What is the recommended work-up for a 25-year-old with functional amenorrhea?

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Last updated: June 11, 2025 • View editorial policy

From the Guidelines

The recommended work-up for a 25-year-old with functional amenorrhea begins with a thorough history and physical examination, followed by laboratory testing including pregnancy test, thyroid-stimulating hormone (TSH), prolactin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol levels, as suggested by the most recent evidence 1.

Initial Evaluation

The initial evaluation should include a comprehensive assessment of the patient's medical history, including age of menarche, regularity of menses, use of medications, presence of other health issues, and family menstrual history 2. A physical examination should assess anthropometry, pubertal stage, signs of energy deficiency, and secondary causes of amenorrhea.

Laboratory Testing

Laboratory testing should include:

  • Pregnancy test
  • Thyroid-stimulating hormone (TSH)
  • Prolactin
  • Follicle-stimulating hormone (FSH)
  • Luteinizing hormone (LH)
  • Estradiol levels Additional tests may include a complete blood count, comprehensive metabolic panel, and assessment for hyperandrogenism with total and free testosterone if clinical signs are present 1.

Specialized Testing

A progesterone challenge test can be performed by administering medroxyprogesterone acetate 10 mg daily for 5-10 days to assess estrogen status and endometrial response. If the patient has risk factors for osteoporosis, a bone mineral density scan should be considered. Pelvic ultrasonography may be indicated to evaluate anatomical abnormalities or polycystic ovary morphology, as the prevalence of polycystic ovarian morphology in women with functional hypothalamic amenorrhea is high, ranging from 41.9% to 46.7% 1.

Treatment

Treatment depends on the underlying cause but often includes lifestyle modifications addressing extreme exercise or weight issues, nutritional counseling, stress management, and possibly hormonal therapy such as combined oral contraceptives to restore regular cycles and protect bone health. For patients desiring pregnancy, ovulation induction with medications like clomiphene citrate may be appropriate, but the Endocrine Society recommends that women with functional hypothalamic amenorrhea should have a BMI higher or equal to 18.5 kg/m2 before ovulation induction is offered 3.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

The recommended work-up for a 25-year-old with functional amenorrhea includes:

  • A detailed history to identify potential causes of amenorrhea, such as eating and exercise habits, presence of psychosocial stressors, body weight changes, and medication use 4, 5
  • A physical examination to identify anthropometric and pubertal development trends 5
  • Laboratory tests, including: + Pregnancy test to exclude pregnancy as a cause of amenorrhea 4, 5, 6 + Serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and thyroid-stimulating hormone (TSH) levels to evaluate hormonal imbalances 4, 5, 6 + Additional tests, such as karyotyping, serum androgen evaluation, and pelvic or brain imaging, may be individualized based on the patient's presentation and initial test results 5

Potential Causes of Functional Amenorrhea

Potential causes of functional amenorrhea include:

  • Hypothalamic amenorrhea, which may be associated with disordered eating and low bone density 4, 5, 7
  • Polycystic ovary syndrome (PCOS), which may be associated with metabolic disease and endometrial cancer risk 4, 5
  • Primary ovarian insufficiency, which may be associated with unpredictable ovarian function and infertility 4, 5
  • Other endocrine gland disorders, such as hyperprolactinemia or thyroid disorders 4, 5, 6

Treatment Approach

The treatment approach for functional amenorrhea should focus on addressing the underlying cause, and may include:

  • Hormone replacement therapy or contraception to regulate menstrual cycles and prevent long-term consequences of hormonal imbalance 4, 5
  • Medical and mental health support to address underlying psychological or emotional issues contributing to amenorrhea 7
  • Lifestyle modifications, such as changes to diet and exercise habits, to help regulate menstrual cycles and improve overall health 4, 5, 7

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.