Case 2: Maxine
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Case Write-Up
Maxine, a 31-year-old nulligravida, is seen for a routine well-woman examination. She notices a recent pattern of missed periods, and over the last three months, she has had an episode of heavy bleeding and has required an hourly tampon change. Her last period was two weeks ago, and she is not on any form of contraception as her husband wants to get her pregnant. Maxine has an unremarkable past medical and surgical history and is taking prenatal vitamins. Examination shows of concern includes weight loss of 21 pounds within one year, BMI of 17.3, withdrawn, poor eye contact, and a bruise on the inner thigh. Other than that, the vag and breast examinations are normal. She has a social history of recent marriage, loss of job as per her husband, and alcohol use during the day. Breast cancer is noted in her family history under her maternal grandmother. All these together, with the history of menstrual changes and weight loss, elicit behavioral and psychosocial issues related to the possible reproductive endocrine system and to warrant further evaluation.
Outline Subjective data.
Identify data provided in your chosen case and any additional data needed.
Outline
Objective findings.
Identify findings provided in your chosen case and any additional data needed.
Identify diagnostic tests, procedures, laboratory work indicated.
Describe the rationale for each test or intervention with supporting references.
Distinguish at least three differential diagnoses.
Describe the rationales for your choice of each diagnosis with supporting references.
Identify appropriate medications, treatments or other interventions associated with each differential diagnosis.
Describe rationales and supporting references for each.
Explain key
Social Determinants of Heath (SDoH) for your chosen case.
Describe collaborative care referrals and patient education needs for your chosen case.
Subjective information is Maxine’s description of her last period which was heavy, and menstrual irregularity over the last three months which includes skipped periods. She does not have any gynecologic pain, she denies infections, and she has no other systemic complaints.
Her plans for pregnancy have led her to discontinue contraceptive use. Menarche for this patient was at age ten, and she has no record of pregnancies, sexually transmitted infections, or reports of complications. Her gynecological cycles have been normal and average five days. Three years ago, she was due for a Pap smear and her results came back normal. Maxine described her wine consumption as one to two glasses and that she drinks while her husband is at work. Since her husband requested her to leave, she has been socially isolated. Though she is without complaints, her withdrawn demeanor and poor eye contact are distressing and suggest the need for further evaluation to determine the presence of psychological distress or safety issues and to assess for intimate partner violence, stress, eating disorders and reproductive coercion.
The objective data shows vital signs are stable. Blood pressure, pulse, temperature, and respiratory rate are within normal limits. She is underweight, with a BMI of 17.3. Last year, she weighed 122 lbs and now weighs 101 lbs. Her appearance is withdrawn, disheveled, and she avoids eye contact. A bruise is present on her right inner thigh which raises concerns for trauma or potential interpersonal violence. No abdominal tenderness or masses were found in the normal examination of her abdomen.
On pelvic exam, no lesions were seen on external genitalia, there’s no cervical motion tenderness, and the uterus is normal-sized with no adnexal masses. While the reproductive exam is mostly unremarkable, weight loss, the bruising, and the behavioral changes stand out. Other objective information required includes: pregnancy status, lab evaluation of the hormonal balance, screens for sexually transmitted infections, nutritional evaluation, and formal screening for partner violence.
In case of potential early pregnancy complications such as heavy bleeding or missed periods, a pregnancy test should be part of the primary evaluation. To determine the cause of heavy menstrual bleeding, a complete blood count (CBC) test is required to assess potential anemia. A thyroid function test (including TSH and free T4) is also required, as thyroid disorders are often associated with menstrual irregularities (Javed et al., 2025). To assess ovulatory dysfunction and STIs such as chlamydia, gonorrhea, HIV, and syphilis, a pelvic ultrasound should be done to check if there are structural issues such as fibroids or polyps causing the bleeding. Some metabolic and nutritional lab tests may be warranted considering the weight and BMI. Due to the bruising, behavioral changes, or social history, screening for partner violence is recommended (Javed et al., 2025).
One potential diagnosis is abnormal uterine bleeding due to dysfunctional ovulation, which could be attributed to considerable stress or significant weight loss. That is because hypothalamic-pituitary-ovarian axis function can be disrupted leading to cycle irregularities (Zhang et al., 2023). Another differential is thyroid disease, hyper or hypothyroidism, which presents frequent concomitant factors (Javed et al., 2025). Intimate partner violence with reproductive coercion is also a strong consideration evidenced by bruises and withdrawal attributed to the husband’s control over employment and reproductive decisions (Grace et al., 2020). Pregnancy-related bleeding, early loss, or implantation bleeding must be excluded and is imperative concerning the age of the female. Finally, bleeding disorders and uterine structural abnormalities like fibroids may account for the heavy bleeding (Zhang et al., 2023). All these conditions can be better evaluated and explained through laboratory tests and imaging to ascertain the cause and treatment.
Maxine’s condition management will depend on the confirmed diagnosis. That is because for patients with ovulatory dysfunction due to low body weight or stress, treatment is centered on nutritional rehabilitation, stress management, and possibly hormonal therapy to regulate cycles (Zhang et al., 2023). On the same, for those with diagnosed complications of pregnancy, care may involve obstetric monitoring, expectant management or treatment of the identified miscarriage. Also, in patients with thyroid disease, management of hypothyroidism may involve the use of the drug levothyroxine and hyperthyroidism may involve antithyroid medications. Javed et al. (2025) state that heavy menstrual bleeding may be treated with nonsteroidal anti-inflammatory drugs or tranexamic acid to reduce the bleeding. Where intimate partner violence is suspected like in Maxine’s case, first priority is given to the safety of the patient, followed by emergency counseling and referral to assistance while in the presence of anemia, iron supplements may be necessary. Hence, Maxine’s case must be developed and adopt personalized management that is in line with the recognized gynecology and primary healthcare guidelines (Zhang et al., 2023).
Maxine’s health is influenced by several social determinants. First, relationship power dynamics may affect her autonomy in employment and reproductive decisions because her husband demands that she stop working and become pregnant (Grace et al., 2020). This is further compounded by the financial reliance on a partner, which increases one’s exposure to domestic violence, abuse, and the financial and geographical barriers that compromise one’s ability to access healthcare. Second, social isolation is a real possibility since she is now a housewife and appeared withdrawn during the visit. This is because isolation is a known precursor for domestic violence and mental health issues (Grace et al., 2020). She may also be utilizing coping strategies or experiencing some stress, which may be evidenced by her health behaviors such as alcohol abuse during the day and her possible nutritional deficiencies as indicated by her weight (Javed et al., 2025). The absence of strong social support networks that integrate health care also limits her ability to access health care. This explains the need for trauma-informed care, partner violence screening, and community and counseling referrals to address the social determinants at play.
Maxine would benefit from a multidisciplinary care approach and a referral for evaluation of abnormal uterine bleeding and fertility planning may be warranted for obstetrician-gynecologist (Kerns et al., 2022). Furthermore, assessing mental health may be necessary to evaluate stress, possible depression, or concerns regarding relationships. Also, if there is suspected intimate partner violence, referrals to social work and community advocacy are critical to creating a safe plan and assisting with resources while if low BMI or disordered eating is a concern, a nutritionist or dietitian may be of assistance. Javed et al. (2025) state that patient education includes information regarding what is normal for menstrual cycles, what is considered excessive or concerning bleeding, and planning for future pregnancies. Additionally, counseling around the use of alcohol and healthy coping strategies is advised. However, it is important that education is provided in a private setting to ensure that Maxine has a safe way to speak about issues that are sensitive and may not be able to be talked about with a partner to achieve better outcomes.
References
Grace, K. T., Decker, M. R., Alexander, K. A., Campbell, J., Miller, E., Perrin, N., & Glass, N. (2020). Reproductive coercion, intimate partner violence, and unintended pregnancy among Latina women. Journal of Interpersonal Violence , 37 (3-4), 886260520922363. https://doi.org/10.1177/0886260520922363
Javed, N., Shakoor, H., Khattak, S., Mustafa, Y., Maghar, M. M., & Jabeen, S. (2025). Exploring the Relationship Between Thyroid Dysfunction and Menstrual Irregularities in Women. Indus Journal of Bioscience Research , 3 (10), 317–324. https://doi.org/10.70749/ijbr.v3i10.2563
Kerns, J., Itriyeva, K., & Fisher, M. (2022). Etiology and management of amenorrhea in adolescent and young adult women. Current Problems in Pediatric and Adolescent Health Care , 52 (5), 101184. https://doi.org/10.1016/j.cppeds.2022.101184
Zhang, Y., Luo, Z., Jia, Y., Zhao, Y., Huang, Y., Ruan, F., Ying, Q., Ma, L., Luo, J., & Zhou, J. (2023). Development and validation of a predictive model of abnormal uterine bleeding associated with ovulatory dysfunction: a case-control study. BMC Women’s Health , 23 (1). https://doi.org/10.1186/s12905-023-02589-5 Maxine, a 31-year-old nulligravida, is seen for a routine well-woman examination. She notices a recent pattern of missed periods
