Long-term assessment of genital reconstruction in female pseudohermaphrodites

Vaginoplasty and creating labia minora in children with disorders of sex development

PURPOSE

To report current results of vaginoplasty using the mucosa of the prepuce, and creating labia minora by penile skin in children with disorders of sex development (DSD).

METHODS

In 10 years, we have performed 22 vaginoplasties using the described technique of vaginoplasty, 21 patients with 46, XX DSD and 1 ovotesticular DSD. The assessment of the results of this technique of vaginoplasty was undertaken in several stages: (a) The evaluation of the cosmetic result. (b) The research for a urinary incontinence and urethrovaginal fistulas. (c) The research for a vaginal stenosis by the introduction of a lubricated feeding tube into the vaginal cavity. The labia minora was evaluated by three criteria: its skin should be thin and very supple, it should have a free edge which partially or totally covers the clitoris, urethral meatus, and vaginal orifice; and it is preferable that its color be darker than the rest of the skin.

RESULTS

The cosmetic outcome was considered by parents and the surgeon as very satisfactory in 11 patients (50% of cases), satisfactory in 4 patients (18.2%), and unsatisfactory in 7 patients (31.8%). The postoperative complications were five cases of proximal stenosis (22.7%), one distal stenosis (stenosis of introitus) and two necrosis of the preputial flap. No urethrovaginal fistula and urinary incontinence were reported.

CONCLUSIONS

In infant and young child, when it is difficult to make use of complete urogenital mobilization, the mucosa of the prepuce can be an alternative to create a neovagina, its histological constitution is identical to a vaginal wall, and it does not prevent to have a good labia minora.

Vaginoplasty using the inner surface or mucosa of the prepuce in children with congenital adrenal hyperplasia

OBJECTIVE

To describe and present the results of the use of the inner surface or mucosa of the prepuce in vaginoplasty for ambiguous genitalia.

PATIENTS AND METHODS

This technique can be used alone in low vaginal insertion or associated with a total urogenital mobilization in cases of high vagina. During the past 7 years, we have performed 18 vaginoplasties using the described technique in 46, XX DSD (female pseudohermaphroditism). All patients had 21-hydroxylase deficiency; four had the simple virilizing form and 14 had additional salt loss. The age of the patients at surgery varied from 4 to 28 months (average 11.2).

RESULTS

The final cosmetic results were considered good by the parents and surgeon for the majority of our patients, and satisfactory in three cases. Clinical examination revealed stenosis of vaginal introitus in only one patient (which responded very well to one dilatation) and one urethra-vaginal fistula.

CONCLUSION

This technique of vaginoplasty, simple in its realization and answering the purpose of treatment with few complications, can be used in the feminizing genitoplasty of young children with 46,XX DSD, ovotesticular DSD (true hermaphroditism), mixed gonadal dysgenesis and dysgenetic male pseudohermaphroditism.

Feminizing genital reconstruction in congenital adrenal hyperplasia

The past several decades have seen multiple advances in the surgical reconstruction for girls born with Disorders of Sexual Differentiation. This surgery can be technically very demanding, and must be individualized for each patient, as the degree of virilization and level of confluence of the vagina and urogenital sinus will dictate the surgical approach.

In this manuscript we present our approach and experience in the surgical options for girls born with Congenital Adrenal Hyperplasia, with special attention regarding clitoroplasty, urogenital mobilization, and vaginoplasty.

Long-term functional outcomes of female genital reconstruction in childhood

There are two very interesting paediatric urology papers; in the first, authors from London describe the long-term functional outcomes of female genital reconstruction in childhood, and in the second, authors from Italy present a morphological and manometric study of VUR.

Fertility in patients with congenital adrenal hyperplasia

Congenital adrenal hyperplasia (CAH) is generally regarded as a paediatric endocrine disease, but nowadays nearly all patients reach adulthood as a result of improved diagnosis and treatment. It is now increasingly recognised that treatment goals shift during life: one of the major treatment goals in childhood and puberty, i.e. normal growth and development, is no longer relevant after childhood, whereas other aspects, such as fertility and side effects of long-term glucocorticoid treatment, become more important in adulthood. This paper focuses on fertility in male and female adult patients with CAH. In males with CAH the fertility rate is reduced compared with the normal population, the most frequent cause being testicular adrenal rest tumours. Development and growth of these tumours is assumed to be ACTH dependent and undertreatment may play an important role. If intensifying glucocorticoid treatment does not lead to tumour decrease, surgical intervention may be considered, but the effect on fertility is not yet known. In females with CAH the degree of fertility depends on the phenotype of the CAH. Most fertility problems are seen in the classic salt-wasting type. Age of menarche and regularity of the menstrual cycle depends on the degree of adrenal suppression. Not only adrenal androgens have to be normalised but also the levels of adrenal progestins (progesterone and 17-OH-progesterone) that interfere with normal ovulatory cycles. The regularity of menstrual cycles can be considered as an important measure of therapeutic control in adolescent females with CAH and therefore as a therapeutic goal from (peri)pubertal years on. Other factors that contribute to impaired fertility in females with CAH are ovarian hyperandrogenism (polycystic ovary syndrome), ovarian adrenal rest tumours, genital surgery and psychological factors. Subfertility in CAH can have its origin already in the peripubertal years and is therefore of interest to the paediatric endocrinologist.

[Feminizing genitoplasty and congenital adrenal hyperplasia: analysis of anatomical results]

OBJECTIVE

To evaluate the anatomical and cosmetic results of feminizing genitoplasty in girls with ambiguous genitalia due to Congenital Adrenal Hyperplasia (CAH).

CASUISTIC AND METHOD

Twenty-seven females with genital ambiguity (Prader III-V) due to CAH underwent an one-stage feminizing genitoplasty and were followed for a mean time of 4 years. In twelve girls, two cutaneous labioscrotal island-flaps were associated with the conventional genitoplasty, to decrease the excess of labia majora and to enlarge the vaginal introitus. Urinary tract infections were observed in sixteen girls in the preoperative and in only seven in the postoperative period. The cosmetic results were obtained by the systematic anatomical evaluation of the different structures that compose the genitalia.

RESULTS

The results of clitoroplasty were considered good in 63% of the cases; however, 4 girls developed clitoral atrophy. An excess of labia majora was present in 25% and persistence of the urogenital sinus occurred in 11% (three children without labioscrotal island flap). The labioscrotal island flap was considered technically feasible and reproducible. Five girls had to be re-operated. The cosmetic results were considered excellent or good in 63% of the cases, satisfactory in 18.5% and unsatisfactory or bad in 18.5%.

CONCLUSIONS

The anatomical and cosmetic results were good in majority of the cases; however, some technical aspects should be adjusted, to avoid irreversible sequels and re-operations.

Cosmetic and anatomic outcomes after feminizing surgery for ambiguous genitalia

BACKGROUND

Reports on anatomic and cosmetic outcomes after genital surgery for children with ambiguous genitalia are mixed, with recent reports using standardized assessments suggesting poor outcomes and that multiple operations may be required.

METHODS

All children with ambiguous genitalia and who had feminizing surgery at the Royal Children's Hospital in Melbourne, Australia, were identified. Standardized genital assessment was undertaken at their clinical review after informed consent. Underlying diagnosis, number and type of procedures performed, and the expertise of the surgeon were recorded from their medical notes.

RESULTS

Of 32 patients examined aged 13 to 33 years, 47% had congenital adrenal hyperplasia. Ten patients had initial surgery performed elsewhere. Overall, there were good anatomic and cosmetic outcomes for those initially treated at our institute by a specialized surgeon, although some required additional intervention in adolescence or adulthood. Initial surgery before or after 2 years of age did not significantly affect outcomes. Those patients who had only 1 operation (by a surgeon with special interest in intersex) had better cosmetic and anatomic outcomes than those patients who had multiple operations.

CONCLUSIONS

Cosmetic and anatomic outcomes of surgery for ambiguous genitalia were generally good when undertaken by pediatric surgeons with specific expertise in intersex surgery.

PASSERINI-GLAZEL FEMINIZING GENITOPLASTY: A LONG-TERM FOLLOWUP STUDY

PURPOSE

We report our experience with early 1-stage Passerini-Glazel feminizing genitoplasty with special emphasis on long-term results of vaginoplasty.

MATERIALS AND METHODS

A total of 66 patients with ambiguous genitalia underwent 1-stage Passerini-Glazel feminizing genitoplasty. Long-term followup included an outpatient visit at 1 year postoperatively and a genital assessment with the patient under general anesthesia performed before menarche courses in those operated on at age 6 months to 8 years, and at 2 years postoperatively for those operated on at 9 years or older.

RESULTS

All patients underwent the first long-term followup evaluation and no major complications were observed. The second long-term followup evaluation was performed in 46 patients (70%). In all cases the vaginal introitus was located in the physiological position and was large and elastic. Vaginal caliber at the suture line between the tubularized flap and vaginal mucosa was the same size as the vaginal introitus and distal native vagina in 20 of 46 patients (43%), slightly smaller in 10 (22%) and stenotic in 16 (35%). Stenosis at the suture line was corrected with simple Y-V introitoplasty performed at the same followup visit.

CONCLUSIONS

Early 1-stage Passerini-Glazel feminizing genitoplasty is a safe and effective procedure that allows total surgical correction of ambiguous genitalia in infancy and good cosmetic results. Incidence of vaginal stenosis at the suture line is high but it can be repaired with simple introitoplasty performed before menarche occurs. Good functional results are presumed.

Psychosexual outcome in women affected by congenital adrenal hyperplasia due to 21-hydroxylase deficiency

PURPOSE

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency results in increased adrenal androgen secretion. When the deficiency is severe, the result is the salt losing (SL) form, and when the deficiency is partial, the result is the simple virilizing (SV) form of CAH. We documented long-term satisfaction with gender, cosmetic appearance and function of the genitalia, and surgical management practices in a group of women with CAH due to 21-hydroxylase deficiency.

MATERIALS AND METHODS

Psychosexual and surgical outcome were assessed in 41 women with CAH using an interview, a written questionnaire and a physical examination. When appropriate, outcome measures were compared to those in unaffected control women.

RESULTS

Women in the SL group were more likely to question their female gender and report sexual concerns, and less likely to have sexual relations with a partner than those with the SV form or control women. Overall women with CAH were moderately satisfied with the cosmetic appearance of the genitalia but the SL group reported worse genital function than the SV group. Physician rated appearance of the genitalia was better than ratings provided by patients and women with the SL form were judged to have a worse cosmetic outcome of genital reconstruction than women with the SV form. The most common response concerning the optimal timing for genital reconstruction was during infancy and early childhood, although a number of women favored waiting until later for these procedures or did not respond to this question.

CONCLUSIONS

Women with the SV form reported greater satisfaction and fewer concerns regarding their psychosexual and surgical outcome than women with the SL form.

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency--the adult woman

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is a disease with a varying phenotype depending on the mutation(s) present and the severity of the disease. All children with CAH need to be continuously cared for from birth or early infancy by specialists in paediatric endocrinology and surgery. Complications due to over- or under-treatment with corticosteroids are often seen during adolescence, and these problems often continue into adulthood. For the young woman with CAH, questions about menstruation, sexuality, fertility and the possible necessity of complementary surgery are always important issues that need to be discussed. To meet the needs of the young woman with CAH, it is important that the transition from paediatric to adult care be a process of parallel consultations over several years, always involving an experienced gynaecologic endocrinologist.

Anatomical studies of the female genitalia: surgical reconstructive implications

Surgery for patients with genital ambiguity must be based on an accurate diagnosis, thorough understanding of the genital anatomy and realistic expectations for the patient, family and treating multi-specialty team. The goal is to create a functional and cosmetic outcome consonant with the gender assignment with the least amount of morbidity to the patient and family. An understanding of the normal genital neuroanatomy is essential for a successful surgical approach and outcome. Based on fetal human specimens, we have refined the three-dimensional relationship of the dorsal nerve of the clitoris, the female cavernosal nerve and the vaginal plexus. The surgical approach to patients with severe clitoral virilization should preserve erectile function and the neural innervation of the clitoris. When indicated, surgery should be performed in infancy to minimize psychological trauma and surgical complications from scarring. Herein, we review the neuroanatomy of the female genitalia and the implications for the rare patient who needs surgical reconstruction.

Pregnancy outcomes in women with congenital virilizing adrenal hyperplasia

Although low fertility rates have traditionally been reported among women with classic CAH and especially among women with the salt-wasting variant, more recent data suggest that fertility rates are significantly improved, largely owing to earlier treatment of CAH, improved compliance with therapy, and surgical advances in genital reconstruction. Furthermore, ovulation induction and assisted reproductive techniques are now available to women who remain infertile despite effective adrenal androgen suppression. Although the pregnancy experience in women with classic CAH remains limited, it is apparent that, once pregnant, these women have a high probability of successful outcome. Key issues should be emphasized in the management of CAH during gestation, including the need for assessing adrenal steroid replacement and adrenal androgen suppression, particularly in light of the interplay between maternal hyperandrogenism and the protective effect of placental aromatase activity, which provides a relatively large margin of safety for the female fetus. Maternal hormone levels should be evaluated in the context of laboratory-specific reference ranges for pregnancy. The infant should be examined for ambiguous genitalia and monitored for evidence of adrenal insufficiency. Although an affected female infant with classic CAH has not been reported as a pregnancy outcome of a mother with classic virilizing CAH, these concerns should be discussed during preconception counseling. Patients should also be aware of the importance of medication compliance and careful hormonal monitoring during the entire pregnancy. In most cases, successful gestational management requires the close coordination of care between the obstetrician and endocrinologist.

Long-term follow-up of female patients with congenital adrenal hyperplasia from 21-hydroxylase deficiency, with special emphasis on the results of vaginoplasty

OBJECTIVE

To assess, in a long-term follow-up, female patients with congenital adrenal hyperplasia (CAH), with special emphasis on vaginal functional outcome and sexual activity after vaginoplasty.

PATIENTS AND METHODS

Twenty-seven patients with CAH (aged 14-33 years; six Prader grade II, 14 grade III, six grade IV and one grade V) underwent surgery between 1972 and 1988. Three of the patients underwent clitoridectomy, 24 clitoroplasty and 25 vaginoplasty (24 with a Fortunoff flap and one a 'pull-through' procedure). In 20 patients the vaginoplasty was a one-stage procedure, undertaken at a mean (range) age of 3.6 (1-9) years, and in five patients a two-stage operation. The analysis was based on the patients' history and examination; the patients also completed a questionnaire, including a psychological profile.

RESULTS

Nine of the 25 patients (36%) who underwent vaginoplasty developed intravaginal stenosis; of these nine, six were Prader grade III and three grade IV. All had undergone a single-stage procedure at a mean (range) age of 4.7 (2-9) years. Of the 16 patients who answered the questionnaire, 14 had problems with their overall body image; patients in whom vaginal stenosis was corrected were particularly anxious about sexual intercourse and had problems with orgasm.

CONCLUSION

The main problem during the long-term follow-up was intravaginal stenosis; all the affected patients had undergone a single-stage procedure early in life to correct ambiguous genitalia. This high rate of vaginal stenosis suggests that vaginoplasty should be undertaken at the beginning of puberty, because higher oestrogen levels may prevent stenosis and, if necessary, dilatation can be performed by the patient. These data also underscore the importance of psychological support in the treatment of children with CAH.

Pediatric management of ambiguous and traumatized genitalia

PURPOSE

The present standard of practice in the management of ambiguous and traumatized genitalia was evaluated.

MATERIALS AND METHODS

Published cases of intersexuality and protocols for the management of traumatized genitalia were reviewed with consideration of the input of intersexual individuals. Independent research on different types of intersexuality is also presented.

RESULTS

The present standard pediatric recommendations and precepts for the management of ambiguous or traumatized genitalia are wanting. Followup studies on which to base treatment decisions are needed. Evidence based principles of medical management are proposed.

CONCLUSIONS

A moratorium on sex reassignment cosmetic surgery is recommended. Also recommended are that followup studies should be instituted on past cases, and honesty and counseling should be the core of initial and subsequent treatment.

Pediatric management of ambiguous and traumatized genitalia

PURPOSE

The present standard of practice in the management of ambiguous and traumatized genitalia was evaluated.

MATERIALS AND METHODS

Published cases of intersexuality and protocols for the management of traumatized genitalia were reviewed with consideration of the input of intersexual individuals. Independent research on different types of intersexuality is also presented.

RESULTS

The present standard pediatric recommendations and precepts for the management of ambiguous or traumatized genitalia are wanting. Followup studies on which to base treatment decisions are needed. Evidence based principles of medical management are proposed.

CONCLUSIONS

A moratorium on sex reassignment cosmetic surgery is recommended. Also recommended are that followup studies should be instituted on past cases, and honesty and counseling should be the core of initial and subsequent treatment.

Functional, social and psychosexual adjustment after vaginal reconstruction

PURPOSE

We assessed the long-term functional, social and psychosexual outcome in children who underwent vaginal reconstruction.

MATERIALS AND METHODS

We interviewed and assessed the psychological development of 16 women 17 to 28 years old (mean age 22) who underwent vaginal reconstruction only or in combination with other urogenital reconstructive procedures at ages 11 months to 18 years (mean 8.8). Psychological measures included the Beck Depression Inventory, Draw-a-Person test and Linkowski acceptance of disability scale as well as a standard questionnaire evaluating the sexual adjustment, social adjustment and ability for self-support of these women.

RESULTS

Mean Beck Depression Inventory was 8.5 with less than 9 defined as minimal depression. Mean acceptance of disability score was 83.9 (range 54 to 94), indicating that patients were well adjusted with respect to the disability. Functionally 10 women were satisfied with the appearance of the vagina, 4 were neutral and 2 were dissatisfied. A total of 12 patients had no doubts about their female identity but 2 had occasional, 1 had significant and 1 had chronic doubts. Of the 16 patients 12 have completed high school, 3 are still in high school and 1 has withdrawn from high school. Of the 12 women who have completed high school 9 are currently in college and 3 have completed college. Socially all 16 participants rated family relationships as good and 13 were at least satisfied with their social life. Of the 16 women 12 have had a sexual encounter, including 1 who did not achieve orgasm. Six women are involved in long-term relationships, of whom 1 is married. In regard to the future all patients believe that they will be independent and financially stable with a fulfilling career.

CONCLUSIONS

While women who have undergone vaginal reconstruction may be at risk for avoiding interpersonal relationships and sexual intimacy, we did not note this finding in our series. The majority of these patients were well adjusted to their physical condition, and had a high level of education and a stable family life.

Late results of operative treatment of intersexuality in children with advanced hypospadias and simultaneous cryptorchidism

In a group of 52 patients operated on for advanced hypospadias with cryptorchidism 42% showed signs of intersexuality. The problem of operative sex determination was stressed. The social adaptation of those children during growing up was also observed.

Ambiguous genitalia: diagnosis, evaluation, and treatment

The pediatric radiologist plays a significant role in the evaluation and the treatment of infants with ambiguous genitalia. On the first day of life, an investigation should be initiated that includes studies, in particular a sonogram, to demonstrate the presence or absence of a uterus, and a genitogram to define the presence of a vagina. Once gender assignment has been made, information regarding the size of the vagina and its position in regard to the urogenital sinus becomes essential to the pediatric urologist when planning a course for reconstruction. Herein we break down intersex states into four major categories: female pseudohermaphroditism, male pseudohermaphroditism without müllerian structures, and male hermaphroditism with müllerian structures and true hermaphroditism. The role of the radiologist in each of these states is discussed.

The surgical management of infants and children with ambiguous genitalia. Lessons learned from 25 years

Over a 25-year period, 91 children with ambiguous genitalia have received surgical management. Female sex assignment was made for 79. Of these, 60 patients underwent extensive clitoral reconstruction consonant with the female assignment. Forty-two patients had vaginal reconstruction. Factors relating to success include: (1) prompt and appropriate sex assignment; (2) early and accurate diagnosis; (3) conservative reconstruction of the clitoris at an early age (less than 1 year); and (4) choice of vaginal reconstruction based on the severity of the malformation. Long-term follow-up demonstrates satisfactory anatomic and functional results when clitoral surgery alone was required. Functional results for patients with extensive vaginal reconstruction have been compromised. Physicians caring for children with congenital intersexual anomalies can expect to encounter a wide spectrum of anatomic and physiologic derangements. Cosmetic appearance alone is an inadequate measure of success because endocrinologic, social, psychological, and sexual factors must be blended into comprehensive evaluation of these patients. The management plan must be flexible and individualized, incorporating long-term follow-up to adulthood.

Functional results in young women having clitoral reconstruction as infants

Nine young women who had clitoral recession for clitoromegaly as infants have been evaluated for anatomical appearance, psychosocial adjustment, and sexual function. Highly satisfactory anatomic results were obtained, although two patients required subsequent revision. The tested psychological parameters were essentially normal. Virtually all patients were sexually active and all but one have achieved regular painless orgasm. Surgical reconstruction has been accomplished by recessing the entire disfigured clitoris, thereby conserving all erectile tissue and preserving sensation. In addition to assessment of anatomical appearance, long-term follow-up of children with ambiguous genitalia requires regular evaluation of social, psychological, and sexual parameters.

Congenital adrenal hyperplasia: long-term results following vaginal reconstruction

Forty-two women with virilizing congenital adrenal hyperplasia who had attempted coitus were studied retrospectively a mean of 23.6 years after vaginal repair. Satisfactory intercourse, as defined by the patient, was observed in 62% of the subjects. The functional success rate was higher if repeat operations were performed after the age of 16 years (61% versus 12%, P less than 0.05) or if the patient suffered from the non-salt-losing variety of the disorder (87% versus 46%, P less than 0.05). The outcome of the initial attempt to exteriorize the vagina did not differ significantly by age at surgery. In cases of moderate virilization, vaginal repair may be delayed until the patient's menarche, maturity, and desires for sexual activity are well established. Clitoroplasty should be performed as soon as possible.

Trends in conservative clitoroplasty

The authors present their trends in conservative clitoroplasty on the basis of 27 cases from January 1980 to August 1985. The technique described preserves as much of clitoral tissue as possible, and gives safe and very satisfying morpho-functional results regardless of the virilization degree. Preserved skin of clitoral shaft and of the foreskin is used to reconstruct labia minora. Erectile function is preserved by freeing and burying corpora cavernosa in the omolateral labial region. Clitoral glans, suitably trimmed when necessary, is preserved on its ventral muco-cutaneous pedicle.

Vaginal amplification using a posterolateral Y-V plasty

Problems encountered in attempts to construct a normal vaginal orifice in girls with congenital adrenal hyperplasia have met with great difficulty. Many procedures are complicated by failure to achieve adequate patency at the time of operation and/or by postoperative stenosis. The usual method of direct posterior Y-V vaginoplasty has been altered by bringing the V flap in from the side of the perineum, between the inferior aspect of the labium majus and the median perineal raphe. Thereby, a thicker, large, more pliable and more moveable flap is obtained. The 11 children on whom this method was done are presented. Followup is from 6 months to 5 1/2 years. The importance of teaching the parents or child the use of home vaginal dilation with Hegar dilators is stressed. Th use of this surgical technique plus home dilation will overcome the problems of restenosis in this group of children.

A new and simplified method for concealing the hypertrophied clitoris

Current surgical procedures that are utilized in the management of patients with an enlarged clitoris are both complex and challenging. We report a new method of concealing the hypertrophied clitoris between the labia majora instead of resorting to the more difficult clitoral amputation or recession. This concealment of the clitoris is simple, may be done on an outpatient basis, and accomplishes the goal of creating normal-appearing female external genitalia.

Diagnosis and management of hydrometrocolpos in infancy

Three cases of hydrometrocolpos in infants are presented, which demonstrate that despite thorough documentation of the clinical findings, the misdiagnosis and the ensuing mismanagement of this condition remain a problem. The presence of other genitourinary abnormalities and the association with anomalies of the anorectal area make it imperative that these infants be evaluated, treated and followed by clinicians who are skilled in these areas. Introital revision may proceed at an early age to avoid the necessity of repeated drainage procedures and allow normal voiding but close followup is necessary.

Subcutaneous reduction clitoroplasty

Congenital clitoral hypertrophy should be corrected in infancy. Most surgeons perform a total clitroectomy or one of several kinds of clitoral recession procedures. There are some reasons for dissatisfaction with both of these alternatives. An operation in which the corpora cavernosum are resected subcutaneously and the glans sutured to the pubis preserves blood supply and sensation and results in a perineal appearance close to normal. The author has performed this operation infive cases of clitoral hypertrophy associated with adrenogenital syndrome and suggests a wider trial of procedure.

The diagnosis and treatment of amenorrheas

Correct diagnosis and treatment of amenorrhea is a challenging problem to the clinician. A systematic approach to the differential diagnosis and treatment, based on functional activity along the hypothalamic-pituitary-ovarian axis, is presented. By obtaining a detailed history, performing a meticulous physical examination, and utilizing several simple clinical and laboratory tests, a correct diagnosis can be reached for the majority of patients. Treatment is relatively simple and geared to the patient's desires. In most instances, understanding of the basic problem helps the patient to cope with it and no treatment is needed. If lack of menses is a problem, cyclic bleeding at regular intervals can be induced. When fertility is a problem, ovulation can be induced, provided that there is no ovarian failure. By spending sufficient time with the patient, paying attention to detail, and giving some thought, a correct diagnosis can be reached and adequate treatment given to most amenorrheic patients.