Medscape is available in 5 Language Editions – Choose your Edition here.


Anovulation Differential Diagnoses

  • Author: Armando E Hernandez-Rey, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG  more...
Updated: Dec 30, 2015

Diagnostic Considerations

Anovulation is a sign and not a disease entity per se; therefore, the purpose of the differential diagnosis is to help distinguish the primary cause of anovulation. Epilepsy and Sheehan syndrome should also be considered, the latter of which should be ruled out with a detailed clinical history and hormonal evaluation.

Important considerations

Diagnosis and treatment of PCOS must begin in a timely fashion in order to help reduce the morbidity and mortality from diabetes mellitus and cardiovascular disease. There is a genetic component to PCOS, and it is usually seen in first- and second-degree relatives.

Patients with chronic anovulation are at increased risk for endometrial hyperplasia and malignancy, and endometrial sampling is imperative.

US Food and Drug Administration (FDA) approval has not been obtained for any of the treatments usually used in the treatment of hirsutism. Patients must be aware of the risks involved in using these medications.

Differential Diagnoses

Contributor Information and Disclosures

Armando E Hernandez-Rey, MD Consulting Staff, Reproductive Endocrinology and Infertility, Robotic and Minimally Invasive Surgery, Conceptions: Center for Fertility & Genetics of Florida; Assistant Professor of Women's Health, Florida International University College of Medicine

Armando E Hernandez-Rey, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, American Society for Reproductive Medicine, Society for Reproductive Investigation, Society of Laparoendoscopic Surgeons, AAGL, Society for Reproductive Endocrinology and Infertility

Disclosure: Received consulting fee from Inuitive Surgical for independent contractor; Received consulting fee from Vita Med MD for speaking and teaching.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Frances E Casey, MD, MPH Director of Family Planning Services, Department of Obstetrics and Gynecology, VCU Medical Center

Frances E Casey, MD, MPH is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Reproductive Health Professionals, Society of Family Planning, National Abortion Federation, Physicians for Reproductive Health

Disclosure: Nothing to disclose.

Chief Editor

Richard Scott Lucidi, MD, FACOG Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Richard Scott Lucidi, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine

Disclosure: Nothing to disclose.


The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors Krystene I Boyle, MD, Cassandra Blot, MD, and Peter G McGovern, MD, to the development and writing of this article.

  1. Warren MP, Vu C. Central causes of hypogonadism--functional and organic. Endocrinol Metab Clin North Am. 2003 Sep. 32(3):593-612. [Medline].

  2. Speroff L, Glass RH, Kase NG. Anovulation and the polycystic ovary syndrome. Clinical Gynecologic Endocrinology and Infertility. Philadelphia, PA: Lippincott Williams & Wilkins; 1999. 487-513.

  3. Spence JE. Anovulation and monophasic cycles. Ann N Y Acad Sci. 1997 Jun 17. 816:173-6. [Medline].

  4. Yen SC, Jaffe RB, Barbieri RL. Chronic anovulation due to CNS-hypothalamic-pituitary dysfunction. Reproductive Endocrinology: Physiology, Pathophysiology and Clinical Management. 4th ed. London, England: Elsevier Science; 1999.

  5. Franks S, Mason H, White D, Willis D. Etiology of anovulation in polycystic ovary syndrome. Steroids. 1998 May-Jun. 63(5-6):306-7. [Medline].

  6. Rasgon N. The relationship between polycystic ovary syndrome and antiepileptic drugs: a review of the evidence. J Clin Psychopharmacol. 2004 Jun. 24(3):322-34. [Medline].

  7. Bilo L, Meo R. Polycystic ovary syndrome in women using valproate: a review. Gynecol Endocrinol. 2008 Oct. 24(10):562-70. [Medline].

  8. Haiman CA, Pike MC, Bernstein L, et al. Ethnic differences in ovulatory function in nulliparous women. Br J Cancer. 2002 Feb 1. 86(3):367-71. [Medline].

  9. Laven JS, Imani B, Eijkemans MJ, Fauser BC. New approach to polycystic ovary syndrome and other forms of anovulatory infertility. Obstet Gynecol Surv. 2002 Nov. 57(11):755-67. [Medline].

  10. Dunaif A. Hyperandrogenic anovulation (PCOS): a unique disorder of insulin action associated with an increased risk of non-insulin-dependent diabetes mellitus. Am J Med. 1995 Jan 16. 98(1A):33S-39S. [Medline].

  11. Guzick DS, Hoeger K. Clinical Updates in Women's Health Care: Polycystic Ovary Syndrome. 2009 Jan.

  12. The Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004 Jan. 81(1):19-25. [Medline].

  13. Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, et al. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril. 2009 Feb. 91(2):456-88. [Medline].

  14. Franks S, Robinson S, Willis DS. Nutrition, insulin and polycystic ovary syndrome. Rev Reprod. 1996 Jan. 1(1):47-53. [Medline].

  15. Pritts EA. Treatment of the infertile patient with polycystic ovarian syndrome. Obstet Gynecol Surv. 2002 Sep. 57(9):587-97. [Medline].

  16. Legro R. Polycystic ovary syndrome. Precis, Reproductive Endocrinology: An Update in Obstetrics and Gynecology. 2nd ed. American College of Obstetricians & Gynecologists; 2002. 85-89.

  17. Thatcher S. Diagnosis of polycystic ovary syndrome. Female patient. 2004. 29:33-41.

  18. Futterweit W. Polycystic ovary syndrome: clinical perspectives and management. Obstet Gynecol Surv. 1999 Jun. 54(6):403-13. [Medline].

  19. Bergfeld WF. Hirsutism in women. Effective therapy that is safe for long-term use. Postgrad Med. 2000 Jun. 107(7):93-4, 99-104. [Medline].

  20. Timpatanapong P, Rojanasakul A. Hormonal profiles and prevalence of polycystic ovary syndrome in women with acne. J Dermatol. 1997 Apr. 24(4):223-9. [Medline].

  21. Schorge JO, Schaffer JI. Amenorrhea. Williams Gynecology. McGraw Hill; 2008.

  22. Frisch RE, McArthur JW. Menstrual cycles: fatness as a determinant of minimum weight for height necessary for their maintenance or onset. Science. 1974 Sep 13. 185(4155):949-51. [Medline].

  23. Andrico S, Gambera A, Specchia C, et al. Leptin in functional hypothalamic amenorrhoea. Hum Reprod. 2002 Aug. 17(8):2043-8. [Medline].

  24. Klein DA, Walsh BT. Eating disorders. Int Rev Psychiatry. 2003 Aug. 15(3):205-16. [Medline].

  25. Yen SC, Jaffe RB, Barbieri RL. Chronic anovulation caused by peripheral endocrine disorders. Reproductive Endocrinology: Physiology, Pathophysiology and Clinical Management. 4th ed. London, England: Elsevier Science; 1999.

  26. Warren MP, Perlroth NE. The effects of intense exercise on the female reproductive system. J Endocrinol. 2001 Jul. 170(1):3-11. [Medline].

  27. Mestman JH. Endocrine diseases in pregnancy. Gabbe S, Neibyl JR, eds. Obstetrics Normal and Problem Pregnancies. New York, NY: Churchill Livingstone; 2002. 4th ed: 1117-8.

  28. Goswami R, Kochupillai N, Crock PA, Jaleel A, Gupta N. Pituitary autoimmunity in patients with Sheehan's syndrome. J Clin Endocrinol Metab. 2002 Sep. 87(9):4137-41. [Medline].

  29. Velduis JD, Weiss J, Mauras N, et al. Appraising endocrine pulse signals at low circulating hormone concentrations: use of regional coefficients of variation in the experimental series to analyze pulsatile luteinizing hormone release. Pediatr Res. 1986 Jul. 20(7):632-7. [Medline].

  30. Bills DC, Meyer FB, Laws ER, et al. A retrospective analysis of pituitary apoplexy. Neurosurgery. 1993 Oct. 33(4):602-8; discussion 608-9. [Medline].

  31. Abe T, Ludecke DK. Transnasal surgery for prolactin-secreting pituitary adenomas in childhood and adolescence. Surg Neurol. 2002 Jun. 57(6):369-78; discussion 378-9. [Medline].

  32. Molitch ME. Disorders of prolactin secretion. Endocrinol Metab Clin North Am. 2001 Sep. 30(3):585-610. [Medline].

  33. Goldman L, Ausiello D. Obesity. Cecil Textbook of Medicine. 22nd ed. 2004. 1346.

  34. Roos N, Kieler H, Sahlin L, Ekman-Ordeberg G, Falconer H, Stephansson O. Risk of adverse pregnancy outcomes in women with polycystic ovary syndrome: population based cohort study. BMJ. 2011 Oct 13. 343:d6309. [Medline]. [Full Text].

  35. ACOG Committee on Practice Bulletins, American College of Obstetricians and Gynecologists. ACOG practice bulletin: management of anovulatory bleeding. Int J Gynaecol Obstet. 2001 Mar. 72(3):263-71. [Medline].

  36. Akande EO. Plasma concentration of gonadotrophins, oestrogen and progesterone in hypothyroid women. Br J Obstet Gynaecol. 1975 Jul. 82(7):552-6. [Medline].

  37. Akande EO, Hockaday TD. Plasma concentration of gonadotrophins, oestrogens and progesterone in thyrotoxic women. Br J Obstet Gynaecol. 1975 Jul. 82(7):541-51. [Medline].

  38. Azziz R, Woods KS, Reyna R, Key TJ, Knochenhauer ES, Yildiz BO. The prevalence and features of the polycystic ovary syndrome in an unselected population. J Clin Endocrinol Metab. 2004 Jun. 89(6):2745-9. [Medline].

  39. Bankowski BJ, Zacur HA. Dopamine agonist therapy for hyperprolactinemia. Clin Obstet Gynecol. 2003 Jun. 46(2):349-62. [Medline].

  40. Barbieri RL. Metformin for the treatment of polycystic ovary syndrome. Obstet Gynecol. 2003 Apr. 101(4):785-93. [Medline].

  41. Baumann EE, Rosenfeld RL. Polycystic ovary syndrome in adolescence. Endocrinologist. 2002. 12:333-48.

  42. Ben-Rafael Z, Orvieto R. Polycystic ovary syndrome: a single gene mutation or an evolving set of symptoms. Curr Opin Obstet Gynecol. 2000 Jun. 12(3):169-73. [Medline].

  43. Boccuzzi G, Angeli A, Bisbocci D, Fonzo D, Giadano GP, Ceresa F. Effect of synthetic luteinizing hormone releasing hormone (LH-RH) on the release of gonadotropins in Cushing's disease. J Clin Endocrinol Metab. 1975 May. 40(5):892-5. [Medline].

  44. Bray GA, York DA. Clinical review 90: Leptin and clinical medicine: a new piece in the puzzle of obesity. J Clin Endocrinol Metab. 1997 Sep. 82(9):2771-6. [Medline].

  45. Brenner PF. Differential diagnosis of abnormal uterine bleeding. Am J Obstet Gynecol. 1996 Sep. 175(3 Pt 2):766-9. [Medline].

  46. Camargo CA. Hypothyroidism and goiter during pregnancy. Brody SA, Ueland K, eds. Endocrine Disorders of Pregnancy. Stamford, Conn: Appleton & Lange; 1989. 1989:165-76.

  47. Campo S. Ovulatory cycles, pregnancy outcome and complications after surgical treatment of polycystic ovary syndrome. Obstet Gynecol Surv. 1998 May. 53(5):297-308. [Medline].

  48. Carmina E, Lobo RA. Polycystic ovary syndrome (PCOS): arguably the most common endocrinopathy is associated with significant morbidity in women. J Clin Endocrinol Metab. 1999 Jun. 84(6):1897-9. [Medline].

  49. Clark RA, Mulligan K, Stamenovic E, et al. Frequency of anovulation and early menopause among women enrolled in selected adult AIDS clinical trials group studies. J Infect Dis. 2001 Nov 15. 184(10):1325-7. [Medline].

  50. Cotran RS, Kumar V, Collins T. Anovulation. Robbin's Pathologic Basis of Disease. 6th ed. Elsevier Science; 1999. 1056.

  51. Daniels GH. Thyroid disease and pregnancy: a clinical overview. Endocrinol Pract. 1995. 1:287-301.

  52. del Pozo E, Wyss H, Tollis G, et al. Prolactin and deficient luteal function. Obstet Gynecol. 1979 Mar. 53(3):282-6. [Medline].

  53. Edwards CR, Forsyth IA, Besser GM. Amenorrhoea, galactorrhoea, and primary hypothyroidism with high circulating levels of prolactin. Br Med J. 1971 Aug. 3(772):462-4. [Medline].

  54. Franks S, Gharani N, Waterworth D, et al. Genetics of polycystic ovary syndrome. Mol Cell Endocrinol. 1998 Oct 25. 145(1-2):123-8. [Medline].

  55. Franks S, McCarthy M. Genetics of ovarian disorders: polycystic ovary syndrome. Rev Endocr Metab Disord. 2004 Mar. 5(1):69-76. [Medline].

  56. Frisch RE, Wyshak G, Vincent L. Delayed menarche and amenorrhea in ballet dancers. N Engl J Med. 1980 Jul 3. 303(1):17-9. [Medline].

  57. Goldsmith R, Sturgis S, Lerman J, et al. The menstrual pattern in thyroid disease. J Clin Endocrinol Metab. 1952 Jul. 12(7):846-55. [Medline].

  58. Golovleva LA, Golovlev EL, Ganbarov KhG, Skriabin GK. [Role of cosubstrates in the microbiologic oxidation of xylene isomers by a culture of Pseudomonas aeruginosa]. Mikrobiologiia. 1977 Jan-Feb. 46(1):5-9. [Medline].

  59. Hamilton-Fairley D, Taylor A. Anovulation. BMJ. 2003 Sep 6. 327(7414):546-9. [Medline].

  60. Inamasu J, Hori S, Sekine K, Aikawa N. Pituitary apoplexy without ocular/visual symptoms. Am J Emerg Med. 2001 Jan. 19(1):88-90. [Medline].

  61. Knochenhauer ES, Key TJ, Kahsar-Miller M, et al. Prevalence of the polycystic ovary syndrome in unselected black and white women of the southeastern United States: a prospective study. J Clin Endocrinol Metab. 1998 Sep. 83(9):3078-82. [Medline].

  62. Malcolm CE, Cumming DC. Does anovulation exist in eumenorrheic women?. Obstet Gynecol. 2003 Aug. 102(2):317-8. [Medline].

  63. Norman RJ. Obesity, polycystic ovary syndrome and anovulation--how are they interrelated?. Curr Opin Obstet Gynecol. 2001 Jun. 13(3):323-7. [Medline].

  64. Norman RJ, Wu R, Stankiewicz MT. 4: Polycystic ovary syndrome. Med J Aust. 2004 Feb 2. 180(3):132-7. [Medline].

  65. Pfeifer SM, Dayal M. Treatment of the adolescent patient with polycystic ovary syndrome. Obstet Gynecol Clin North Am. 2003 Jun. 30(2):337-52. [Medline].

  66. Sabogal JC, Munoz L. Leptin in obstetrics and gynecology: a review. Obstet Gynecol Surv. 2001 Apr. 56(4):225-30. [Medline].

  67. Sakakura M, Takebe K, Nakagawa S. Inhibition of luteinizing hormone secretion induced by synthetic LRH by long-term treatment with glucocorticoids in human subjects. J Clin Endocrinol Metab. 1975 May. 40(5):774-9. [Medline].

  68. Schlechte J, Sherman B, Halmi N, et al. Prolactin-secreting pituitary tumors in amenorrheic women: a comprehensive study. Endocr Rev. 1980 Summer. 1(3):295-308. [Medline].

  69. Serri O, Chik CL, Ur E, Ezzat S. Diagnosis and management of hyperprolactinemia. CMAJ. 2003 Sep 16. 169(6):575-81. [Medline].

  70. Shangold MM. Athletic amenorrhea. Clin Obstet Gynecol. 1985 Sep. 28(3):664-9. [Medline].

  71. Thomas R, Reid RL. Thyroid disease and reproductive dysfunction: a review. Obstet Gynecol. 1987 Nov. 70(5):789-98. [Medline].

  72. Tolino A, Nicotra M, Romano L, et al. Subclinical hypothyroidism and hyperprolactinemia. Acta Eur Fertil. 1991 Sep-Oct. 22(5):275-7. [Medline].

  73. Tsilchorozidou T, Overton C, Conway GS. The pathophysiology of polycystic ovary syndrome. Clin Endocrinol (Oxf). 2004 Jan. 60(1):1-17. [Medline].

  74. Use of exogenous gonadotropins in anovulatory women: a technical bulletin. Fertil Steril. 2008 Nov. 90(5 Suppl):S7-12. [Medline].

  75. Veldhuis JD, Hammond JM. Endocrine function after spontaneous infarction of the human pituitary: report, review, and reappraisal. Endocr Rev. 1980 Winter. 1(1):100-7. [Medline].

  76. Warren MP, Brooks-Gunn J, Fox RP, et al. Persistent osteopenia in ballet dancers with amenorrhea and delayed menarche despite hormone therapy: a longitudinal study. Fertil Steril. 2003 Aug. 80(2):398-404. [Medline].

  77. Warren MP, Goodman LR. Exercise-induced endocrine pathologies. J Endocrinol Invest. 2003 Sep. 26(9):873-8. [Medline].

  78. Warren MP, Vu C. Central causes of hypogonadism--functional and organic. Endocrinol Metab Clin North Am. 2003 Sep. 32(3):593-612. [Medline].

  79. Wilansky DL, Greisman B. Early hypothyroidism in patients with menorrhagia. Am J Obstet Gynecol. 1989 Mar. 160(3):673-7. [Medline].

  80. Wilson JD, Foster DW, Kronenberg HM. Disorders of the ovaries and female reproductive tract. Williams Textbook of Endocrinology. 10th ed. WB Saunders Co; 2003. 751-817.

  81. Winters SJ, Berga SL. Gonadal dysfunction in patients with thyroid disorders. Endocrinologist. 1997. 7:167-73.

  82. Yen SC, Jaffe RB, Barbieri RL. Polycystic ovary syndrome: Hyperandrogenic chronic anovulation. Reproductive Endocrinology: Physiology, Pathophysiology and Clinical Management. 4th ed. London, England: Elsevier Science; 1999.

  83. Zakarija M, McKenzie JM. Pregnancy-associated changes in the thyroid-stimulating antibody of Graves' disease and the relationship to neonatal hyperthyroidism. J Clin Endocrinol Metab. 1983 Nov. 57(5):1036-40. [Medline].

  84. Zawadski JK, Dunaif A. Diagnostic criteria for polycystic ovary syndrome. Givens J, Haseltine F, Merriman G. The Polycystic Ovary Syndrome. Cambridge, MA: Blackwell Scientific; 1992. 377-384.

  85. Prior JC, Naess M, Langhammer A, Forsmo S. Ovulation prevalence in women with spontaneous normal-length menstrual cycles - a population-based cohort from HUNT3, Norway. PLoS One. 2015. 10(8):e0134473. [Medline].

  86. Schliep KC, Zarek SM, Schisterman EF, et al. Alcohol intake, reproductive hormones, and menstrual cycle function: a prospective cohort study. Am J Clin Nutr. 2015 Oct. 102(4):933-42. [Medline].

  87. Palihawadana TS, Wijesinghe PS, Seneviratne HR. Factors associated with nonresponse to ovulation induction using letrozole among women with World Health Organization group II anovulation. J Hum Reprod Sci. 2015 Apr-Jun. 8(2):75-9. [Medline].

Anovulation. Polycystic ovary. Courtesy of Jairo E. Garcia, MD.
Anovulation. On the left is an unaffected patient aged 12 years. On the right is the same patient aged 13 years after developing Cushing disease.
Anovulation. Left adrenal mass discovered incidentally.
Anovulation. MRI showing a nonenhancing area in the pituitary consistent with a microadenoma in a patient with hyperprolactinemia.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.