This document discusses the evaluation and diagnosis of a 17-year-old girl presenting with absence of menses (amenorrhea). It provides a list of potential causes to consider and evaluate through history, physical exam, and testing, including pregnancy, medical conditions, and endocrine or anatomical abnormalities. If diagnosis is secondary amenorrhea, potential causes include pituitary disorders, stress, prolactinoma, Sheehan's syndrome, or ovarian failure; if primary amenorrhea, causes may include vaginal atresia, imperforate hymen, Turner syndrome, or other intersex conditions. Laboratory tests and imaging can help identify the specific diagnosis.

1. A 17 year old girl with a complaint of
Absence Of Menses
Amenorrhea is not pathologic until age 16 years.

2. Let’s discuss

3. Make sure to explore this issues before
making a diagnosis
• Age
• Adolecent (Development Delay/Abnormality)
• Old (Menopause)
• Sexually Active
• Exclude Pregnancy
• Gauge the anthropometry
• Too Thin (Anorexia?)
• Too Fat (PCOS ?)
• Any congenital syndrome (Turner ? Swyer syndrome ?)
• Post-Partum Hemorrage ?
• Any breast discharge ? / Headache / Visual Disturbances ?
• Cytotoxic Chemo ?
Be careful w the presentation

4. Relevant PE Findings

5. Look for signs like :
• Obesity
• Hirsutism / Virilism
• Other puberty signs (Gonadarche, , Pubarche)
• Thyroid assessment
• Vaginal inspection
Thelarche

6. Laying down the diagnosis
Secondary Amenorrhea
• Pituitary Disorders
• Stress
• Prolactinoma
• Sheehan’s Syndrome
• Asherman Syndrome
Other notable endocrine disorder
• Ovarian failure / Menopause
• PCOS
• Ovarian Tumors
Primary Amenorrhea
Female & Sexually Developed
• Vaginal Atresia
• Imperforate Hymen
• Swyer syndrome (XY Female)
• Leptin deficiency
• Constitutional delay of menarche
Female w Sexual Infantilism
• Turners syndrome
• Gonadal Dysgenesis
• Pan-Hypopituitarism
Female w Virilism
• CAH (Adult onset)
• XY Female

7. Planning an investigation
Blood tests may include:
• Estradiol
• FSH
• LH
• Prolactin
• Testosterone
• TSH
• T3 and T4
• 17 hydroxyprogesterone
• Chromosome analysis
• Serum progresterone
• Serum testosterone levels
Ultrasonography
-Pelvic ultrasonography
congenital abnormalities of the uterus, cervix, and vagina, or
absence of these organs.
-However, a report of absence of the uterus on ultrasonography
does not always mean that the patient does not have a uterus. In
primary amenorrhea in association with estrogen deficient states,
the uterine fundus may be underdeveloped and may not be readily
visible at the time of ultrasonography. With proper estrogen
replacement, it may reach the normal size.
Magnetic resonance imaging
MRI of the pituitary and hypothalamus is often indicated in the
evaluation of amenorrhea.

8. Treatment

9. Laying down the diagnosis
Secondary Amenorrhea
• Pituitary Disorders
• Stress
• Prolactinoma
• Sheehan’s Syndrome
Other notable endocrine disorder
• Ovarian failure
• PCOS
• Ovarian Tumors
• Asherman Syndrome
Primary Amenorrhea
Female & Sexually Developed
• Vaginal Atresia
• Imperforate Hymen
• Swyer syndrome (XY Female)
• Leptin deficiency
• Constitutional delay of menarche
Female w Sexual Infantilism
• Turners syndrome
• Gonadal Dysgenesis
• Pan-Hypopituitarism
Female w Virilism
• CAH (Adult onset)
• XY Female