidism can cause menstrual irregularities, depression, and other symptoms. While less likely, these conditions can have significant consequences if left untreated.
  • Adrenal Disorders: Certain adrenal disorders, such as congenital adrenal hyperplasia, can cause irregular periods, acne, and other symptoms.
• Rare diagnoses
  • Androgen Insensitivity Syndrome: This rare genetic disorder can cause irregular periods, acne, and other symptoms due to androgen resistance.
  • Congenital Adrenal Hyperplasia: This rare genetic disorder can cause irregular periods, acne, and other symptoms due to adrenal gland dysfunction.
  • Other rare hormonal or genetic disorders: There are several rare disorders that can cause irregular periods, acne, and other symptoms, such as 17-alpha-hydroxylase deficiency or aromatase deficiency. While these are unlikely, they should be considered if other diagnoses are ruled out.