What is the best course of action for a 22-year-old female with a late menstrual cycle, spotting, and a negative human chorionic gonadotropin (HCG) test, who is actively trying to conceive and has no symptoms of ectopic pregnancy or other severe conditions?

Clinical Note Review: 22-Year-Old Female with Late Menstrual Cycle and Negative HCG

Your clinical note is well-structured and demonstrates appropriate management, but several critical gaps need addressing to ensure comprehensive care for this patient actively trying to conceive.

Strengths of Your Current Approach

Your documentation appropriately includes:

• Comprehensive history covering key red flags (hemorrhaging, fever, abdominal pain) 1
• Appropriate HCG testing to rule out pregnancy and ectopic pregnancy, with modern tests achieving 98% sensitivity by 7 days post-missed period 1
• Safety netting with clear return precautions for hemorrhaging 1
• Physical examination ruling out acute pathology 2

Critical Gaps That Need Addressing

1. Incomplete Differential Diagnosis Workup

You should have pursued additional diagnostic testing beyond HCG, particularly given her 12-day delayed cycle and active attempts to conceive. The patient's presentation warrants evaluation for:

• Thyroid function testing (TSH) - thyroid disorders are a common cause of menstrual irregularity and can impact fertility 2
• Prolactin level - hyperprolactinemia causes menstrual irregularity and anovulation 2
• Consideration of pelvic ultrasound - to evaluate for structural pathology (polyps, fibroids) or polycystic ovary morphology, especially given prolonged infertility 2, 3
• Progesterone level in mid-luteal phase - to confirm ovulation, particularly relevant given her infertility history 3, 4

2. STI Testing Refusal Requires More Nuanced Counseling

The patient's refusal of STI testing based on being married with one partner represents a missed opportunity for education. You should have:

• Explained that chlamydia and gonorrhea can be asymptomatic and are important causes of tubal factor infertility 2
• Documented specific counseling about the clinical rationale, not just that she declined 2
• Considered offering testing again after explaining that undiagnosed STIs could explain her inability to conceive 2

3. Inadequate Fertility Counseling

Given her active attempts to conceive since [DATE], your note should have addressed:

• Duration of infertility - if >12 months (or >6 months if age >35), she meets criteria for infertility evaluation and warrants referral to reproductive endocrinology 3, 5
• Menstrual cycle variability assessment - women with high cycle variability have 51% lower per-cycle pregnancy probability compared to those with regular cycles 5
• Fertility awareness methods - teaching basal body temperature tracking and cervical mucus monitoring can identify ovulation timing and improve conception rates 3
• Preconception optimization - folic acid supplementation, lifestyle modifications 3

4. Timing of HCG Testing May Be Premature

A single negative HCG at 12 days late does not definitively rule out pregnancy. Consider:

• Early pregnancy loss - detectable HCG can occur transiently in early conceptual loss, with studies showing 27-39% of fertile women demonstrate transient HCG elevation without clinical pregnancy 4, 6
• Repeat testing recommendation - you should have advised repeat HCG in 48-72 hours if menses does not occur, as HCG levels double every 48 hours in viable pregnancy 1
• Quantitative beta-HCG would be more informative than qualitative urine testing in this context 4, 6

Specific Documentation Improvements

What to Add to Your Note:

Assessment and Plan Section Enhancement:

• "Differential diagnosis includes: anovulation, early pregnancy loss, thyroid dysfunction, hyperprolactinemia, polycystic ovary syndrome, and structural uterine pathology 2, 3"

• "Ordered: TSH, prolactin, repeat quantitative beta-HCG in 48-72 hours if no menses 2, 3"

• "Counseled patient on importance of STI screening despite monogamous relationship; patient declined after shared decision-making discussion 2"

• "Fertility counseling provided: Discussed cycle tracking with basal body temperature and cervical mucus monitoring; advised preconception folic acid 400-800 mcg daily 3"

• "Referral criteria discussed: If no pregnancy within 6 months (given age 22, can wait 12 months total), will refer to reproductive endocrinology for formal infertility evaluation 3, 5"

Red Flags You Appropriately Ruled Out

Your examination correctly excluded:

• Ectopic pregnancy signs (no abdominal pain, CVA tenderness) 1
• Hemorrhagic complications 1
• Acute infection (no fever, dysuria) 2

Bottom Line Recommendation

Your note demonstrates safe acute care management but lacks the comprehensive evaluation needed for a patient with prolonged infertility and menstrual irregularity. Before discharge, you should have:

1. Ordered thyroid and prolactin testing 2, 3
2. Provided specific fertility counseling with cycle tracking education 3
3. Arranged follow-up within 1-2 weeks to review labs and discuss next steps, not just "F/U with PCM" 2, 3
4. Documented quantitative beta-HCG plan if menses does not occur 1, 4
5. Established clear timeline for reproductive endocrinology referral 3, 5

The patient's 12-day delay with spotting could represent early pregnancy loss, anovulation, or underlying endocrine pathology - all of which require more thorough evaluation than a single negative HCG test. 4, 6, 5