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The diagnosis of amenorrhea may be perplexing because of the sheer number of possible causes and the complexity of the structures involved (ie, the CNS-pituitary-ovarian axis). By using the same approach with all amenorrheic patients, rather than classifying them according to primary and secondary amenorrhea, physicians can narrow the diagnostic possibilities quickly and avoid unnecessary and expensive laboratory testing. Referral to a gynecologist or an endocrine specialist is recommended when the workup becomes overly complex.

The key to a successful infertility workup is to follow a protocol carefully and completely. After preliminary history taking and physical examination, tests are carried out systematically to investigate all possible ovulatory, cervical, tubal, and endometrial factors. A basal body temperature chart is essential for proper timing of tests, and a flow sheet helps keep track of results. Thorough evaluation of the man is also needed to identify possible causative factors.

Ovulatory dysfunction is a leading cause of female infertility in the United States. Fortunately, ovulatory dysfunction is often amenable to treatment. Thorough testing is necessary to identify the exact cause of anovulation before conventional ovulation-inducing therapy is started. Careful patient monitoring is essential to avoid risks such as the ovarian hyperstimulation syndrome. Several newer ovulation-inducing agents are available for use in special situations.

The anovulatory patient presents the primary care physician with what is often a diagnostic and therapeutic challenge. To meet this challenge and avoid doing a disservice to the patient, the physician needs to have both a firm understanding of the disease process and an adequate understanding of available treatment methods. Anovulation must be considered before it can be recognized. Once it is suspected, a thorough yet judicious approach to diagnosis must be undertaken. In these days of diagnosis-related groups (DRGs) and prospective reimbursement, a thoughtful, logical, cost-effective approach to the diagnosis of anovulation is more critical than ever. Finally, once the diagnosis is achieved, investigation of the etiologic factor can proceed in an orderly, stepwise fashion. There is no place for a shotgun approach in the work-up of the anovulatory patient. Even more important to the primary care physician is a firm understanding of when to refer. While straightforward aspects of the patient evaluation are best accomplished at the local level (indeed, the tertiary care center could not and should not try to cope with total referral), complex diagnostic and therapeutic regimens should be handled by the reproductive endocrinologist. Patients with hyperprolactinemia, those who have failed ovulation induction with clomiphene citrate (Clomid), those with suspected outflow tract anomalies, and hypoestrogenic patients surely should be evaluated and treated in consultation with the specialist. This approach of careful, efficient initial assessment coupled with appropriate use of the reproductive endocrinologist and tertiary referral center leads to optimum care of the anovulatory patient.

Dysfunctional uterine bleeding is not a specific diagnosis. It encompasses a spectrum of endocrinologic dysfunction which must be considered in reference to the presence or absence of ovulation. Specific causes must not be forgotten, particularly in those women who do not respond as expected to hormonal therapy. A variety of empiric therapies are used which have no benefit, such as thyroid hormone in the absence of proven hypothyroidism, corticosteroid in the absence of proven adrenal hypofunction, and megavitamin therapies in the absence of nutritional disorders. Curettage is valuable for diagnosis, not for therapy. Medical therapy offers a successful alternative to hysterectomy in many women, but the choice must be made on an individual basis. Medical and surgical management should not be viewed as competitive treatment regimens.