History and physical examination

History:

• age of menarche and development of secondary sexual characteristics
• menstrual history - including regularity of cycle, any abrupt change
• personal or family history of hirsutism
• hot flushes
• galactorrhoea
• headaches
• visual symptoms (1)
• drug usage - especially, combined oral contraceptive pill, phenothiazines, metoclopramide, alpha-methyldopa, tricyclic antidepressants, Rauwolfia alkaloids
• psychological factors - recent emotional upset, new job, regularity of work hours
• recent weight change - up or down; exercise history
• presence of normal sense of smell
• symptoms of thyroid, adrenal, and pituitary disorders
• diabetes and it's control
• gynaecological operations
• menarche and menstrual history of mother and sisters
• genetic defects in family members
• previous CNS chemotherapy or radiation; pelvic radiation (2)

Examination:

• secondary sexual characteristics - breasts, pubic hair
  • Tanner assessment of pubertal development may be used as a guide (2)
• height and weight - expressed as percentage of ideal; BMI (2)
• features of gonadal dysgenesis e.g. webbed neck of Turner's syndrome
• hirsutism
• evidence of thyroid, adrenal, pituitary disease
• breast examination - breast development indicates that some oestrogenic activity has occurred; galactorrhoea may suggest hyperprolactinaemia, breast feeding, neuroleptics
• abdominal and pelvic examination: - external genitalia - clitoromegaly - presence of uterus - palpable ovaries - pelvic masses or tenderness
  • a bimanual examination is inappropriate in young girls who are not sexually active (1)
• features of androgen insensitivity syndrome - undescended testes; external genital appearance; pubic hair (2)

Reference:

• (1) Maruthini D et al. Modern management of amenorrhoea. Trends Urol Gynaecol Sex Health 2008;13(2):24-28
• (2) Master-Hunter T et al. Amenorrhea: evaluation and treatment. AFP 2006;73(8):1374-82.