Hormones involved:

  1. Hypothalamus secretes GnRH which acts on pituitary
  2. Pituitary secretes FSH, LH, which acts on the ovary
  3. Action on the ovary depends on pattern of secretion
    1. Proliferative phase: FSH and LH cause follicle to secrete estrogen
    2. Ovulation: LH surge
    3. Secretory phase: LH acts on corpus luteum, which secretes estrogen and progesterone

Differential Diagnosis (the quick version)

Outflow tract obstruction



  1. H&P
  2. Pregnancy Test
  3. Serum Prolactin, TSH
  4. Serum FSH if low estrogen state suspected
  5. Progestin challenge
    1. (+) if menstruation-like bleeding
      1. what is the key question or history/physical
      2. depending on this factor, what tests do you order?
    2. (-) if minimal or no bleeding


CHLA Board Review Course 2005

Braverman PK Sondheimer, SJ: Menstrual Disorders. Pediatrics in
Review 18:17-26, 1977.
Kliegman RM et al: Practical Strategies in Pediatric Diagnosis and
Therapy. Philadelphia, WB Saunders, 1996.