What should be included in a comprehensive Electronic Health Record (EHR) template for managing irregular menses?

EHR Template for Irregular Menses Management

A comprehensive EHR template for irregular menses should include detailed assessment of menstrual patterns, associated symptoms, risk factors, physical examination findings, and management plan to ensure proper evaluation and treatment of the underlying causes. 1, 2

Chief Complaint and History of Present Illness

• Document duration of irregular menses (polymenorrhea: <23 days, oligomenorrhea: >35 days, amenorrhea: no bleeding >6 months) 1
• Record age at menarche and previous menstrual patterns 2
• Document specific bleeding characteristics:
  • Frequency, duration, and amount of flow 1
  • Presence of intermenstrual bleeding or spotting 1
  • Pattern changes over time 1

Associated Symptoms

• Presence of pain (dysmenorrhea, pelvic pain, dyspareunia) 1
• Vasomotor symptoms (hot flashes, night sweats) 2
• Hirsutism, acne, or other signs of hyperandrogenism 3
• Weight changes (gain or loss) 1
• Galactorrhea 1
• Psychological symptoms (mood changes, depression, anxiety) 4

Medical and Reproductive History

• Previous pregnancies and outcomes 1
• Current contraceptive method and any side effects 1
• History of sexually transmitted infections 1
• Chronic medical conditions (thyroid disorders, diabetes, PCOS) 2
• Current medications 1
• Previous gynecological procedures or surgeries 2

Family History

• Family history of reproductive disorders (PCOS, endometriosis) 5
• Family history of gynecological cancers 6
• Family history of endocrine disorders 2

Social and Lifestyle History

• Exercise patterns (frequency, intensity, duration) 2
• Dietary habits and nutritional status 2
• Stress levels and coping mechanisms 2
• Sleep patterns 4
• Substance use (alcohol, tobacco, recreational drugs) 2

Physical Examination

• Vital signs including BMI and blood pressure 3
• Thyroid examination 2
• Breast examination (looking for galactorrhea) 1
• Assessment for hirsutism using Ferriman-Gallwey score 1
• Assessment for acne, male pattern baldness, or other signs of hyperandrogenism 3
• Abdominal examination 2
• Pelvic examination when indicated 2

Laboratory and Diagnostic Testing

• Pregnancy test 2
• Hormonal evaluation:
  • FSH, LH (and ratio) 5
  • Prolactin 1
  • TSH 2
  • Total and free testosterone if signs of hyperandrogenism 3
  • DHEAS if indicated 1
• Complete blood count (to assess for anemia) 5
• Glucose/insulin levels if PCOS suspected 1
• Pelvic ultrasonography when indicated 1

Assessment

• Primary diagnosis (specific cause if identified) 2
• Secondary diagnoses (comorbid conditions) 4
• Risk assessment for long-term complications (metabolic syndrome, endometrial hyperplasia, osteoporosis) 4, 6

Plan

Management of Bleeding Irregularities

• For hormonal contraceptive users with irregular bleeding:
  • NSAIDs (5-7 days of treatment) for unscheduled spotting or heavy bleeding 1
  • Hormonal treatment options based on contraceptive method 1
  • Consideration of alternative contraceptive methods if bleeding persists 1

Treatment Plan Based on Underlying Etiology

• Lifestyle modifications (weight management, exercise) 2
• Hormonal therapy options 2
• Non-hormonal medication options 1
• Referrals to specialists if needed 2

Patient Education

• Expected timeline for improvement 1
• Potential side effects of treatments 1
• Importance of follow-up 1
• When to seek urgent medical attention 1

Follow-up Plan

• Timing of next appointment 1
• Parameters to monitor at follow-up visits 1
• Instructions for patient self-monitoring 1

Documentation of Counseling

• Discussion about impact on fertility if relevant 2
• Long-term health implications 4, 6
• Importance of regular gynecological care 1
• Contraceptive counseling if appropriate 1

Preventive Care

• Screening recommendations based on age and risk factors 1
• Vaccination status 1
• Bone health considerations if amenorrhea is prolonged 2