What are the potential diagnoses for a 14-year-old female patient with a history of depression, anxiety, PTSD, ADHD, autism spectrum disorder, oppositional defiant disorder, endometriosis, and PCOS, who presents with ongoing depressive symptoms, suicidal ideation, trauma, and persistent abnormal uterine bleeding following endometriosis surgery?

Potential Diagnoses for This 14-Year-Old Patient

This patient's presentation is most consistent with her existing diagnoses of major depressive disorder, PTSD, ADHD, autism spectrum disorder, and ODD, with the critical addition of persistent abnormal uterine bleeding requiring urgent gynecologic evaluation to rule out complications from endometriosis surgery, retained products, or other structural pathology. 1

Psychiatric Diagnoses (Already Established)

Major Depressive Disorder

• The patient meets full criteria with chronic low mood, pervasive guilt, fatigue, sleep disturbance, difficulty concentrating, recurrent suicidal ideation (most recent passive thoughts 2 days prior), and suicide attempt 3 months ago 1, 2
• Depression symptoms began at age 10 with self-hatred and self-injurious behaviors, representing a chronic course 1
• Current treatment with venlafaxine (Effexor) is appropriate for major depression, though monitoring for clinical worsening and suicidality is essential given her age and recent suicidal ideation 2

Post-Traumatic Stress Disorder (PTSD)

• Clear trauma exposure from assault 2 years ago with ongoing nightmares, hypervigilance, and persistent fear 3
• Trauma-related nightmares are frequent and contribute to non-restorative sleep despite adequate duration 3
• PTSD commonly co-occurs with depression and requires trauma-informed care 1, 3

ADHD

• Chronic distractibility, difficulty with focus, and impaired task completion even for activities of personal interest (homework, creative writing) 1
• Current treatment with atomoxetine (Strattera) and guanfacine is appropriate for ADHD, though she reports poor tolerance with worsened mood on stimulants and guanfacine 1
• In patients with intellectual disabilities or autism spectrum disorder, inattentive symptoms typically do not decrease in teen years as they do in typically developing children 1

Autism Spectrum Disorder (ASD)

• Previously diagnosed, with social isolation (only 2 current friends, no neighborhood or school peer contact) 1
• Women with ASD have significantly elevated rates of PCOS (increased compared to healthy controls), suggesting potential shared familial or biological factors 4, 5
• Psychiatric comorbidities occur at least 3 times more often in children with autism spectrum disorder, particularly ODD, ADHD, and anxiety disorders 1

Oppositional Defiant Disorder (ODD)

• Previously diagnosed, though current presentation focuses more on mood symptoms and self-harm rather than oppositional behavior toward authority 1, 3
• Children with ODD have significantly increased rates of prior victimization trauma, which is present in this patient 3

Critical Self-Harm Behaviors Requiring Immediate Attention

Compulsive Self-Choking for Hypoxia

• Last episode 1 week prior to evaluation, described as "addictive rather than suicidal" 1
• This represents a dangerous compulsive behavior that can result in accidental death regardless of intent 1
• Requires intensive behavioral intervention and close monitoring 1

Self-Biting Episodes

• Last episode 1 month ago, with history dating to childhood 1
• Part of pattern of self-injurious behaviors that began at age 10 1

Gynecologic Diagnoses and Urgent Concerns

Persistent Abnormal Uterine Bleeding Post-Endometriosis Surgery

This is the most urgent medical concern requiring immediate gynecologic evaluation. 1

• Fifteen weeks of moderate to heavy bleeding following endometriosis excision surgery and IUD placement is abnormal and requires investigation 1
• Bleeding described as moderate to heavy with infrequent pad changes (twice daily) and occasional bleeding through pads 1
• Pain and systemic symptoms improved post-surgery, but menorrhagia remains unresolved 1

Differential Diagnosis for Persistent Bleeding:

• IUD-related bleeding (most common cause): Abnormal bleeding is common in first 3-6 months after IUD placement but should be evaluated if persistent beyond this timeframe 1
• Incomplete endometriosis excision or recurrence: Endometriosis affects at least one-third of women with infertility and can recur after surgery 1
• Endometrial pathology: Endometrial biopsy is preferred over dilation and curettage for diagnosing endometrial hyperplasia or cancer, though less likely at this age 1
• Structural abnormalities: Polyps, adenomyosis, or intracavitary leiomyoma (submucosal myoma) 1
• Coagulopathy: Should be considered in adolescents with heavy menstrual bleeding 1
• Ovulatory dysfunction: Common in adolescents and in patients with PCOS 1

Recommended Evaluation:

• Transvaginal ultrasonography (or transabdominal if virginity is an issue) to assess endometrial thickness, IUD position, and structural abnormalities 1
• Saline infusion sonohysterography has sensitivity of 96-100% for detecting focal lesions possibly missed by endometrial sampling 1
• Hysteroscopy allows visualization of endometrial cavity and endocervix to diagnose focal lesions 1
• Endometrial biopsy if endometrial thickness is concerning or if bleeding persists despite treatment 1
• Coagulation studies if family history or clinical suspicion for bleeding disorder 1

Endometriosis (Surgically Confirmed)

• Diagnosed early 2024 following years of severe dysmenorrhea, chronic pelvic pain, and menorrhagia beginning at menarche (age 10) 1
• Pain was severe enough to cause functional impairment including inability to walk 1
• Surgical excision performed with IUD placement for ongoing management 1, 6
• Endometriosis is associated with chronic inflammation, hypertension, and increased cardiovascular disease risk 1
• Family history is significant with mother having endometriosis, suggesting genetic predisposition 7

Polycystic Ovary Syndrome (PCOS)

• Previously diagnosed, though specific diagnostic criteria not detailed in this note 1
• PCOS affects 4-13% of women and is the leading cause of anovulatory infertility 1, 7
• PCOS is strongly associated with psychiatric comorbidities, particularly depression, anxiety, bipolar disorder, OCD, and ADHD 8, 9, 4, 10
• Women with PCOS have significantly increased odds of depression (OR 2.79), anxiety (OR 2.75), bipolar disorder (OR 1.78), and OCD (OR 1.37) 10
• Adolescents with PCOS exhibit increased psychiatric comorbidities with mood disorders reported in 43.6% and significantly higher rates of ADHD/conduct disorders 9
• PCOS is associated with metabolic syndrome, obesity, insulin resistance, hypertension, and increased cardiovascular risk 1
• Family history is significant with mother having PCOS, and siblings of women with PCOS have elevated risk for psychiatric disorders including depression, anxiety, and ASD 7, 4

Diagnostic Considerations and Pitfalls

Distinguishing PCOS from Functional Hypothalamic Amenorrhea (FHA)

• This patient has documented PCOS, but given her history of restrictive eating, excessive stress, and trauma, functional hypothalamic amenorrhea should be considered as a contributing factor 1
• FHA is characterized by low gonadotropins (especially LH), low estrogen, thin endometrium, and presence of typical causes (underweight, caloric deficiency, excessive exercise, stress) 1
• LH to FSH ratio <1 is seen in about 82% of FHA patients, while LH to FSH ratio >2 is typical in PCOS 1
• Endometrial thickness is a good indicator: thin endometrium suggests FHA with estrogen deficiency 1
• The patient's history of intermittent restrictive eating "for self-punishment or religious reasons" raises concern for energy deficit contributing to menstrual dysfunction 1

Medication-Related Considerations

• Venlafaxine (Effexor) can cause anxiety, insomnia, changes in appetite/weight, and abnormal bleeding 2
• In children and adolescents, height and weight should be monitored during treatment with venlafaxine 2
• Venlafaxine may increase blood pressure, which should be monitored regularly 2
• Guanfacine is reported to worsen mood in this patient, which is a known adverse effect 1
• Lamotrigine use is uncertain ("possibly as needed"), but this medication requires careful titration and is not typically used as needed 2

Comorbidity Patterns Requiring Attention

• The combination of autism spectrum disorder, ADHD, ODD, depression, anxiety, and PTSD represents a complex psychiatric profile with high risk for ongoing functional impairment 1
• Risk factors for psychiatric comorbidity include severity of cognitive and adaptive impairments, socialization deficits, trauma, and single biological parent as caregiver (though this patient lives with both parents) 1
• Strained relationship with older sibling following psychiatric hospitalizations may represent additional psychosocial stressor 1

Immediate Management Priorities

Gynecologic Evaluation (URGENT)

• Coordinate with gynecologist for evaluation of persistent abnormal uterine bleeding 1
• Family meeting with gynecologist to address ongoing menorrhagia 1
• Consider more frequent pad changes with alarm/timer to better assess bleeding volume and prevent complications 1

Psychiatric Safety Monitoring

• Weekly or biweekly psychiatric follow-up while in current program 1, 2
• Close monitoring for clinical worsening, suicidality, and unusual changes in behavior, especially given recent passive suicidal ideation 2 days prior 2
• Ongoing monitoring of compulsive self-harm behaviors (self-choking, self-biting) 1
• Parental consent confirmation for medication management 2

Medication Reconciliation and Optimization

• Medication reconciliation with parents to clarify current regimen, particularly lamotrigine use 2
• Potential adjustment of ADHD and mood medications pending further evaluation and parental input 1, 2
• Monitor for venlafaxine-related side effects including blood pressure changes, bleeding, anxiety, and weight changes 2

Trauma-Informed Care

• Continued trauma-informed care and support for psychosocial stressors 3
• Address ongoing nightmares and sleep disturbances related to trauma 3