Evaluation of Irregular Menstrual Cycles with White Skin Patches, Headaches, and Persistent Abdominal Pain
You need immediate evaluation for three distinct but potentially interconnected problems: shortened menstrual cycles (2 days instead of 7), white skin patches requiring dermatologic assessment for vitiligo or fungal infection, and menstrual-related headaches with persistent abdominal pain that warrant gynecologic and possibly gastrointestinal investigation. 1, 2
Menstrual Irregularity Assessment
Your 2-day menstrual cycles are abnormal and require systematic evaluation:
- Obtain pregnancy testing first to exclude pregnancy as a cause of altered bleeding patterns 1
- Measure core hormonal panel: TSH, free T4, prolactin (morning resting sample), LH, FSH (average of three measurements 20 minutes apart on cycle days 3-6), and testosterone 1, 2, 3
- Check mid-luteal progesterone (day 21 of cycle) when cycles resume—levels <6 nmol/L indicate anovulation suggesting PCOS or other chronic anovulatory conditions 2, 3
- Screen for metabolic complications with fasting glucose, 2-hour oral glucose tolerance test, and fasting lipid panel, as insulin resistance commonly accompanies menstrual irregularities 2
Your cycle pattern (lasting only 2 days) falls outside the normal definition of menstrual regularity, which requires cycles between 23-35 days with bleeding lasting 3-7 days 1. This shortened bleeding duration may indicate anovulation, hormonal imbalance, or endometrial pathology.
White Skin Patches Evaluation
The white patches on your skin require separate dermatologic evaluation, as this is not typically related to menstrual disorders:
- Consider vitiligo, an autoimmune condition that can be associated with other autoimmune disorders including thyroid dysfunction (which also causes menstrual irregularity) 3
- Rule out fungal infections (tinea versicolor) or other dermatologic conditions through dermatology consultation
- Check thyroid function (TSH, free T4) as thyroid dysfunction commonly causes both menstrual irregularity and can be associated with vitiligo 3
Headache and Abdominal Pain Assessment
Your headaches and persistent abdominal pain require careful characterization:
Menstrual-Related Headaches
- Document headache timing relative to your menstrual cycle—menstrual migraines occur on day 1 ± 2 of menstruation in at least 2 of 3 cycles 4, 5
- Identify aura symptoms (visual changes, numbness, speech difficulty) as this affects treatment options—combined hormonal contraceptives are contraindicated if you have migraine with aura 4
- Consider estrogen withdrawal as the trigger for perimenstrual headaches, which provides specific treatment opportunities 4, 5
Persistent Abdominal Pain
Your abdominal pain lasting beyond menstruation is concerning and requires investigation:
- Obtain pelvic ultrasound (transvaginal preferred) between cycle days 3-9 to evaluate for ovarian cysts, polycystic ovaries (>10 peripheral cysts, 2-8 mm diameter), fibroids, or masses 1, 2
- Consider gastrointestinal causes including inflammatory bowel disease, irritable bowel syndrome, or chronic pelvic pain syndromes 6
- Rule out endometriosis, which is associated with menstrual irregularities and causes pain that can persist beyond menstruation 6
Potential Diagnoses to Consider
Polycystic Ovary Syndrome (PCOS)
PCOS is the most common cause of menstrual irregularity in reproductive-age women, affecting 4-6% of the general female population 1. Diagnosis requires:
- LH/FSH ratio >2 (measured as average of three samples 20 minutes apart) 2, 3
- Hyperandrogenism (elevated testosterone, clinical hirsutism, or acne) 2
- Polycystic ovaries on ultrasound 2
Thyroid Dysfunction
Primary hypothyroidism commonly causes both menstrual irregularity and can be associated with vitiligo 3. Treatment of thyroid dysfunction alone may normalize menstrual cycles 3.
Long COVID Considerations
If you have had recent COVID-19 infection, menstrual alterations are more likely, with irregular menstruation being one of the most common menstrual changes 6. Individuals with COVID-19 and menstrual changes were more likely to experience fatigue, headache, body ache and pain 6.
Treatment Approach
For Menstrual Irregularity
Combined oral contraceptives (COCs) are first-line therapy to regulate menstrual cycles once pregnancy and contraindications are excluded 1, 2:
- Prefer 17β-estradiol-based COCs (such as 17βE + nomegestrol acetate or 17βE + dienogest) over ethinylestradiol formulations when available for more favorable metabolic profiles 2
- Use continuous or extended regimens (skipping placebo pills or using only 2 placebo days) to prevent estrogen withdrawal if menstrual migraines are present 4, 7
- Do NOT use COCs if you have migraine with aura, as this represents an unacceptable health risk 4
Add metformin 1000 mg daily if insulin resistance is confirmed on testing or if BMI is elevated 2.
For Menstrual-Related Headaches
- NSAIDs for acute treatment (5-7 days during menstruation) for both headache and dysmenorrhea 6, 8
- Triptans as gold standard for acute migraine treatment 8
- Short-term perimenstrual prophylaxis with NSAIDs if symptomatic treatment is insufficient 8
- Magnesium supplementation has some evidence for efficacy in menstrual-related symptoms 8
For Persistent Abdominal Pain
Treatment depends on underlying cause identified through imaging and laboratory evaluation. If endometriosis is suspected, hormonal suppression with continuous COCs or levonorgestrel IUD may be beneficial 1.
Referral Criteria
Refer to gynecology if 1:
- Amenorrhea persists >6 months
- Abnormal hormone levels suggest specific pathology
- Structural abnormalities found on imaging
- Pain persists despite initial management
Refer to dermatology for evaluation and management of white skin patches.
Refer to endocrinology if 1:
- Thyroid dysfunction is confirmed
- PCOS is diagnosed and requires metabolic management
- Hyperprolactinemia is identified