Amenorrhea physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

Physical examination of patients with amenorrhea is based on underlying disease. Amenorrhea is seen with a number of disorders. The presence of hirsutism and acne on physical examination is suggestive of polycystic ovary disease. The presence of galactorrhea and vision loss on physical examination is suggestive of hyperprolactinemia (prolactinoma). The presence of bulging in vulva and imperforate hymen on physical examination is highly suggestive of imperforate hymen.

Physical Examination

• Physical examination of patients with amenorrhea is based on underlying disease.
• Amenorrhea is seen with a number of disorders:
  • The presence of hirsutism and acne on physical examination is suggestive of polycystic ovary disease.
  • The presence of galactorrhea and vision loss on physical examination is suggestive of hyperprolactinemia (prolactinoma).
  • The presence of bulging in vulva and imperforate hymen on physical examination is highly suggestive of imperforate hymen.

Physical examination of different causes of amenorrhea is as following:

Appearance of the Patient

• Patients with amenorrhea usually appear normal.
• Patients with hyperthyroidism may be restless and agitated, while hypothyroidism patients may be calm and even drowsy.
• Patients with polycystic ovary syndrome and Cushing's disease are obese.
• Patients with functional amenorrhea may have low body weight.
• Patients with Turner syndrome have short stature.
• Patients with androgen-secreting tumor have virilization.

Vital Signs

• Hypothermia may be present in hypothyroidism.
• Hyperthermia may be present in hyperthyroidism.
• Tachycardia with regular pulse may be present in hyperthyroidism.
• Bradycardia with regular pulse may be present in hypothyroidism.
• High blood pressure with normal pulse pressure may be present in 17-betahydroxysteroid dehydrogenase deficiency or Cushing's disease.

Neck

• Webbed neck may be present in Turner syndrome.
• Thyromegaly or thyroid nodules may be present in thyroid diseases.

Chest

• Widely spaced nipples may be present in Turner syndrome.
• Scarce or absent axillary hair may be present in complete androgen insensitivity syndrome.
• Galactorrhea may be present in hyperprolactinemia (prolactinoma)

Abdomen

• Purple striae and significant central obesity may be present in Cushing's disease.

Back

• Buffalo hump may be present in Cushing's disease.

Genitourinary

• Uterus is absent or rudimentary in mullerian agenesis or androgen insensitivity syndrome.
• Transverse vaginal septum or imperforate hymen may cause outflow tract obstruction.
• Undescended testes (as pelvic mass) may be present in androgen insensitivity syndrome.
• Clitoral hypertrophy (clitoromegaly) may be present in androgen-secreting tumor.
• Hematometra/hematocolpos may be present in outflow tract obstruction.
• Male external genitalia may be present in mild androgen insensitivity syndrome.
• Partial masculinization of external genitalia may be present in partial androgen insensitivity syndrome.
• Scarce or absent pubic hair may be present in complete androgen insensitivity syndrome.
• Female or ambiguous external genitalia with normal vagina and uterus may be present in Swyer syndrome.

Neuromuscular

• Proximal muscle weakness may be present in Cushing's disease.

Extremities

• Easy bruising may be present in Cushing's disease.

Tanner's staging

• Secondary sexual characteristics are absent in primary amenorrhea.
• Secondary sexual characteristics are present in secondary amenorrhea.

Stage 1

Prepubertal external genitalia Prepubertal pubic hair Growth 5-6 cm/year

Stage 2

Enlargement of scrotum and testes; scrotum skin become hyperpigmented and harder Sparse growth of long, slightly pigmented hair, straight or curled, at base of penis Growth 5-6 cm/year

Boys

Stage 3

Enlargement of penis (length at first); further testes growth Darker, coarser, and more curled hair, spreading over pubes Growth 7-8 cm/year

Stage 4

Increased penis size with growth and development of glans; testes and scrotum larger, scrotum skin darker Adult type hair, but smaller area; no spread to medial surface of thighs Growth 10 cm/year

Stage 5

Adult external genitalia Adult type hair with same horizontal distribution ("feminine") No further height increase after 17 years

Tanner staging

Stage 1

Prepubertal external genitalia Prepubertal pubic hair Growth 5-6 cm/year

Stage 2

Breast bud with elevation of breast and papilla; enlargement of areola Sparse growth of long, slightly pigmented hair, straight or curled, along labia Growth 7-8 cm/year

Girls

Stage 3

Further enlargement of breast and areola; no separation of their contour Darker, coarser and more curled hair, spreading sparsely over junction of pubes Growth 8 cm/year

Stage 4

Areola and papilla form a secondary mound above level of breast Adult type hair, but smaller area than in adult; no spread to medial surface of thighs Growth 7 cm/year

Stage 5

Mature breast: projection of papilla only, related to recession of areola Adult type hair with horizontal distribution ("feminine") No further growth after 16 years