History or Findings Suggesting Causes of Amenorrhea
History or Finding | Possible Associated History or Findings | Possible Cause |
|---|---|---|
Use of certain medications | ||
Medications and drugs that affect dopamine (which helps regulate prolactin secretion):
| Galactorrhea | Hyperprolactinemia |
Hormones and certain other medications that affect the balance of estrogenic and androgenic effects:
| Virilization | Drug-induced virilization |
Body habitus | ||
High body mass index (eg, > 30 kg/m2) | Virilization | |
Low body mass index (eg, < 18.5 kg/m2) | Chronic disease, excessive exercise | Functional hypothalamic amenorrhea |
Hypothermia, bradycardia, other arrhythmias and/or palpitations, hypotension | Functional hypothalamic amenorrhea due to anorexia nervosa or starvation, possibly with electrolyte abnormalities (eg, hypokalemia, hypomagnesemia) | |
Reduced gag reflex, palatal lesions, subconjunctival hemorrhages | Functional hypothalamic amenorrhea due to bulimia with frequent vomiting | |
Short stature | Primary amenorrhea, webbed neck, widely spaced nipples | |
Skin abnormalities | ||
Warm, moist skin | Tachycardia, tremor | |
Coarse, thick skin; loss of eyebrow hair | Bradycardia, delayed deep tendon reflexes, weight gain, constipation | |
Acne | Hirsutism or virilization | Androgen excess due to
|
Striae | Moon facies, buffalo hump, truncal obesity, thin extremities, virilization, hypertension | |
Acanthosis nigricans | Obesity, virilization | |
Vitiligo or hyperpigmentation of the palm | Orthostatic hypotension | |
General findings suggesting estrogenic or androgenic abnormalities | ||
Symptoms of estrogen deficiency (eg, hot flushes, night sweats, particularly with vaginal dryness or atrophy) | Risk factors such as chemotherapy, pelvic irradiation, or an autoimmune disorder | Functional hypothalamic amenorrhea |
Hirsutism or virilization | ― | Androgen excess due to
|
Primary amenorrhea | Androgen excess due to
| |
Enlarged ovaries | Androgen excess due to
| |
Breast and genital abnormalities | ||
Galactorrhea | — | Hyperprolactinemia |
Nocturnal headache, visual field defects | Pituitary tumor | |
Absence or incomplete development of breasts (and of secondary sexual characteristics) | Normal adrenarche | Primary amenorrhea caused by ovulatory dysfunction due to isolated ovarian failure |
Absence of adrenarche | Primary amenorrhea caused by ovulatory dysfunction due to hypothalamic-pituitary dysfunction | |
Absence of adrenarche with impaired sense of smell | ||
Delay of breast development and secondary sexual characteristics | Family history of delayed menarche | Constitutional delay of growth and puberty |
Normal breast development and secondary sexual characteristics with primary amenorrhea | Cyclic abdominal pain, bulging vagina, uterine distention | Genital outflow obstruction |
Ambiguous genitals | Virilization | True hermaphroditism Pseudohermaphroditism |
Fused labia, clitoral enlargement at birth | ― | Androgen exposure during the 1st trimester, possibly indicating
|
Clitoral enlargement after birth | Virilization | Androgen-secreting tumor (usually ovarian) Use of anabolic steroids |
Normal external genitals with incompletely developed secondary sexual characteristics (sometimes with breast development but minimal pubic hair) | Apparent absence of cervix and uterus | Androgen insensitivity syndrome |
Ovarian enlargement (bilateral) | Symptoms of estrogen deficiency | Primary ovarian insufficiency due to autoimmune oophoritis |
Hirsutism or virilization | 17-Hydroxylase deficiency | |
Lesions | ||
Pelvic mass (unilateral) | Pelvic pain Pelvic kidney or other urinary tract anomalies | Congenital or acquired structural pelvic abnormalities Rarely, pelvic tumors (eg, granulosa cell tumors, cystic teratoma) |