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The initial evaluation involves careful physical examination including assessment of hyperandrogenism, serum or urine human chorionic gonadotropin (hCG), and serum FSH levels (Fig. 175-1). Anatomic defects are usually diagnosed by physical examination, though hysterosalpingography or direct visual examination by hysteroscopy may be required. A karyotype should be performed when gonadal dysgenesis is suspected. The diagnosis of PCOS is based on the coexistence of chronic anovulation and androgen excess, after ruling out other etiologies for these features. The evaluation of pituitary function and hyperprolactinemia is described in Chap. 168. Disorders of the Anterior Pituitary and Hypothalamus. In the absence of a known etiology for hypogonadotropic hypogonadism, MRI of the pituitary-hypothalamic region should be performed when gonadotropins are low or inappropriately normal.

Treatment: Amenorrhea

Disorders of the outflow tract are managed surgically. Decreased estrogen production, whether from ovarian failure or hypothalamic/pituitary disease, should be treated with cyclic estrogens, either in the form of oral contraceptives or conjugated estrogens (0.625-1.25 mg/d PO) and medroxyprogesterone acetate (2.5 mg/d PO or 5-10 mg during the last 5 days of the month). PCOS may be treated with medications to induce periodic withdrawal menses (medroxyprogesterone acetate 5-10 mg or progesterone 200 mg daily for 10-14 days of each month, or oral contraceptive agents) and weight reduction, along with treatment of hirsutism and, if desired, ovulation induction (see below). Individuals with PCOS may benefit from insulin-sensitizing drugs, such as metformin, and should be screened for diabetes mellitus.

Outline

Section 13. Endocrinology and Metabolism