Sections

Anovulation

Presentation

History

Past medical and surgical history

Obtain information about infections, history of pelvic surgery, anatomic anomalies, previous diagnosis of chromosomal abnormalities, past history of dilatation and curettage (history of postsurgical changes in menstrual flow, including amenorrhea and Asherman syndrome).

Past family history

Does/did the mother and/or sisters have similar symptoms?

History of pubertal development

When was the onset of menarche, pubarche, and growth spurt?

Detailed history of the menses

What is the current frequency, regularity or irregularity, length, and quantity of uterine bleeding?

Past reproductive history

Obtain information about pregnancy losses; antepartum, intrapartum, and postpartum complications, including dilatation and curettage, because of retained products of conception after an early pregnancy loss and after a normal vaginal delivery.

Past and current sexual activity

Obtain information about the number of partners, as well as a history of sexually transmitted diseases, painful intercourse, and vaginal symptoms (eg, burning, postcoital bleeding).

Contraceptivepractices

What are the methods of contraception and duration of use, such as type of oral contraceptives and intrauterine devices (IUDs), including progestin-IUDs?

Dietary history

Has there been any recent weight gain or weight loss?

Medications

Obtain information about past and present medication use.

Psychologic history

Is there/has there been a history of depression, emotional lability, anxiety, and/or stress (including status of current relationships)?

History of previous malignancies

Obtain information about previous malignancies (eg, craniopharyngioma, leukemia, Hodgkin disease) and treatments received (eg, radiation, alkylating chemotherapeutic agents).

Review of symptoms

Has the patient experienced any of the following:

Headaches
Visual disturbances
Changes in hair distribution or appearance
Deepening of voice
Breast secretions (unilateral, bilateral)

Physical Examination

Obtain and document the patient's vital signs.

General

Evaluate the patient's voice, affect, and presentation (eg, disheveled, well-groomed).

Dermatologic

Does the patient have facial acne (cystic), acanthosis nigricans (velvety dark patches usually found on the lateral aspects of the neck, axillae, and inner aspects of the thighs), stigmata of hepatic disease (telangiectasia, caput medusae), and/or violaceous striae usually in the flanks (Cushing syndrome)?

Head, eyes, ears, nose, and throat

Assess the following:

Head - Hair distribution (male pattern baldness), facial hair, cushingoid facies
Eyes - Exophthalmos, visual acuity and visual fields (ruling out bitemporal hemianopsia)
Ears - Enlarged, disproportionate (acromegaly)
Nose - Enlarged (disproportionate to rest of face [acromegaly]), anosmia (scent of orange peels [Kallmann syndrome])
Throat - Webbing of neck (Turner syndrome [ie, remnants of cystic hygroma]), carotid bruits, thyromegaly

Breasts/chest

Evaluate the patient's Marshall-Tanner staging, areola (protuberance, pigmentation), secretions, shape of breasts (cylindrical as in exogenous estrogen exposure), decrease in breast size (androgen exposure), and/or presence of a shield chest (Turner syndrome).

Heart/lungs

Are murmurs present?

Abdomen

Assess for a linea alba, infraumbilical hair distribution, waist/hip ratio, and striae (as above).

Genitourinary

Assess the mons pubis, Marshall-Tanner staging, male-female escutcheon, absence of pubic hair (androgen insensitivity syndrome), vulvar skin (hypoestrogenized), vulvovaginal mucosa (hypoestrogenized), and clitoris (clitoral index, >35 mm²). Perform a bimanual examination to exclude ovarian/adnexal masses, age-appropriateness of genitalia

Extremities

Assess for the presence of lanugo (anorexia) versus male hair characteristics (hirsutism).

Differential Diagnoses

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Media Gallery

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.

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Anovulation Clinical Presentation