What are the differential diagnoses for a 15-year-old female (G0) presenting with heavy menstrual bleeding, severe bloating, pelvic pain, back pain during menses, anxiety, mood swings, and lack of interest in daily activities?

Differential Diagnoses for Heavy Menstrual Bleeding with Mood Symptoms in an Adolescent

The three most likely differential diagnoses for this 15-year-old with heavy menstrual bleeding, severe pelvic pain, and mood symptoms are: (1) primary dysmenorrhea with premenstrual syndrome, (2) underlying bleeding disorder (particularly von Willebrand disease), and (3) secondary dysmenorrhea from endometriosis.

1. Primary Dysmenorrhea with Premenstrual Syndrome (PMS)

This is the most common diagnosis in adolescents presenting with menstrual pain and mood symptoms, particularly when pain is confined to the menstrual period without progressive worsening. 1

Key Clinical Features:

• Pain characteristics: Confined to 1-3 days of menstruation without progressive worsening over years 1
• Psychological symptoms: Anxiety, mood swings, and lack of interest in activities are classic PMS features affecting up to 39.6% and 34.6% of women respectively 2
• Physical symptoms: Severe bloating, pelvic pain, and back pain are commonly reported with dysmenorrhea 2
• Functional impairment: Missing school and disrupted daily routine occurs in approximately 40% of women with menstrual symptoms 2

Important Caveat:

While primary dysmenorrhea is most common, the severity of bleeding (2 pads every 1-2 hours) suggests possible underlying pathology requiring further investigation 3, 4.

2. Underlying Bleeding Disorder (von Willebrand Disease)

Menorrhagia in an adolescent should be attributed to a coagulopathy until proved otherwise, as up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder. 5, 4

Key Clinical Features:

• Bleeding pattern: "Flooding" (changing pad/tampon more frequently than hourly) and clots ≥1 inch diameter predict bleeding disorders 3
• Prevalence: Coagulation disorders affect approximately 90% of women with underlying bleeding disorders through heavy menstrual bleeding 3
• Screening indication: All adolescents with menorrhagia require screening for coagulopathy 5

Diagnostic Approach:

• Initial labs: Complete blood count to assess for anemia from menorrhagia 6
• Bleeding history: Personal or family history of bleeding accompanied by flooding/prolonged menses warrants hematology referral 3
• Coagulation studies: Women with high-risk factors or adolescents with menorrhagia failing medical therapy should be screened 5

3. Secondary Dysmenorrhea from Endometriosis

Endometriosis should be strongly considered given the combination of severe pelvic pain, back pain, and potential progressive symptoms, as it affects 2-10% of reproductive-aged women and can present in adolescence. 1

Key Clinical Features:

• Pain pattern: Progressive worsening over time and pain extending beyond menstruation suggests secondary dysmenorrhea 1
• Associated symptoms: Sacral backache with menses is characteristic of endometriosis 1
• Systemic manifestations: Mood symptoms may reflect chronic systemic inflammation from endometriosis 6

Red Flags Suggesting Secondary Dysmenorrhea:

• Progressive worsening of pain severity over months to years 1
• Pain timing extending beyond menstruation 1
• Failure to respond to NSAIDs and hormonal contraceptives after 3-6 months 1

Diagnostic Evaluation:

• First-line imaging: Transvaginal ultrasound (sensitivity 82.5%, specificity 84.6%) when secondary causes need exclusion 1
• Advanced imaging: Pelvic MRI if ultrasound equivocal or to characterize deep infiltrating endometriosis 6
• Inflammatory markers: ESR and CRP to assess systemic inflammation 6

Critical Clinical Pitfalls to Avoid

Do not assume primary dysmenorrhea without excluding bleeding disorders in adolescents with severe menorrhagia. The severity of bleeding (2 pads every 1-2 hours) exceeds typical primary dysmenorrhea and mandates coagulation screening 3, 5.

Do not delay empiric treatment while pursuing diagnosis. NSAIDs (ibuprofen 400 mg every 4-6 hours) provide immediate pain relief, and continuous oral contraceptives are as effective as GnRH agonists with fewer side effects 6.

Refer to gynecology if symptoms persist despite 3-6 months of empiric hormonal therapy or if severe symptoms significantly interfere with quality of life. 6 Refer to hematology if flooding, prolonged menses, or personal/family bleeding history is present 3.