Amenorrhea: Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps:

• General physical examination – including blood pressure, pulse, body weight, height; further:
  • Inspection (viewing).
    • Skin and mucous membranes [look for possible androgenization signs such as acne, hirsutism/male distribution pattern of terminal (long) hair]
    • Abdomen
      • Shape of the abdomen?
      • Skin color? Skin texture? [Look for possible androgenization signs such as acne, hirsutism/male distribution pattern of terminal (long) hair].
      • Efflorescences (skin changes)?
      • Pulsations? Bowel movements?
      • Visible vessels?
      • Scars? Hernias (fractures)?
  • Inspection and palpation (palpation) of the thyroid gland [goiter (thyroid enlargement)?]
• Gynecological examination
  • Inspection
    • Vulva (external, primary female sexual organs).
    • Vagina (vaginal) [in primary amenorrhea: exclusion of vaginal malformations, e.g., hymenal atresia (congenital malformation of the hymen in which the vagina is completely occluded by the hymen), vaginal aplasia, due toembryonically not created vagina]
    • Cervix uteri (cervix), or portio (cervix; transition from the cervix (cervix uteri) into the vagina (vagina)), if necessary, taking a Pap smear (for early detection of cervical cancer).
  • Palpation (bimanual; palpation with both hands) of the internal genital organs.
    • Cervix uteri (cervix).
    • Uterus (uterus) [Normal: anteflexed/angled anteriorly, normal size, no tenderness; in primary amenorrhea: exclusion of uterine malformations, eg. Mayer-von-Rokitansky-Küster-Hauser syndrome (MRKHS, synonym: Küster-Hauser syndrome; congenital malformation of the female genitalia (frequency is approximately 1:5,000) due to inhibition malformation of the Müller ducts in the second embryonic month. Ovarian function (estrogen and progestin synthesis) is not disturbed, allowing normal development of secondary sexual characteristics. In about 25% of affected women, there is only a strand of tissue (uterine ridge) at about the site where the uterus (womb) and vagina (vagina) normally lie. In some women, a vaginal pit of about 2-3 cm is present at the entrance of the vagina; in secondary amenorrhea: exclusion of a gravidity / pregnancy; Asherman syndrome (mechanically caused endometrial loss (uterine lining loss) as a result of forced curettage / uterine scraping after pregnancy; often, as a result, adhesion-related uterine obliterations / occlusions are also present].
    • Adnexa (appendages of the uterus, i.e., the ovary (ovary) and uterine tubule (fallopian tube)) [Normal: free]
    • Parametria (pelvic connective tissue in front of the cervix to the urinary bladder and on both sides to the lateral pelvic wall) [Normal: free].
    • Pelvic walls [Normal: free]
    • Douglas space (pocket-like bulge of the peritoneum (abdominal wall) between the rectum (rectum) at the back and the uterus (uterus) at the front) [Normal: clear].
  • Inspection of the mammae (breasts), right and left; nipple (breast), right and left; and skin [Normal: unremarkable; furthermore, note the following:
    • Galactorrhea/diseased breast milk discharge (due to hyperprolactinemia/elevation of blood prolactin levels);
    • In primary amenorrhea: assessment of the mammaries according to “Tanner’s pubertal development” (see below).
  • Palpation of the mammae, the two supraclavicular pits (upper clavicle pits) and axillae (axillae) [Normal: unremarkable].
• Health check

Square brackets [ ] indicate possible pathological (pathological) physical findings.Pubertal development according to Tanner (here: mamma/breast)