From the Guidelines
The initial step in the workup of a patient with amenorrhea is to perform a pregnancy test, as pregnancy is the most common cause of secondary amenorrhea, and this should be done regardless of the patient's sexual history or contraceptive use. This approach is crucial because undiagnosed pregnancy could lead to inappropriate diagnostic testing or treatments that might harm a developing fetus, and early identification of pregnancy allows for timely prenatal care or counseling regarding pregnancy options 1. A urine pregnancy test is typically sufficient as a first-line test due to its high sensitivity, ease of administration, and immediate results.
If the pregnancy test is negative, further evaluation should proceed based on whether the patient has primary amenorrhea (never had a menstrual period by age 15 or within 3 years of breast development) or secondary amenorrhea (absence of menses for 3 consecutive months in a previously menstruating woman). The subsequent workup typically includes:
- Assessment of other common causes such as hormonal imbalances, structural abnormalities, or systemic conditions through targeted history, physical examination, and laboratory testing.
- Obtaining clinical and social information from the client, including medical history to identify safe methods of contraception and to understand factors that might influence the client’s choice of a contraceptive method 1.
- For female clients, the medical history should include menstrual history, which is crucial for understanding the patient's condition and for guiding further diagnostic steps.
After ruling out pregnancy and gathering initial information, more specific evaluations can be tailored to the individual's presentation, including assessments for menstrual dysfunction, which may involve laboratory tests and physical examinations to rule out other gynecological pathologies 1. The key is to prioritize the patient's health and safety by first addressing the possibility of pregnancy and then proceeding with a comprehensive evaluation to determine the underlying cause of amenorrhea.
From the Research
Initial Step in the Workup of Amenorrhea
The initial step in the workup of a patient with amenorrhea involves a systematic evaluation, including:
- A detailed history
- Physical examination
- Laboratory assessment of selected serum hormone levels 2, 3, 4 This approach can usually identify the underlying cause of amenorrhea.
Key Components of the Initial Workup
The initial workup of primary and secondary amenorrhea includes:
- A pregnancy test
- Serum levels of luteinizing hormone, follicle-stimulating hormone, prolactin, and thyroid-stimulating hormone 2, 4 These tests help to narrow down the differential diagnosis and guide further evaluation.
Considerations in the Workup
It is essential to consider the following in the workup of amenorrhea:
- Primary amenorrhea: evaluate for chromosomal irregularities, anatomic abnormalities, and other causes 2, 3, 5
- Secondary amenorrhea: rule out pregnancy and evaluate for polycystic ovary syndrome, hypothalamic amenorrhea, hyperprolactinemia, and primary ovarian insufficiency 2, 4, 6 A thorough history and physical examination can help direct the evaluation and guide further testing.