Melanie Cree, MD, PhD, on multidisciplinary approaches for evaluation, management of menstrual disorders in teens

Melanie Cree, MD, professor in pediatric endocrinology at the University of Colorado Anschutz Medical Campus and practicing physician at Children’s Hospital Colorado, discussed approaches to evaluating primary amenorrhea and managing conditions such as Turner syndrome, polycystic ovary syndrome (PCOS), and the female athlete triad.

Initial evaluation for primary amenorrhea

Cree emphasized that pregnancy should always be excluded first. “That’s the number one cause of amenorrhea in females,” she said. Following this, clinicians should assess ovarian function. “So you check an FSH, and then you can check a prolactin and a thyroid hormone,” she noted.

Additional testing is guided by history and physical examination. For example, if Turner syndrome is suspected, karyotype testing and antimüllerian hormone measurement may be indicated. “If everything was normal, you may then consider adding on testosterone, sex hormone binding globulin…you would also want to rule out an adrenal tumor with DHEAS and late onset congenital adrenal hyperplasia,” Cree explained.

Pelvic ultrasound is used rarely in this workup, reserved for suspected outflow obstruction or chromosomal abnormalities affecting genitalia.

Role of multidisciplinary clinics

Cree highlighted the benefits of multidisciplinary clinics in conditions affecting ovulation and menstrual health. “Certainly, a multidisciplinary approach is really the best approach for many kinds of female conditions where they affect multiple systems,” she said. At her institution, Turner syndrome, female athlete, and PCOS clinics include dietitians, physical therapists, psychologists or social workers, and gynecologists, in addition to endocrinology specialists.

Patient-driven management in PCOS

Management of PCOS in adolescents often depends on patient concerns. “With the exception of making sure that we keep their endometrium healthy…pretty much everything is driven by the patient,” Cree stated.

• For bothersome hair growth: estrogen therapy or spironolactone
• For acanthosis nigricans: metformin
• For menstrual regulation: cyclic estrogen and progesterone

In athletes, the focus is on nutrition and caloric balance, with attention to exercise load and avoidance of overtraining.

Fertility considerations

All conditions discussed can impact long-term fertility, with variation by diagnosis. “Turner’s is the most in that 80% of girls don’t even have menarche,” Cree said. Families often raise fertility concerns early in the diagnostic process.

For PCOS, fertility conversations require sensitivity. “We need to be really careful when we bring up the fertility in PCOS, we really don’t know in adolescents what their individual prognosis is going to be,” she said. “As an adolescent, all they can do is take care of their general health, and they’ll have to see where they are down the line.”

For the female athlete triad, restoring adequate caloric intake and menstrual regularity supports better fertility outcomes. Fertility counseling is most direct when the prognosis is poor, such as in Turner syndrome or some disorders of sexual differentiation.

Disclosure: Cree reports no relevant disclosures

Reference:

Cree M. Evaluation and Management of Menstrual Disorders in Teens. Presentation. Presented at: American Academy of Pediatrics 2025 National Conference & Exhibition. September 26-30, 2025. Denver, Colorado.