Differential Diagnosis for Absent Menses in a 32-year-old Woman
- Single most likely diagnosis
- Sheehan syndrome is unlikely given the normal TSH level, but Hypothalamic Amenorrhea is a strong consideration due to the patient's history of postpartum hemorrhage, which can lead to pituitary apoplexy or Sheehan syndrome, although less likely with normal TSH. However, the more likely cause of hypothalamic amenorrhea in this context is the physiological stress and potential for transient hypopituitarism postpartum, combined with the physical and emotional demands of new motherhood and possibly the return to work. The absence of galactorrhea and the normal FSH and TSH levels support this diagnosis over others like prolactinoma.
- Other Likely diagnoses
- Postpartum Thyroiditis: Although the TSH level is normal, postpartum thyroiditis can sometimes present with a normal TSH level initially, and the patient's symptoms of fatigue could be consistent with this condition. It's a common condition postpartum and can cause menstrual irregularities.
- Pituitary Adenoma (including Prolactinoma): Although less likely given the absence of galactorrhea and normal FSH and TSH levels, a pituitary adenoma could still be a consideration, especially if there were any symptoms suggestive of a mass effect or if the patient had undergone further testing that revealed an abnormality.
- Polycystic Ovary Syndrome (PCOS): Given the patient's history of regular menstrual cycles before pregnancy, PCOS might seem less likely, but the patient's BMI of 31 kg/m2 and the absence of menses postpartum could suggest an underlying hormonal imbalance that became more pronounced postpartum.
- Do Not Miss diagnoses
- Pituitary Apoplexy or Sheehan Syndrome: Despite the normal TSH level, these conditions are critical to rule out due to their potential severity and the patient's history of postpartum hemorrhage. Sheehan syndrome, in particular, is a condition that must not be missed due to its potential for significant morbidity if left untreated.
- Uterine Synechiae (Asherman Syndrome): Given the patient's history of suction and sharp curettage, there is a risk of uterine synechiae, which could cause amenorrhea. This condition is crucial to diagnose as it can lead to significant reproductive issues if not addressed.
- Rare diagnoses
- Premature Ovarian Failure (POF): This would be unusual at the patient's age but could be considered if other tests revealed elevated FSH levels or if there were other symptoms suggestive of menopause.
- Other rare endocrine disorders: Such as adrenal insufficiency or genetic disorders affecting the hypothalamic-pituitary-gonadal axis, though these would be less likely and typically present with additional symptoms beyond amenorrhea.