MCQs on Amenorrhea

Written by Dr. Priya Menon (MBBS, FRANZCOG) – Obstetrician and Gynaecologist

Question 1

Angelina, accompanied by her mother, is in your office for consultation. She is 15 years old, and is concerned because she has not started her periods yet. She says: “I am about the same height as everybody else in my class at school. Their periods have started but mine not.” Which one of the following is the most appropriate initial question to ask her?

A) When she had her breast buds developed.
B) When she had her pubic hair.
C) Whether she gets cyclic abdominal pain.
D) Whether she had accelerated growth.
E) When she had her axillary hair.

Correct Answer: A) When she had her breast buds developed.

Explanation:
This case is about primary amenorrhea, which is defined as the absence of menses by age 16 in the presence of normal growth and secondary sexual characteristics, or by age 13–14 if secondary sexual characteristics are absent.

The first sign of puberty in girls is breast development (thelarche), typically occurring before the growth spurt and the appearance of pubic or axillary hair. Menarche usually follows within 2–3 years of breast budding. Therefore, determining whether breast development has occurred is the most appropriate initial step, as it indicates whether puberty has started and how far it has progressed.

Asking about other secondary sexual characteristics (pubic hair, axillary hair, growth spurt) is useful, but only after confirming that puberty has started. Cyclic abdominal pain may suggest an outflow obstruction, but this is relevant only if puberty and menstruation have already commenced.

Question 2

A 17-year-old girl is brought to your practice for evaluation because her periods have not started yet. She also complains of abdominal pain every month and about the same time. On examination, she has fully developed breasts and axillary and pubic hair. She does not consent to a vaginal exam. Which one of the following could be the most likely diagnosis?

A) Imperforated hymen.
B) Absent vagina.
C) Mullerian agenesis.
D) Turner syndrome.
E) Normal variant.

Correct Answer: A) Imperforated hymen.

Explanation:
This girl presents with primary amenorrhea, which is defined as the absence of menses by age 15–16 in the presence of secondary sexual characteristics or by age 13–14 if no secondary sexual characteristics are present. In her case, the presence of fully developed breasts and pubic/axillary hair indicates that puberty has occurred.

She also reports cyclical abdominal pain, which strongly suggests that endometrial shedding is happening, but outflow of menstrual blood is obstructed—a classic sign of imperforated hymen. This condition is one of the most common causes of outflow tract obstruction in adolescent girls.

Imperforated hymen occurs when the hymen fails to perforate during fetal development, resulting in trapped menstrual blood (hematocolpos). On physical examination (if performed), there may be a bulging bluish membrane at the vaginal introitus.

Option B (Absent vagina) and Option C (Müllerian agenesis) can cause primary amenorrhea but typically do not involve cyclic pain, since there is no functional uterus in most cases.
Option D (Turner syndrome) usually presents with short stature, streak gonads, and lack of secondary sexual development; cyclical pain is absent because menstruation never occurs.
Option E (Normal variant) is not applicable; lack of menstruation at age 17 with cyclic pain is not normal and requires evaluation.

Thus, the combination of developed secondary sexual characteristics, cyclical abdominal pain, and amenorrhea points most clearly to imperforated hymen.

Question 3

A 22-year-old woman presents with complaint of amenorrhea of one year duration. Her menses were regular before. She has no other complaints or symptoms. Physical examination is inconclusive. Pelvis ultrasonography is unremarkable. Thyroid function tests show a TSH of 3.5mU/L (0.5-5mU/L). Which one of the following is most likely to be the cause of her amenorrhea?

A) Mullerian agenesis.
B) Ovarian dysgenesis.
C) Hormonal dysfunction.
D) Hyperthyroidism.
E) Subclinical hyperthyroidism.

Correct Answer: C) Hormonal dysfunction.

Explanation:
Secondary amenorrhea is defined as cessation of periods after they have started. In contrast, primary amenorrhea is the lack of menstrual flow by age 14 with absence of secondary sexual characteristics or lack of menstrual flow by age 16 with presence of secondary sexual characteristics.

Since this woman had previous regular menstruation, she has secondary amenorrhea. Mullerian agenesis (option A) and ovarian dysgenesis (option B) cause primary amenorrhea and are unlikely here. Among uterine causes, only Asherman’s syndrome can cause secondary amenorrhea.

Hyperthyroidism (option D) can cause menstrual abnormalities like amenorrhea or oligomenorrhea; however, her normal TSH excludes hyperthyroidism. Subclinical hyperthyroidism (option E) is characterized by low TSH with normal T3 and T4, which is not present here.

Therefore, hormonal dysfunction is the most likely cause. This may include conditions such as pituitary tumors, hyperprolactinemia, ovarian insufficiency, or polycystic ovary syndrome (PCOS).

Previous Next

14. Gynecology Module

14.1 Abnormal Uterine Bleeding

14.2 Amenorrhea

14.3 Subfertility

14.4 Contraception

14.5 Menopause

14.6 Gynecological Oncology

14.7 Other Gynecological Disorders

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