Major Conditions and Organ System Dysfunction to Consider
Based on this patient's constellation of symptoms (fatigue, heavy menses, cold intolerance, weight gain) following upper thoracic radiation for Hodgkin lymphoma, hypothyroidism is the primary condition to consider, with additional evaluation needed for anemia, cardiovascular disease, and persistent/recurrent malignancy.
Primary Consideration: Endocrine Dysfunction
Hypothyroidism
- Radiation-induced hypothyroidism occurs in approximately 50% of long-term survivors who received neck or upper mediastinal irradiation 1
- The classic symptom constellation present in this patient—fatigue, cold intolerance, weight gain despite maintained exercise and nutrition, heavy menstrual bleeding, dry/coarse skin—strongly suggests thyroid dysfunction 2
- Hypothyroidism typically manifests 5-10 years after radiation therapy but can occur earlier 1
- Thyroid function tests (TSH and free T4) should be performed immediately as this is a highly treatable cause of her symptoms 1, 3
Secondary Considerations Requiring Evaluation
Hematologic System
- Anemia must be evaluated given the heavy menstrual bleeding and fatigue 1, 3
- Complete blood count with differential is essential to assess for iron deficiency anemia from menorrhagia or other causes 3
- While myelosuppression from chemotherapy typically resolves shortly after treatment completion, persistent cytopenias warrant investigation 1
Cardiovascular System
- Mediastinal radiation and anthracycline-based chemotherapy create significant risk for cardiac disease, which may be asymptomatic initially 1
- RT-induced cardiotoxicity typically emerges 5-10 years post-treatment, though cardiovascular symptoms can appear at any age 1
- Fatigue and exercise intolerance despite maintained fitness regimen could indicate subclinical cardiac dysfunction 1
- Blood pressure monitoring and assessment of cardiovascular risk factors are recommended 1
Malignancy Recurrence or Secondary Malignancy
- Disease recurrence or development of secondary malignancies must be considered in any cancer survivor presenting with new constitutional symptoms 4, 3
- Fatigue is a common presenting symptom of recurrent lymphoma or treatment-related secondary cancers 1
- Given her recent cancer-free status (6 months ago), this is less likely but cannot be excluded without appropriate evaluation 1
Additional Contributing Factors to Assess
Nutritional and Metabolic Status
- Comprehensive metabolic panel to evaluate liver and kidney function, electrolyte balance 3
- Assessment for vitamin deficiencies (particularly B12, folate, vitamin D) that may contribute to fatigue 3
Sleep Disturbance
- Evaluation of sleep quality, quantity, and potential sleep disorders (sleep apnea, insomnia) 1, 4, 3
- Sleep disturbances frequently cluster with fatigue and may be both cause and consequence 4
Psychological Factors
- Screen for depression and anxiety, which commonly co-occur with cancer survivorship and fatigue 1, 4
- Post-cancer emotional distress can manifest with physical symptoms including fatigue and weight changes 1
Critical Pitfalls to Avoid
- Do not attribute all symptoms to "cancer-related fatigue" without thorough evaluation of treatable medical conditions 1
- Hypothyroidism is frequently overlooked in cancer survivors despite being extremely common after thoracic radiation 1
- Medication side effects should be reviewed, though this patient's symptom onset appears unrelated to new medications 1, 4
- Fatigue rarely occurs in isolation and typically clusters with other symptoms requiring comprehensive assessment 4, 3