Differential diagnosis and the menstruation taboo

15 November 2016.

This week’s blog cuts to the very core of what Menstrual Matters is about- how the menstrual cycle (and/or hormonal medication) is all too easily dismissed, or denied, as a potential cause of ill health. Today we look at how the menstruation taboo, among other factors, has resulted in a diagnostic blind spot when it comes to differentiating between female-prevalent chronic health conditions.

differential-diagnosis-definition

1. Differential diagnosis in practice:

  1. The doctor gathers information from the patient and creates a symptoms list.
  2. The doctor considers all possible causes for these symptoms, paying particular attention to those which may indicate a serious disease or condition.
  3. The doctor prioritizes symptoms by placing the most urgently dangerous possible causes at the top of the list.
  4. The doctor rules out or treats possible causes, beginning with the most urgently dangerous condition before working down the list. For example, using blood tests, clinical procedures, or a physical examination.

In the UK, NHS General Practitioners (GPs) typically have only 10 minutes with each patient. This means that they must quickly prioritise any symptoms that could indicate a serious (life threatening) disease or condition, or if none are present, suggest ‘a most likely’ diagnosis based on experience, or epidemiological information (i.e. the statistical likelihood of this type of patient having this type of disease or condition).

Whilst this is probably the best method for reducing the risk of misdiagnosis of serious health issues, it can artificially separate inter-connected symptoms, and in the process of doing so, bypass the reasons why certain types of patient are more likely to experience certain symptoms, or health conditions.

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2. What is missed out in this process?

First, take a look at the symptom table below- note how many of the symptoms of chronic ill-health conditions (that disproportionately affect women of reproductive age) can also be caused by the menstrual cycle, or hormonal medication (yellow)*.

symptom-table-1

*Symptoms as listed under each health condition on www.nhs.uk – retrieved 14 November 2016.

Between 80-91% of the symptoms involved in a diagnosis of any one of these chronic ill-health conditions could potentially be caused by the menstrual cycle and/or hormonal medication.

So why aren’t patients routinely asked about their menstrual cycle, and/ or hormonal medication, during the differential diagnosis process? Well, quite simply because more often than not, their symptoms already fit a chronic health condition that is known to be more prevalent in people like them! Once a more serious health issue has been ruled out, the remaining symptoms, organised in order of relative severity, will be ‘proof’ enough to diagnose one of these conditions.

For example, a female patient, aged 23, presents with symptoms of anxiety, nausea, insomnia, fatigue, and headaches. The anxiety is of greatest personal concern. Previous blood tests and a physical examination have ruled out conditions such as anaemia and hyperthyroidism. The GP knows that women of reproductive age are particularly at risk of generalised anxiety disorder (GAD), which has all of these symptoms. Their likely hypothesis is, therefore, GAD.

The consultation time limitation, together with a range of societal pressures (e.g. to help the patient immediately, with an increasing expectation that this be done through pharmacological means, and to avoid multiple consultations in order to save the NHS money), pushes the GP towards making a ‘working diagnosis’ as soon as possible.

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3. How does the menstruation taboo further limit the differential diagnosis process?

The first step of the process relies on getting accurate information from the patient. As previously noted, patients can be extremely reluctant to discuss gynaecological or menstrual cycle-related health issues, and may only mention those symptoms that they think are ‘most important’, or severe, especially if aware of the 10 minute time limit. Without a full picture of all symptoms, and their occurrence, a doctor cannot distinguish between hormone-related problems or those caused by a chronic health condition.

A previous blog post outlines how the use of menstrual cycle euphemisms can lead to miscommunication between doctor and patient. An incorrect presumption that hormone-related symptoms only occur in the few days before menstruation, can also lead to the premature dismissal of the menstrual cycle as a possible cause of ill health.

Patients and some doctors remain unconvinced that the menstrual cycle, or even hormonal medication, is capable of causing ill-health, particularly severe symptoms. This is despite substantial clinical research (e.g. on depression and the contraceptive pill, migraine and the menstrual cycle, and premenstrual asthma), and literally thousands of years of documented examples e.g. starting with the Kahun Gynaecological Papyrus from 1800 BC. It is hard not to conclude that sexism (stemming in part from the ancient menstruation taboo) must play a role in the continued denial of the legitimacy of ‘female-prevalent’ illnesses, and their causes.

As a result of the taboo, the menstrual cycle remains ‘matter out of place’ within clinical medicine. Rather than sitting under endocrinology (the study of hormonal systems), menstrual cycle-related symptoms are split into different clinical specialisms (e.g. psychiatry, neurology, gastroenterology), further undermining the legitimacy of a hormone-related diagnosis.

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4. What’s the solution?

For those with a menstrual cycle, or on contraceptive medication, the use of a symptom diary becomes a critical tool in the differential diagnosis process. Recording the occurrence and severity of all symptoms for (at least) three menstrual cycles can rule out, or confirm, a diagnosis of menstrual cycle-related symptoms. Although this might delay diagnosis, it can ultimately improve the long term understanding and management of a patient’s health and wellbeing, and potentially reduce repeat consultations, and costly (and ineffective) prescription medication.

For those on hormonal medication but without a menstrual cycle, recording symptoms over time can still be of value, if only to rule out any other external or environmental factor e.g. an allergy, or food intolerance. The most important thing is to read the medication side effect information, and try to establish when symptoms first started. N.B. Some people suddenly start to experience side effects, even after several years on the same medication, without issue.

If a hormonal factor or pattern is identified, a hormone-balancing diet can alleviate even very severe symptoms (preferably once hormonal medication has been stopped). Again, this could reduce NHS costs, and improve the long term health and wellbeing of the patient.


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