||If USMLEWORLD says so, it is wrong
Algorithm for evaluation of amenorrhea with normal puberty with uterus present
Obtain a pregnancy test.
If the pregnancy test result is positive, refer the patient to the appropriate specialist.
If the pregnancy test result is negative, obtain TSH, prolactin, FSH and LH levels.
If the TSH level is elevated, the diagnosis is hypothyroidism.
If the prolactin level is elevated, hyperprolactinemia is the diagnosis. Causes include prolactinoma, CNS tumors and medications.
If the FSH level is low, obtain MRI of the head. If the MRI is abnormal, consider hypothalamic disease, pituitary disease or pituitary tumor. If MRI is normal, proceed with clinical evaluation to exclude chronic disease, anorexia nervosa, marijuana or cocaine use, and social or psychological stresses.
If FSH is elevated, ovarian failure is the diagnosis. Obtain a karyotype.
If the karyotype is abnormal, consider pure gonadal dysgenesis, such as Turner syndrome or mosaic or mixed gonadal dysgenesis.
If the karyotype is normal (46 XX), the cause is ovarian failure.
Consider premature ovarian failure, autoimmune oophoritis, exposure to radiation or chemotherapy, resistant ovary syndrome or multiple endocrine neoplasm (MEN) syndrome.
If TSH, prolactin, and FSH levels are within reference range, perform a progestin challenge test.
If withdrawal bleeding occurs, consider anovulation secondary to PCO syndrome.
If no withdrawal bleed occurs, proceed with estradiol priming followed by a progestin challenge.
If the challenge does not induce menses, consider Asherman syndrome or outlet obstruction.
If hirsutism is present, check testosterone, DHEAS, and 17-OH progesterone level.
If the testosterone and DHEAS levels are within the reference range or moderately elevated, perform a progesterone challenge.
If withdrawal bleeding occurs, the diagnosis is PCOS.
If the 17-OH progesterone level is elevated, the diagnosis is adult onset adrenal hyperplasia.
If the testosterone level or DHEAS is 2 or more times higher than the reference range, consider PCO syndrome, hyperthecosis or an androgen secreting tumor of the ovary or adrenal gland