Key History
Primary vs. secondary, duration, possible pregnancy; associated symptoms (headache, decreased peripheral vision, galactorrhea, hirsutism, virilization, hot flashes, vaginal dryness, symptoms of thyroid disease); history of anorexia nervosa, excessive dieting, vigorous exercise, pregnancies, D&Cs, uterine infections; drug use; medications.
Key Physical Exam
Vital signs; breast exam; complete pelvic exam.
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Presentation |
Differential |
Workup |
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■ 40 yo F presents with amenorrhea, morning nausea and vomiting, fatigue, and polyuria. Her last menstrual period was 6 weeks ago, and her breasts are full and tender. She uses the rhythm method for contraception. |
Pregnancy Anovulatory cycle Hyperprolactinemia UTI Hypothyroidism |
Urine hCG U/S—abdomen/pelvis Pelvic exam CBC UA, urine culture Prolactin, TSH Baseline Pap smear, cervical cultures, rubella antibody, HIV antibody, hepatitis B surface antigen, VDRL/ RPR |
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■ 23 yo obese F presents with amenorrhea for 6 months, facial hair, and infertility for the past 3 years. |
Polycystic ovary syndrome Thyroid disease Hyperprolactinemia Pregnancy Ovarian or adrenal malignancy Premature ovarian failure |
Urine hCG LH/FSH, TSH, prolactin Pelvic exam Testosterone, DHEAS |
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■ 35 yo F presents with amenorrhea, galactorrhea, visual field defects, and headaches for the past 6 months. |
Amenorrhea secondary to prolactinoma Pregnancy Thyroid disease Premature ovarian failure Pituitary tumor |
Urine hCG LH/FSH, TSH, prolactin MRI—brain Pelvic and breast exams |
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AMENORRHEA (cant'd) |
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Presentation |
Differential |
Workup |
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■ 48 yo F presents with amenorrhea for the past 6 months accompanied by hot flashes, night sweats, emotional lability, and dyspareunia. |
Menopause Pregnancy Pituitary tumor Thyroid disease |
Urine hCG LH/FSH, TSH, prolactin Testosterone, DHEAS Pelvic exam CBC MRI—brain |
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■ 35 yo F presents with amenorrhea, cold intolerance, coarse hair, weight loss, and fatigue. She has a history of abruptio placentae followed by hypovolemic shock and failure of lactation 2 years ago. |
Sheehan’s syndrome Premature ovarian failure Pituitary tumor Thyroid disease Asherman’s syndrome |
Urine hCG LH/FSH, prolactin CBC Pelvic exam TSH, FT4 ACTH MRI—brain Hysteroscopy |
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■ 18 yo F presents with amenorrhea for the past 4 months. She is 5 feet, 6 inches (167.6 cm) and weighs 90 lbs (40.9 kg). She has a history of exercise and heat intolerance. |
Anorexia nervosa Pregnancy Hyperthyroidism |
Urine hCG CBC TSH, FT4 LH/FSH |
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■ 29 yo F presents with amenorrhea for the past 6 months. She has a history of occasional palpitations and dizziness. She lost her fiancé in a car accident in which she was a passenger. |
Anxiety-induced amenorrhea Posttraumatic stress disorder Depression Hyperthyroidism |
CBC TSH, FT4 Urine cortisol level Progesterone challenge test LH/FSH, estradiol levels |
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