Differential Diagnosis
The patient's symptoms of menstrual cramps, heavy menstrual flow, fatigue, and weight gain, along with physical examination findings, suggest several potential diagnoses.
Single most likely diagnosis
- Elevated TSH (Hypothyroidism): The patient's symptoms of fatigue, weight gain, and heavy menstrual flow, along with physical examination findings of puffy face, telangiectasias, thinning of the eyebrows, and delayed relaxation of deep tendon reflexes, are consistent with hypothyroidism. Hypothyroidism can cause menstrual irregularities, including heavy or prolonged menstrual bleeding.
Other Likely diagnoses
- Endometrial overgrowths (Endometrial Hyperplasia): The patient's heavy menstrual flow and prolonged menstrual periods could be due to endometrial overgrowths, which can be caused by hormonal imbalances, such as anovulatory cycles or unopposed estrogen.
- Decreased von Willebrand factor level (von Willebrand Disease): The patient's heavy menstrual flow could be due to a bleeding disorder, such as von Willebrand disease, which is a common cause of heavy menstrual bleeding in adolescents.
- Elevated androgens (Polycystic Ovary Syndrome - PCOS): Although the patient's symptoms do not fully align with PCOS, the presence of heavy menstrual flow, weight gain, and fatigue could be related to hormonal imbalances, including elevated androgens.
Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Prolonged aPTT (Bleeding Disorder): A prolonged activated partial thromboplastin time (aPTT) could indicate a bleeding disorder, such as hemophilia or a lupus anticoagulant, which could be life-threatening if not diagnosed and treated promptly.
- Elevated midnight cortisol (Cushing's Syndrome): Although less likely, Cushing's syndrome could cause weight gain, fatigue, and menstrual irregularities, and would be a critical diagnosis to not miss due to its potential for serious complications.
Rare diagnoses
- Benign uterine neoplasms (Uterine Fibroids): Although less common in adolescents, uterine fibroids could cause heavy menstrual flow and pelvic pain.
- Elevated LH:FSH ratio (Premature Ovarian Failure): An elevated luteinizing hormone (LH) to follicle-stimulating hormone (FSH) ratio could indicate premature ovarian failure, although this is a rare diagnosis in a 16-year-old girl.