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Abnormaluterinebleedinginadolescents:Differentialdiagnosisandapproach
Author
NirupamaKDeSilva,MD

SectionEditors
DeputyEditor
AmyBMiddleman,MD,MPH,MSEdMaryMTorchia,MD
MitchellGeffner,MD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Mar2015.|Thistopiclastupdated:Nov18,2014.
INTRODUCTIONMenstrualcyclesareoftenirregularinthefirstmonthsaftermenarche.Accordingtoastudy
bytheWorldHealthOrganization,themedianlengthofthefirstcycleaftermenarchewas34days,with38
percentofthecyclesexceeding40daysand7percentoccurringlessthan20daysapart[1].Menstrual
disordersandabnormaluterinebleeding(AUB)areamongthemostfrequentgynecologiccomplaintsof
adolescents[2,3].Abnormaluterinebleeding(AUB)referstobleedingthatisexcessiveoroccursoutsideof
normalcyclicmenstruation[4].AUBisdescribedbyavarietyoftermsandmaybecausedbyanumberof
genitalandnongenitaltractdiseases,systemicdisorders,andmedications(table1).(See"Differentialdiagnosis
ofgenitaltractbleedinginwomen".)
MostcasesofAUBinadolescentsarecausedbyanovulatorycyclesduringthefirst12to18monthsafter
menarche,whichisrelatedtoimmaturityofthehypothalamicpituitaryovarianaxis[4,5].Othercommoncauses
includepregnancy,infection,theuseofhormonalcontraceptives,stress(psychogenicorexerciseinduced),
bleedingdisorders,andendocrinedisorders(eg,hypothyroidism,polycysticovarysyndrome)[4].
Thetreatmentforthesedisordersrangesfromobservationtopharmacologicand/orsurgicaltherapy.Potential
sequelaeofAUBincludeanemia[6]andendometrialcancer[7,8].Withappropriatemanagementofthe
underlyingproblem,thesesequelaemaybeprevented.Thus,itiscrucialtoestablishthecorrectdiagnosis
beforeanytherapyisadministered[9].
TheevaluationofAUBinadolescentswillbediscussedhere.ThemanagementofAUBinadolescentsis
discussedseparately,asistheevaluationofAUBinpremenopausalwomen.(See"Abnormaluterinebleedingin
adolescents:Management"and"Approachtoabnormaluterinebleedinginnonpregnantreproductiveage
women".)
GENERALAPPROACHThedifferentialdiagnosisofgenitaltractbleedinginadolescentsissimilartothatin
adultwomen(table1).However,themostcommoncausesvaryaccordingtoage(table2).Inadolescentsin
particular,disordersofpregnancyandthepossibilityofpelvicinfectionshouldbeconsideredearlyinthe
evaluation[10].Itisessentialtoruleoutpregnancyintheadolescent,regardlessofthestatedsexualhistory.
Thisisespeciallyimportantinthoseadolescentswhopresentwithunexplainedvaginalbleeding[11].(See
"Ectopicpregnancy:Clinicalmanifestationsanddiagnosis"and"Clinicalfeaturesanddiagnosisofpelvic
inflammatorydisease".)
Oncepregnancyhasbeenexcluded,itishelpfultodeterminewhetherthebleedingiscyclic(regular)oracyclic
(irregular)innature.Thedifferentialdiagnosisvariesaccordingly.Asanexample,anovulatorybleedingisthe
mostcommoncauseofexcessivemenstrualflowinadolescentswithirregularbleeding,whereasblood
dyscrasiasandstructuralanomalies(eg,polyps,fibroids)aremorecommoninthosewithcyclicbleeding.
Asageneralrule,bleedingthatisprecededbypremenstrualsymptoms(breasttenderness,waterweightgain,
moodswings,orabnormalcramping)isovulatory[9].Incontrast,heavybleedingthatoccursirregularlyis
usuallyanovulatory.However,manypatientsarebetweentheseextremes,anddeterminationoftheovulatory
statusmaybedifficult.
Commoncausesofabnormaluterinebleedinginadolescentscanbegroupedintofourpatterns:

Amenorrhea
Irregularbleeding
Heavymenstrualbleeding
Intermenstrualbleeding

(See"Abnormaluterinebleedinginadolescents:Definitionandevaluation",sectionon'Terminology'.)
Characterizationintooneofthesepatternsmaybedifficultbecauseoftherangeofvariabilityincyclesduring
thefirstonetotwoyearspostmenarcheandthedifficultyinquantifyingvolumeofflow.Inaddition,thecausative
conditionsmayoverlapcategoriesorpresentatypically.Nevertheless,thecategorizationschemeishelpfulin
narrowingthedifferentialdiagnosisanddirectingtheadditionallaboratoryevaluation.
AMENORRHEAAmenorrheaistheabsenceofmenses,whichmaybeprimaryorsecondary.Althoughthere
areseveraluniquecausesofprimaryamenorrhea(eg,congenitalabnormalitiesinMlleriandevelopmentor
urogenitalsinusdevelopment),allcausesofsecondaryamenorrheaalsocancauseprimarydisease.Themost
commoncauseofamenorrheainafemaleofreproductiveageispregnancy.(See"Pregnancyinadolescents",
sectionon'Diagnosisofpregnancy'.)
PrimaryPrimaryamenorrheaiscommonlydefinedastheabsenceofmenarchebyage15years.The95th
percentileformenarcheinNorthAmericais14.5years[12,13].Thecauses,evaluation,andtreatmentof
primaryamenorrheaarediscussedindetailseparately.(See"Etiology,diagnosis,andtreatmentofprimary
amenorrhea"and"Evaluationofoligomenorrheainadolescence".)
SecondarySecondaryamenorrheaisdefinedastheabsenceofmensesformorethanthreecyclesorsix
monthsinwomenwhopreviouslyhadmenses[14].Inadolescents,itisuncommonforgirlstoremainwithout
theirmensesfor>90days(the95thpercentileforcyclelength).Thus,adolescentswithoutmensesfor90days
warrantanevaluation[15].Oncepregnancyisexcluded,astepwiseendocrinologicevaluationcanbe
considered.Iflabsarenormal,aprogesteronechallenge(suchasmicronizedoralprogesterone[200mg]for12
days)oratrialofhormonalcontraceptionmaybenecessarytoreestablishmenses.(See"Etiology,diagnosis,
andtreatmentofsecondaryamenorrhea"and"Evaluationofoligomenorrheainadolescence".)
IRREGULARBLEEDING
AnovulatoryuterinebleedingInadolescents,duringthefirst12to18monthsaftermenarcheandinthe
absenceofpregnancy,themostcommoncauseofirregularmenstrualbleedingisanovulationduetoan
immaturehypothalamicpituitaryovarianaxis[4,5].Thisconditionisanormalfindinginthefirstfewyearsafter
menarche,butallotherpathologicdiagnosesmustberuledout(table3).(See"Approachtoabnormaluterine
bleedinginnonpregnantreproductiveagewomen",sectionon'History'.)
Everyyoungadolescentfemaleispronetoanovulatorycyclesinwhichtheendometriumlacksthestabilizing
effectofprogesterone.Insuchcycles,theendometriumbecomesexcessivelythickened.Itbreaksdownand
sloughswhenestrogeniswithdrawn(estrogenwithdrawalbleeding)orwhenitbecomesunstable(estrogen
breakthroughbleeding)[16,17].(See"Abnormaluterinebleedinginadolescents:Definitionandevaluation",
sectionon'Normalmenstrualcycle'.)
Adolescentswithregularmenseshavecyclicestrogensecretionthatpermitsorderlygrowthandsheddingofthe
endometrium(onaccountofhormonewithdrawal),evenintheabsenceofovulation.Inaddition,thesecretionof
progesteroneassociatedwiththeoccasionalovulatorycycleintheseadolescentshelpstostabilizeendometrial
growthandpermitsmorecompleteshedding[10].
Incontrast,adolescentswithanovulatorybleedingappeartohavedelayedmaturationofnormalnegative
feedbackcyclicity[18].Inthesegirls,risinglevelsofestrogendonotcausesuppressionoffolliclestimulating
hormone(FSH)[19].Estrogensecretionissustained,andtheconcentrationofFSHisincreasedrelativetothat
ofluteinizinghormone(LH).Inthesegirlswithsustainedacyclicestrogensecretion,theendometrium
proliferatesbeyondestrogen'sabilitytomaintainitsintegrity.Bleedingoccurswhentheendometriumbecomes

unstable(estrogenbreakthroughbleeding)andcontinuesuntilestrogeninducedrepairtakesplace[16,17].
Episodesofamenorrheamaybefollowedbysuddenandsubstantialhemorrhage[17].
Othercausesofirregularmensesmustbeexcludedbeforeadiagnosisofanovulatorybleedingcanbemade.In
girlsinwhomadiagnosisofanovulatorybleedingisconsidered,additionalevaluationmayincludeFSH,LH,
thyroidstimulatinghormone(TSH),andprolactinondaythreeofthemenstrualcycle(byconvention,thefirst
dayofmensesisdayoneofthecycle,eveningirlswithirregularcycles).AlthoughtheconcentrationsofLHand
FSHvarythroughoutthecycle(figure1),theyaremostreproducibleondaythree,whentheyareattheirlowest
concentrations.Ifdaythreehappenstofallonaweekend,thebloodmaybedrawnondayfourorfive.Freeand
totaltestosteroneanddehydroepiandrosteronesulfate(DHEAsulfate)shouldbeobtainedifsignsof
hyperandrogenismarepresent(see'Polycysticovarysyndrome'below).Ifallpathologiccausesareruledout,
andthepatientisnotbotheredbyirregularmenses,anovulatorybleedingmaybemanagedexpectantlyforthe
firstfewyearsaftermenarche.
PolycysticovarysyndromePolycysticovarysyndrome(PCOS)isacommoncauseofabnormalbleedingin
theadolescentwithchronicanovulation[19].ThediagnosisofPCOSisbaseduponclinicalandbiochemical
criteria.Itshouldbepursuedinalladolescentswithobesity,menstrualirregularity,insulinresistance,and/or
signsofhyperandrogenism(hirsutism,acne,clitoromegaly)[20].Becausesignsofhyperandrogenismarenot
invariablypresent,PCOSalsoshouldbeconsideredingirlswithprolongedmenstrualirregularityand/or
severelyanovulatorybleeding,evenintheabsenceofhirsutismoracne.(See"Definition,clinicalfeaturesand
differentialdiagnosisofpolycysticovarysyndromeinadolescents".)
IfPCOSisaconsideration,othercausesofhyperandrogenismandothercausesofirregularmensesmustbe
ruledout.Theseincludecongenitaladrenalhyperplasia(CAH),tumorsoftheovaryoradrenalgland,Cushing
syndrome,hyperprolactinemia,andthyroiddysfunction.Thedifferentialdiagnosisandevaluationof
hyperandrogenisminadolescentsisdiscussedindetailseparately.(See"Definition,clinicalfeaturesand
differentialdiagnosisofpolycysticovarysyndromeinadolescents".)
OthercausesOtherhormonalcausesofirregularbleedinginadolescentsincludehypothyroidismand
hyperprolactinemia[21].Thecausesofhyperprolactinemiaarediscussedseparatelybutincludepituitarytumors
andcertainmedications(eg,metoclopramideandmethyldopa).(See"Causesofhyperprolactinemia".)
Psychologicorexerciseinducedstressandeatingdisorderswithlargeweightlossmaycauseacuteanovulation
inadolescents.However,thesedisordersaretypicallyassociatedwithahypoestrogenicstateandamenorrhea.
(See"Etiology,diagnosis,andtreatmentofprimaryamenorrhea"and"Etiology,diagnosis,andtreatmentof
secondaryamenorrhea".)
Finally,intermenstrualbleedingrelatedtobacterialorviralinfectionsofthevulva,vagina,orcervixmaygivean
adolescentthefalseimpressionthathermensesare"irregular".(See'Intermenstrualbleeding'below.)
EXCESSIVEMENSTRUALBLEEDINGExcessivemenstrualflowmaybeexcessiveinitsduration(>7days)
oritsvolume(>80mL/cycle).Unfortunately,neitherpatientsnorclinicianscanaccuratelyestimatetheamountof
bloodloss.Heavymenstrualbleedingintheadolescenttypicallyoccursatirregularintervals,indicatingthatitis
anovulatory.(See'Irregularbleeding'aboveand"Abnormaluterinebleedinginadolescents:Definitionand
evaluation",sectionon'History'.)
BleedingdisordersHeavymenstrualbleedingthatoccursatregularintervalsorattheonsetofmensesis
oftenrelatedtoableedingdiathesisandlesscommonlytosystemicillnessorstructurallesions[2228].Inherited
bleedingdisordersshouldbeconsideredinthedifferentialdiagnosisofallpatientspresentingwithheavy
menstrualbleeding[29].Inretrospectivestudies,theprevalenceofbleedingdisordersamongadolescents
hospitalizedforheavymenstrualbleedingrangesfrom5to28percent[22,2427].Inoneseriesof59
adolescentswhowerehospitalizedwithacuteheavymenstrualbleedingandinwhomgenitaltractpathology
hadbeenexcluded,anunderlyingcoagulopathywaspresentinapproximatelyonefifthoverall,onethirdof
thoserequiringatransfusion,andonehalfpresentingatmenarche[22].

CoagulationdisordersamongadolescentswithheavymenstrualbleedingincludevonWillebranddisease,
immunethrombocytopenia(ITP),plateletdysfunction,andthrombocytopeniasecondarytomalignancyor
treatmentformalignancy(ie,chemotherapyorhematopoieticstemcelltransplantation)[2126,28].Bleeding
diathesisinadolescentsalsomayberelatedtotheuseofmedicationssuchasanticoagulantorplatelet
inhibitors.Thesedisordersarediscussedseparately.(See"Clinicalpresentationanddiagnosisofvon
Willebranddisease"and"Immunethrombocytopenia(ITP)inchildren:Clinicalmanifestationsanddiagnosis"
and"Congenitalandacquireddisordersofplateletfunction".)
Excessivebleedingshouldpromptanevaluationofhematologicstatus.Theminimumlaboratoryevaluation
shouldinclude[29]:
Completebloodcountwithplateletsandexaminationoftheperipheralbloodsmearandferritintodetect
anemiaorthrombocytopenia
Coagulationpanel(activatedpartialthromboplastintime(aPTT)andprothrombintime(PT))
Weconsiderthediagnosisofableedingdyscrasiainadolescentswhopresentwithextremelyheavyfirst
menses,bleedingrequiringbloodtransfusion,andpatientswithrefractoryheavymenstrualbleedingand
concomitantanemia.Insuchpatients,thesecondaryevaluationalsoshouldincludeavonWillebrandpanel(ie,
plasmavonWillebrandfactor(VWF)antigenplasmaVWFactivity(ristocetincofactoractivity)andfactorVIII
activity)[29,30].ItisimportantthatthevonWillebrandpanelbeobtainedwhenthepatientisnottaking
hormones,becauseexogenousestrogenmayelevateVWFintothenormalrange[31].Thus,thepanelshould
beobtainedatthetimeofpresentationorafterexogenousestrogenhasbeendiscontinuedforsevendays.Itis
alsoimportanttoobtainbloodgrouptypingsincebloodgroupOisassociatedwithlowerlevelsofVWF,andto
consultwithahematologistifthelevelsarelow.(See"Abnormaluterinebleedinginadolescents:Management"
and"ClinicalpresentationanddiagnosisofvonWillebranddisease".)Ifableedingdisorderisconsidered,
consultationwithahematologistiswarranted.
OthercausesLesscommoncausesofheavymenstrualbleedinginadolescentsincludesystemicillness,
endocrinedisorders,andstructurallesions.Systemicillnessmayaffectovarianorliverfunction,causing
abnormalitiesinovulationorcoagulation,respectively.Examplesincludediabetesmellitus,systemiclupus
erythematosus,renalfailure,malignancy,andmyelodysplasia.Hypothyroidismandhyperthyroidismmaycause
heavymenses,aswellasanovulatorycycles.Structurallesionsthatcauseheavymenstrualbleedingin
adolescentsincludecervicalpolypsanduterineleiomyomas(fibroids).(See'Irregularbleeding'aboveand
"Clinicalmanifestationsofhypothyroidism"and"Congenitalcervicalanomaliesandbenigncervicallesions".)
Inadolescentswithheavymenstrualbleedinginwhomableedingdiathesishasbeenexcluded,additional
laboratoryevaluationmayinclude:
MeasurementofserumTSHtoexcludethyroidabnormalities
Evaluationforchronicorsystemicdiseasesaswarrantedbythehistoryandphysicalexamination
Pelvicultrasonography(ifithasnotalreadybeenperformed)toexcludestructuralcauses,suchasfibroids,
polyps,and/orovariantumors
INTERMENSTRUALBLEEDING
ExogenoushormonesExogenoushormoneadministration(eg,hormonalcontraception)isacommoncause
ofabnormaluterinebleedinginadolescents.Intermenstrualbleedingisacommonsideeffectoforal
contraceptives,depotmedroxyprogesteroneacetate,thecontraceptivepatch[32],andthering,implant,and
intrauterinedevices.Bleedingmayoccurifthesemedicationsarenottakenasprescribedorasasideeffectof
thesemedications.Thus,itisimportanttoaskdetailedquestionsabouthowmedicinesaretakenorused.(See
"Risksandsideeffectsassociatedwithestrogenprogestincontraceptives",sectionon'Breakthroughbleeding'
and"Overviewofcontraception".)

InfectionSexuallyactiveadolescentswhohaveahistoryofacutevaginalbleedingunrelatedtomenses
shouldbeassessedforcervicitisrelatedtosexuallytransmittedinfections.Thisalsoappliesforgirlswhohave
beensexuallyabused.TheprevalenceofC.trachomatisinwomenwithAUBisunderestimated[33].(See
"Sexuallytransmitteddiseases:Overviewofissuesspecifictoadolescents"and"Clinicalfeaturesanddiagnosis
ofpelvicinflammatorydisease".)
OthercausesOthercausesofintermenstrualbleedinginadolescentsincludecervicalpolyps,ectropion
(particularlyingirlswithcysticfibrosis[10]),foreignbodies(retainedtamponsaremostcommonamong
adolescents),trauma,andcertainmedications(eg,anticoagulants).(See"Congenitalcervicalanomaliesand
benigncervicallesions"and"Evaluationofsexualabuseinchildrenandadolescents".)
Lesscommoncausesofnonuterinegenitaltractbleedinginadolescentsarediscussedseparately.(See
"Differentialdiagnosisofgenitaltractbleedinginwomen".)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.
Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.
BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticles
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arecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
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Basicstopic(see"Patientinformation:Absentorirregularperiods(TheBasics)")
BeyondtheBasicstopic(see"Patientinformation:Absentorirregularperiods(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONSTheinitialevaluationofalladolescentswithAUBshouldinclude
exclusionofpregnancy,assessmentofhemodynamicstatus(bloodpressure,heartrate),andhemoglobinor
hematocritandplateletcounttoevaluatethepresenceofanemiaorthrombocytopenia.Theadditional
evaluationdependsuponfindingsfromthehistoryandphysicalexamination:
Theapproachtoamenorrheaisdiscussedseparately.(See"Etiology,diagnosis,andtreatmentofprimary
amenorrhea"and"Etiology,diagnosis,andtreatmentofsecondaryamenorrhea".)
Anovulatorybleedingaccountsforthemajorityofabnormaluterinebleedinginadolescentshowever,other
pathologiccausesofbleedingmustbeexcluded(table3).
Obesityand/orsignsofhyperandrogenism(eg,hirsutism,acne,clitoromegaly)ingirlswithAUBshould
promptevaluationforPCOS.ThistypicallyincludestotalandfreetestosteroneandDHEAsulfate
additionaltestingmaybenecessarytoexcludeothercausesofhyperandrogenism(eg,prolactin,TSH,
cortisol).(See"Definition,clinicalfeaturesanddifferentialdiagnosisofpolycysticovarysyndromein
adolescents".)
Aprogesteronechallengecanbeperformedingirlswithchronicanovulatorycyclestoevaluateresponse
toendogenousestrogen.Inaddition,progesteroneorhormonalcontraceptionisanimportantcomponent
inthemanagementofprolongedanovulatorybleeding.(See"Abnormaluterinebleedinginadolescents:
Management"and"Endometrialcarcinoma:Epidemiologyandriskfactors".)
BleedingdisordersshouldbeconsideredinalladolescentswithAUBwhopresentwithextremelyheavy
firstmenses,bleedingrequiringbloodtransfusion,andpatientswithrefractoryheavymenstrualbleeding
andconcomitantanemia.(See"Approachtothechildwithbleedingsymptoms".)

 Sexuallytransmittedinfectionsandpelvicinflammatorydiseaseshouldbeconsideredinallsexuallyactive
(orsexuallyabused)adolescentswhocomplainofirregular,intermenstrual,orpostcoitalbleeding.(See
"Sexuallytransmitteddiseases:Overviewofissuesspecifictoadolescents".)
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Topic114Version16.0

GRAPHICS
Causesofabnormaluterinebleedingintheadolescentgirl
Anovulatoryuterinebleeding
Pregnancyrelatedproblems
Threatened,spontaneous,incomplete,missed
abortion
Problemswithterminationprocedures
Ectopicpregnancy
Gestationaltrophoblasticdisease

Infection

Blooddyscrasia
Thrombocytopenia
Clottingdisorders
Liverdisease

Endocrinedisorders
Anovulatorybleeding
Thyroiddisease
Adrenaldisorders

Pelvicinflammatorydisease

Hyperprolactinemia

Endometritis

Polycysticovarysyndrome

Cervicitis

Ovarianfailure

Vaginitis

Vaginalabnormalities
Carcinoma
Lacerations

Cervicalproblems
Cervicitis
Polyp
Hemangioma
Carcinoma

Uterineproblems
Submucousmyoma
Congenitalanomalies
Polyp
Carcinoma
Intrauterinedevice
Intermenstrualbleeding

Ovarianproblems
Cyst
Tumor

Endometriosis
Trauma
Foreignbody
Systemicdisease
Diabetesmellitus
Renaldisease
Systemiclupuserythematosus

Medications
Hormonal
Anticoagulants,plateletinhibitors
Androgens,spironolactone
Antipsychotics

Ovulatorybleeding

Adaptedfrom:EmansSJ.Dysfunctionaluterinebleeding.In:PediatricandAdolescentGynecology,5th
ed,EmansSJ,LauferMR(Eds),LippincottWilliams&Wilkins,Philadelphia2005.p.270.
Graphic62751Version4.0

Usualcausesofabnormalgenitalbleedinginwomenbyagegroup
Neonates
Estrogenwithdrawal

Premenarchal
Foreignbody
Trauma,includingsexualabuse
Infection
Urethralprolapse
Sarcomabotryoides
Ovariantumor
Precociouspuberty

Earlypostmenarche
Ovulatorydysfunction(hypothalamic
immaturity)
Bleedingdiathesis
Stress(psychogenic,exerciseinduced)
Pregnancy
Infection

Reproductiveage
Ovulatorydysfunction
Pregnancy
Cancer
Polyps,leiomyomas,adenomyosis
Infection
Endocrinedysfunction(polycysticovary
syndrome,thyroid,hyperprolactinemia)
Bleedingdiathesis
Medicationrelated(eg,hormonal
contraception)

Menopausaltransition
Anovulation
Polyps,fibroids,adenomyosis
Cancer

Menopause
Endometrialatrophy
Cancer
Postmenopausalhormonetherapy

Adaptedfrom:APGOeducationalseriesonwomen'shealthissues.Clinicalmanagementofabnormal
uterinebleeding.AssociationofProfessorsofGynecologyandObstetrics,May2002.
Graphic61684Version5.0

Causesofanovulatorygenitaltractbleedinginadolescents
Agerelated
Immaturehypothalamicpituitaryovarian
axisattheonsetofmenarche
Declineinovarianfunctionduring
menopause

Systemicillnessandneoplasms
Hypothyroidismandhyperthyroidism
Chronicliverandrenaldisease
Hypercortisolism(Cushingsyndrome)
Polycysticovarysyndrome
Prolactinoma
Emptysellasyndrome
Pituitaryinfarctionafterpostpartum
hemorrhage(Sheehansyndrome)
Adrenalandovariantumors
Tumorsinfiltratingthehypothalamus
Graphic78931Version4.0

Medications
Oralcontraceptives
Progestins
Antipsychoticdrugs
Corticosteroids
Chemotherapeuticagents

Other
Suddenweightloss
Stress
Intenseexercise

Hormonalchangesduringnormalmenstrualcycle

Sequentialchangesintheserumconcentrationsofthehormonesreleasedfromthe
pituitary(FSHandLHleftpanel)andfromtheovaries(estrogenandprogesterone
rightpanel)duringthenormalmenstrualcycle.Byconvention,thefirstdayof
mensesisday1ofthecycle(shownhereasday14).Thecycleisthendividedinto
twophases:thefollicularphaseisfromtheonsetofmensesuntiltheLHsurge(day
0)andthelutealphaseisfromthepeakoftheLHsurgeuntilthenextmenses.To
convertserumestradiolvaluestopmol/L,multiplyby3.67,andtoconvertserum
progesteronevaluestonmol/L,multiplyby3.18.
Graphic72415Version1.0