History Taking for Amenorrhea Investigation
Begin with a pregnancy test in all women of reproductive age presenting with amenorrhea, followed by immediate hormonal assessment including FSH, LH, prolactin, and TSH to identify the underlying cause. 1, 2
Essential Historical Elements
Menstrual History Details
- Age at menarche and pattern of cycles since onset (regular vs. irregular intervals) 2, 3
- Duration of amenorrhea: document whether previously regular menses ceased for ≥3 months or irregular menses ceased for ≥6 months 4, 5
- Cycle length when present: intervals <23 days (polymenorrhea) or >35 days (oligomenorrhea) 6, 2
- Last menstrual period date to calculate duration of amenorrhea 6
Weight and Nutritional Assessment
- Recent weight changes (gain or loss) and timeline 2, 3
- Current BMI calculation (obesity associated with PCOS; low BMI with hypothalamic amenorrhea) 6, 2
- Eating patterns and dietary restrictions to screen for disordered eating 4, 3
- Waist-to-hip ratio if truncal obesity suspected (>0.9 abnormal) 6
Exercise and Activity Level
- Type, frequency, and intensity of exercise (excessive exercise causes functional hypothalamic amenorrhea) 4, 3
- Athletic participation requiring evaluation for Female Athlete Triad or Relative Energy Deficiency in Sport 4, 2
Psychosocial Stressors
- Recent life stressors (stress disrupts hypothalamic-pituitary-gonadal axis) 4, 3
- Psychological symptoms including anxiety or depression 3
Medication and Substance Use
- Current medications: antipsychotics, antiepileptics, hormonal contraceptives (all can cause amenorrhea) 2, 3
- Smoking, alcohol, and recreational drug use (may reduce fertility) 6
- Recent discontinuation of hormonal contraceptives 2
Symptoms Suggesting Specific Etiologies
Hyperprolactinemia indicators:
- Galactorrhea (spontaneous or expressible breast discharge) 6, 2, 3
- Nipple crusting in non-lactating women 6
Hyperandrogenism signs:
- Hirsutism (male-pattern hair growth, Ferriman-Gallwey scoring) 6, 2
- Acne (new onset or worsening) 6
- Male escutcheon pattern 6
Thyroid dysfunction symptoms:
Pituitary pathology warning signs:
Estrogen deficiency symptoms:
- Vasomotor symptoms (hot flashes, night sweats) 3
Reproductive and Sexual History
- Coital frequency and timing if fertility desired 6
- Contraceptive practices 6
- Previous pregnancies: gravidity, parity, outcomes, complications 6
- Infertility history: duration trying to conceive, previous evaluations 6
Medical and Surgical History
- Chronic illnesses (thyroid disorders, endocrine disorders) 6, 3
- Previous pelvic surgeries (indications and outcomes) 6
- Cancer treatment history (chemotherapy/radiation causing ovarian insufficiency) 6, 4
- Childhood disorders affecting development 6
Family History
- Age at menarche in mother and sisters 3
- Family history of reproductive failure, early menopause, or genetic conditions 6
Physical Examination Priorities
Anthropometric Measurements
Pubertal Development Assessment
- Tanner staging of breast and pubic hair development 4, 2
- Presence or absence of secondary sexual characteristics (critical for primary amenorrhea) 4
Signs of Endocrine Disorders
- Thyroid examination for enlargement or nodules 2
- Skin changes suggesting thyroid dysfunction 3
- Acanthosis nigricans (insulin resistance marker in PCOS) 3
Pelvic Examination (when appropriate)
Critical Pitfalls to Avoid
- Never assume amenorrhea in women <40 years is simply "early menopause" without full evaluation, as prolonged hypoestrogenism increases osteoporosis and cardiovascular disease risk regardless of cause 1
- Do not overlook eating disorders, as adolescents and young women may minimize or deny disordered eating behaviors 4
- Never delay hormonal assessment, as time is critical for fertility preservation options if primary ovarian insufficiency is confirmed 1
- Do not assume all amenorrhea in athletes or stressed individuals is benign, as other pathology must be excluded 4
- Failing to perform pregnancy test first can lead to misinterpretation of all subsequent hormonal results 2