Hyperprolactinemia occurs in approximately 25% of adult women with secondary amenorrhea but is a much less common cause of oligomenorrhea in adolescents Nevertheless, the possibility of hyperprolactinemia must be considered in all adolescents with oligomenorrhea because only 40% to 50% of hyperprolactinemic patients have spontaneous or expressible galactorrhea Hyperprolactinemia can be a side effect of several commonly used medications (see Table 51.3 ) A pituitary adenoma is a rare, but important cause of hyperprolactinemia In one retrospective review of teenagers with pituitary adenomas, over 50% of the females presented with either oligomenorrhea or secondary amenorrhea Other central nervous system tumors should also be considered as a potential cause for hyperprolactinemia The occasional patient with galactorrhea but with a normal prolactin level should be reevaluated periodically in an effort to identify a treatable cause of the problem Ovarian Disorders Ovarian failure in adolescents may be caused by primary or acquired etiologies Primary ovarian failure most commonly is due to gonadal dysgenesis from genetic causes, most commonly Turner syndrome Secondary causes of premature ovarian failure include sequelae of chemotherapy, pelvic irradiation, or autoimmune disease Ovarian tumors or other hormone-secreting tumors may result in ovarian failure Endometrial destruction that results from overly vigorous curettage or pelvic tuberculosis is an exceedingly rare cause of oligomenorrhea Thyroid Disorders Hypothyroidism and hyperthyroidism can both produce menstrual irregularities The provider who sees a female patient presenting with either infrequent bleeding or excessive bleeding should have hypothyroidism and hyperthyroidism on the differential diagnosis It can be beneficial to send thyroid studies (TSH) from the emergency department Miscellaneous Among adolescents who not have overt signs of PCOS, hyperprolactinemia, or malnutrition, suppression of the hypothalamic–pituitary axis is the most common cause of oligomenorrhea that occurs more or persists for at least years after menarche Although oligomenorrhea in otherwise normal-appearing adolescents has historically been ascribed to psychosocial stressors (family disruption, moving, depression), many patients with apparently psychogenic menstrual irregularity prove on careful evaluation to have disordered eating patterns or nutritional deficits It should be noted that diagnosis of stress as the cause of oligomenorrhea is one of exclusion Pseudocyesis is a rare cause of amenorrhea in women who believe they are pregnant and who exhibit many presumptive symptoms and signs of pregnancy, including nausea, vomiting, hyperpigmented areolae, galactorrhea, and abdominal distension The diagnosis is made when a patient who insists that she is pregnant nevertheless has no true uterine enlargement, no demonstrable fetal parts or heart sounds, and a negative pregnancy test result Psychiatric consultation should be obtained for such patients APPROACH TO DIAGNOSIS Patients with oligomenorrhea but few other symptoms or signs of disease may require laboratory evaluation to differentiate among the many potential causes of oligomenorrhea after pregnancy has been excluded This workup is usually done in an outpatient setting Figure 51.1 outlines a strategy for initial emergency diagnostic evaluation Helpful labs to be obtained in the ED include TSH and prolactin An elevated TSH level points to hypothyroidism either as the cause of oligomenorrhea or as a concomitant condition while a low TSH could point to hyperthyroidism An elevated prolactin level suggests a pituitary adenoma in nonbreastfeeding patients who are not taking any of the drugs known to cause hyperprolactinemia and galactorrhea ( Table 51.3 ) For the purposes of the emergency clinician, once pregnancy and life-threatening causes are ruled out, patients can be referred to their primary care physician, adolescent physician, or gynecologist for further evaluation If an Emergency Provider were to send additional labs to assist in the outpatient workup, the following would be helpful: LH, FSH, free and total testosterone levels The finding of a mildly elevated total or free testosterone level constitutes strong evidence for a diagnosis of PCOS A total testosterone level of more than 200 ng per dL suggests an ovarian or adrenal tumor FSH values of more than 40 mIU per mL confirm ovarian failure If the laboratory evaluation discloses no abnormalities or only a low FSH level, the patient likely has one of the many conditions that cause hypothalamic–pituitary suppression TABLE 51.3 PARTIAL LIST OF DRUGS THAT CAN CAUSE HYPERPROLACTINEMIA AND/OR GALACTORRHEA Antipsychotic and antidepressant agents Phenothiazines (e.g., chlorpromazine [Thorazine], clomipramine [Anafranil], fluphenazine [Prolixin], prochlorperazine [Compazine], thioridazine [Mellaril]) Haloperidol (Haldol) Pimozide (Orap) Risperidone (Risperdal) Thiothixene (Navane) Drugs used to treat gastrointestinal disorders Cimetidine (Tagamet) Metoclopramide (Reglan) Antihypertensive agents Methyldopa (Aldomet) Reserpine (Hydromox, Serpasil, others) Verapamil (Calan, Isoptin) Opiates Codeine Morphine The administration of exogenous progestin is often used by specialists as an in vivo test of ovarian and endometrial function for oligomenorrheic patients with the supposition that “withdraw flow,” if it appears, provides the patient and her physician with tangible evidence of the basic integrity of the organs and the hypothalamic–pituitary axis For diagnosis in adolescents, however, laboratory investigation is much preferable to progestin administration Keep in mind, however, that nearly all nonpregnant adolescents with oligomenorrhea will have a withdrawal bleed; laboratory investigation may still be recommended Appropriate follow-up will be essential ACKNOWLEDGMENTS We would like to thank Dr Jennifer H Chuang and Dr Jan Paradise for their work on earlier editions of this chapter Suggested Readings and Key References Akgül S, Bonny AE Metabolic syndrome in adolescents with polycystic ovary syndrome: prevalence based on different diagnostic criteria J Pediatr Adolesc Gynecol 2019;32(4):383–387 American Academy of Pediatrics, Committee on Adolescence, American College of Obstetricians and Gynecologists and Committee on Adolescent Health Care Menstruation in girls and adolescents: using the menstrual cycle as a vital sign Pediatrics 2006;118:2245–2250 DiVasta AD, Emans SJ Androgen abnormalities in the adolescent girl In: Emans SJ, Laufer MR, Goldstein DP, eds Pediatric and Adolescent Gynecology , 6th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2012:168–187 Fauser B, Tarlatzis B, Rebar R, et al Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group (2012) Consensus on women’s health aspects of polycystic ovary syndrome (PCOS) Hum Reprod 27(1):14–24 Fraser IS, Critchley HO, Broder M, et al The FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding Semin Reprod Med 2011;29(5):383–390 Hillard PJ Menstruation in adolescents: what’s normal, what’s not Ann N Y Acad Sci 2008;1135:29–35 O’Brien RF, Emans SJ Polycystic ovary syndrome in adolescents J Pediatr Adolesc Gynecol 2008;21:119–128 Paradise JE Evaluation of oligomenorrhea in adolescence UpToDate Version 17.2 http://www.uptodate.com Accessed October 13, 2009 The American College of Obstetricians and Gynecologists Practice bulletin: diagnosis of abnormal uterine bleeding in reproductive-aged women Obstet Gynecol 2012;120(1):197–206 Wiksten-Almstromer M, Hirschberg AL, Hagenfeldt K Prospective follow-up of menstrual disorders in adolescence and prognostic factors Acta Obstet Gynecol Scand 2008;87(11):1162–1168 Witchel SF, Oberfield S, Rosenfield RL, et al The diagnosis of polycystic ovary syndrome during adolescence Horm Res Paediatr 2015;83(6):376–389 ... menstrual cycle as a vital sign Pediatrics 2006;118:2245–2250 DiVasta AD, Emans SJ Androgen abnormalities in the adolescent girl In: Emans SJ, Laufer MR, Goldstein DP, eds Pediatric and Adolescent Gynecology... drugs known to cause hyperprolactinemia and galactorrhea ( Table 51.3 ) For the purposes of the emergency clinician, once pregnancy and life-threatening causes are ruled out, patients can be referred... their primary care physician, adolescent physician, or gynecologist for further evaluation If an Emergency Provider were to send additional labs to assist in the outpatient workup, the following