Understand Abnormal Menses (Irregular Menstruation) with clinically relevant information for healthcare professionals. This resource addresses Menstrual Irregularity diagnosis, medical coding, and documentation best practices for accurate and efficient clinical workflows. Learn about causes, symptoms, and treatment options related to Abnormal Menses, supporting improved patient care and optimized medical record keeping.
Also known as
Noninflammatory disorders of female genital tract
Covers abnormal menstruation, excessive/frequent bleeding, and other menstrual irregularities.
Absence of menstruation
Specifically addresses the absence of menstrual periods (amenorrhea).
Ovarian dysfunction
Ovarian issues can be a cause of irregular menses and are addressed here.
Ovarian dysfunction in other diseases classified elsewhere
Addresses ovarian dysfunction when it is secondary to another condition.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the patient pregnant?
Yes
Is it related to an ectopic/molar pregnancy?
No
Is it post-partum/lactational amenorrhea?
When to use each related code
| Description |
|---|
| Irregular periods with variable frequency or duration. |
| Absence of menstruation for 3+ months in women who previously menstruated. |
| Painful menstruation, often with cramping. |
Coding AUB/IMB without specifying menorrhagia if present leads to undercoding severity and impacts quality metrics.
Insufficient documentation of cycle frequency, duration, and flow hinders accurate coding and may trigger audits.
Focusing solely on irregular menses without coding underlying conditions like PCOS or fibroids risks DRG downcoding.
Q: What are the most common differential diagnoses for abnormal menses in adolescents, and how can I effectively differentiate between them?
A: Differential diagnoses for abnormal menses in adolescents can include polycystic ovary syndrome (PCOS), hypothalamic amenorrhea, thyroid disorders, bleeding disorders, and pregnancy. Differentiating between them requires a thorough history, including menarcheal age, cycle characteristics, associated symptoms (hirsutism, weight changes, galactorrhea), and family history. Physical examination should assess for signs of PCOS (acne, hirsutism), thyroid abnormalities, or bleeding disorders. Targeted laboratory investigations, such as hormone levels (LH, FSH, estradiol, TSH, prolactin), coagulation studies, and pregnancy tests, are crucial. Consider implementing a diagnostic algorithm based on initial presentation and findings. Explore how age and other clinical factors can influence the likelihood of each diagnosis. Learn more about specific diagnostic criteria for each condition to ensure accurate diagnosis and appropriate management.
Q: How do I approach managing irregular menstruation in a patient with a history of an eating disorder, considering the potential impact on bone health and hormonal balance?
A: Managing irregular menstruation in a patient with an eating disorder requires a multidisciplinary approach, addressing both the underlying eating disorder and the menstrual irregularity. Restoring nutritional balance and achieving a healthy weight is paramount. Collaborate with a registered dietitian and mental health professional to address the eating disorder. Monitor bone health with bone mineral density assessments and consider calcium and vitamin D supplementation as needed. Hormonal evaluation, including estradiol, LH, and FSH levels, can assess hypothalamic-pituitary-ovarian axis function. Explore the potential benefits and risks of hormonal therapy, such as combined oral contraceptives, in consultation with the patient and the care team, considering both the patient's physical and psychological well-being. Consider implementing strategies to promote weight restoration and regular menses while minimizing risks to bone health. Learn more about the long-term implications of hypothalamic amenorrhea on fertility and overall health.
Patient presents with abnormal menses, characterized by irregular menstruation and menstrual irregularity. The patient reports [frequency of menses e.g., oligomenorrhea, polymenorrhea, amenorrhea] with a cycle length varying between [number] days. Flow is described as [e.g., heavy menstrual bleeding menorrhagia, light menstrual flow, spotting between periods metrorrhagia] and lasting for [number] days. The patient experiences [symptoms e.g., dysmenorrhea painful periods, premenstrual syndrome PMS, intermenstrual bleeding, abnormal uterine bleeding AUB]. Onset of menarche was at age [number]. Past medical history includes [relevant medical history e.g., PCOS polycystic ovary syndrome, endometriosis, uterine fibroids, thyroid disorders, bleeding disorders]. Family history is significant for [relevant family history e.g., menstrual irregularities, early menopause]. Medications include [list medications]. Physical examination reveals [relevant findings]. Differential diagnoses include anovulation, hormonal imbalance, uterine polyps, endometrial hyperplasia, and reproductive tract malignancies. Initial workup includes pelvic exam, transvaginal ultrasound, and blood tests to assess hormone levels including FSH follicle-stimulating hormone, LH luteinizing hormone, prolactin, thyroid panel, and complete blood count CBC. Treatment plan will be determined based on the underlying cause and may include hormonal therapy such as oral contraceptives, progestins, or GnRH agonists. Patient education provided on menstrual cycle tracking, lifestyle modifications, and potential complications of irregular menses. Follow-up scheduled in [timeframe] to review results and discuss management options. ICD-10 code considerations include [relevant ICD-10 codes e.g., N92.5, N92.6, N91.0 depending on specific presentation]. This documentation supports medical necessity for diagnostic testing and treatment related to abnormal menses.