| Findings | Associations |
|---|---|
| History | |
| Chemotherapy or radiation | Impairment of specific organ or structure, (e.g., brain, pituitary, ovary) |
| Family history of early or delayed menarche | Constitutional delay of puberty |
| Galactorrhea | Pituitary tumor |
| Hirsutism, acne | Hyperandrogenism, PCOS, ovarian or adrenal tumor, CAH, Cushing syndrome |
| Illicit or prescription drug useLoss of smell (anosmia) | Multiple associations, consider effect on prolactin |
| Loss of smell (anosmia) | Kallman syndrome (GnRH deficiency) |
| Menarche and menstrual history | Primary vs. secondary amenorrhea |
| Sexual activity | Pregnancy |
| Significant headaches or vision changes | Central nervous system tumor, empty sella syndrome |
| Temperature intolerance, palpitations, diarrhea, constipation, tremor, depression, skin changes | Thyroid disease |
| Vasomotor symptoms (e.g., hot flashes or night sweats) | Primary ovarian insufficiency, natural menopause |
| Weight loss, excessive exercise, poor nutrition, psychosocial distress, diets | Functional hypothalamic amenorrhea |
| Physical examination | |
| Abnormal thyroid examination | Thyroid disorder |
| Acanthosis nigricans or skin tags | Hyperinsulinemia (PCOS) |
| Anthropomorphic measurements; growth charts | Multiple associations; Turner syndrome, constitutional delay of puberty |
| Body mass index | High: PCOS Low: Functional hypothalamic amenorrhea |
| Bradycardia | Functional hypothalamic amenorrhea (e.g., anorexia nervosa) |
| Breast development (normal progression) | Presence of circulating estrogen* |
| Dysmorphic features (e.g., webbed neck, short stature, low hairline) | Turner syndrome |
| Male pattern baldness, increased facial hair, acne | Hyperandrogenism, PCOS, ovarian or adrenal tumor, CAH, Cushing syndrome |
| Pelvic examination | |
| Absence or abnormalities of cervix or uterus | Rare congenital causes including Müllerian agenesis or androgen insensitivity syndrome |
| Clitoromegaly | Androgen-secreting tumor; CAH; 5α-reductase deficiency |
| Presence of transverse septum or imperforate hymen | Outflow tract obstruction |
| Reddened or thin vaginal mucosa | Decreased endogenous estrogen |
| Sexual maturity rating abnormal | Turner syndrome, constitutional delay of puberty, rare causes |
| Striae, buffalo hump, central obesity, hypertension | Cushing syndrome |