What is the workup for a 21-year-old female with recurrent syncope (fainting spells) and menorrhagia (prolonged menstrual period lasting 7 days)?

From the Guidelines

For a 21-year-old with recurrent syncope and prolonged menstrual periods, I recommend a comprehensive workup focusing on both cardiac and hematologic causes. Start with a complete blood count to assess for anemia, which can result from heavy menstruation (menorrhagia) and lead to syncope, as suggested by 1. Include ferritin levels to evaluate iron stores. Obtain an electrocardiogram (ECG) to screen for arrhythmias, QT interval abnormalities, and structural heart disease, as recommended by 1 and 1. Consider 24-hour Holter monitoring or an event recorder if the ECG is normal but cardiac causes are still suspected. Orthostatic vital signs should be measured to detect postural hypotension, following the guidelines outlined in 1 and 1. Echocardiography may be warranted to evaluate cardiac structure and function. For the menstrual issues, thyroid function tests, prolactin levels, and pelvic ultrasound are appropriate to rule out underlying endocrine or anatomical abnormalities, as indicated by 1. A gynecological consultation is essential to address the prolonged menstrual bleeding, which may require hormonal therapy such as combined oral contraceptives to regulate cycles and reduce bleeding. The connection between these symptoms is important - iron deficiency anemia from menorrhagia can cause decreased oxygen-carrying capacity, leading to cerebral hypoperfusion and syncope, especially with positional changes or exertion, as supported by the guidelines in 1 and 1.

Some key points to consider in the workup include:

• The patient's age and the period over which recurrent episodes have occurred, as mentioned in 1.
• The presence of prodromal symptoms, such as sweating or feeling warm or hot before syncope, as discussed in 1.
• The presence of severe bradycardia due to atrioventricular block, which may require urgent cardiac pacing, as recommended by 1.
• The potential for cardiac arrhythmia, such as TLoC during exercise, history or physical signs of heart failure, or ECG abnormality, as outlined in 1 and 1.

Overall, a comprehensive approach is necessary to address both the cardiac and hematologic aspects of the patient's condition, with a focus on identifying the underlying causes of syncope and menorrhagia, and providing appropriate treatment to improve the patient's quality of life and reduce the risk of adverse outcomes.

From the Research

Diagnostic Approach

The diagnostic approach for a 21-year-old female with recurrent syncope and menorrhagia involves a thorough evaluation of the cause of syncope, as it is a common clinical problem characterized by transient, spontaneously self-terminating loss of consciousness with complete and prompt recovery 2. The following steps can be taken:

• Determine the underlying cause of syncope through careful and thorough evaluation, as syncope can be caused by various factors, including cardiac disorders, autonomic-mediated reflex syncope, psychologic problems, and neurological and metabolic disorders 3
• Perform a detailed clinical history, physical examination, and 12-lead ECG as the initial evaluation 4
• Consider further workup based on the suspicion or documented presence of heart disease, such as exercise testing, cardiac electrophysiology, and tilt-table testing 4

Specific Considerations

In the case of a 21-year-old female with recurrent syncope and menorrhagia, the following considerations can be taken into account:

• Autonomic-mediated reflex syncope (AMS) is a common cause of syncope in young females, and the patient's symptoms and history can be evaluated to determine if AMS is a possible cause 3
• Menorrhagia can be a contributing factor to syncope, and its treatment may be necessary to prevent further episodes of syncope
• A thorough physical examination, including supine and standing blood pressure measurement and carotid sinus massage, can be performed to evaluate the patient's cardiovascular system 5

Diagnostic Tests

The following diagnostic tests can be considered:

• Echocardiography and ECG monitoring to evaluate the patient's cardiac function 5
• Head-up tilt test to diagnose 'malignant vasovagal syndrome' or other forms of autonomic-mediated reflex syncope 6
• Electrophysiological study or ILR implantation if the cause of syncope remains unclear after initial evaluation 5
• Routine blood tests, such as blood electrolytes and blood glucose, may not be necessary unless the patient has a history of metabolic diseases 3