Chapter 5: Amenorrhea Evaluation & Management

Amenorrhea Evaluation & Management clearly distinguishes between primary amenorrhea, often associated with genetic anomalies like Turner syndrome or congenital defects such as uterine agenesis and imperforate hymen, and secondary amenorrhea, which is frequently attributed to pregnancy, menopause, or lifestyle factors. The text emphasizes a systematic diagnostic reasoning process, establishing the exclusion of pregnancy via urine or serum beta-hCG testing as the mandatory first step. A focused clinical history is prioritized, examining sexual development, contraceptive use, nutritional status, and physical stressors, given that conditions like anorexia nervosa, bulimia, and high-intensity athletic training can suppress the HPO axis through significant weight loss and low body fat percentages. The physical examination incorporates Tanner staging to assess sexual maturity and scrutinizes patients for signs of androgen excess, such as hirsutism, acne, and obesity, which are hallmark indicators of Polycystic Ovarian Syndrome (PCOS). Diagnostic protocols include the measurement of Thyroid-Stimulating Hormone (TSH) to rule out hypothyroidism and prolactin levels to detect potential pituitary adenomas or prolactinomas. The chapter details the utility of the Progesterone Challenge Test (PCT) to assess endogenous estrogen production and outflow tract patency; a positive withdrawal bleed confirms an intact system, whereas a lack of bleeding necessitates further investigation with an Estrogen/Progesterone Challenge Test (E/PCT) to identify issues like Asherman syndrome or severe hypoestrogenism. Further laboratory analysis involves measuring Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH) to differentiate between primary ovarian insufficiency (characterized by FSH levels greater than 40 mU/mL) and hypothalamic-pituitary dysfunction. The summary also addresses specific differentials including Sheehan syndrome following obstetric hemorrhage, premature ovarian failure, and various chromosomal abnormalities requiring karyotyping.