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Oligo/amenorrhoea, hirsutism, acne, female infertility


Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Arrested puberty (16 years and over)
    • Suspected hypopituitarism
    • New onset virilisation in a female (hirsutism, acne, balding)
    • Serum testosterone >5nmol/l in a female
  • Category 2
    (appointment within 90 calendar days)
    • Delayed puberty (16 years and over)
    • Primary or secondary oligo/amenorrhoea
  • Category 3
    (appointment within 365 calendar days)
    • Biochemical hyperandrogenism and/or related clinical signs of acne and/or hirsutism without evidence of severe androgen excess
    • Polycystic ovarian syndrome as per Rotterdam criteria in the absence of any other explanation
    • All referrals for infertility (definition: - infertility is the failure to achieve pregnancy after 12 months or more of regular unprotected intercourse)

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • History including
    • family history of delayed puberty or hypogonadism.  History of chronic ill health or any medications
    • reproductive features (hirsutism, infertility and pregnancy complications), and
    • metabolic implications (insulin resistance, metabolic syndrome, IGT, T2DM and potentially CVD)

Infertility include

  • History of
    • previous pregnancies, STIs and PID, surgery, endometriosis
    • other medical conditions
  • Include the following information about partner
    • age and health, reproductive history, testicular conditions
  • Weight/ BMI
  • FBC, group and antibodies, rubella IgG, varicella IgG, syphilis serology, Hepatitis BsAg, HBC serology, HIV
  • FSH, LH (Day 2 - 5), prolactin, TSH if cycle prolonged and/or irregular
  • Day 21 serum progesterone level (7 days before the next expected period)
  • Endocervical swab or first catch urine for chlamydia +/- gonorrhoea NAA
  • Partner
    • Seminal analysis of partner (≥4 days of abstinence) report
    • Repeat in 4-6 weeks if abnormal

Polycystic ovarian disease investigations include

  • SHBG
  • Testosterone, DHEA-S
  • Fasting blood glucose
  • Lipids, TSH

Hirsutism investigations include

  • Fasting glucose, lipids
  • Testosterone, SHBG

Amenorrhea include

  • Duration of amenorrhoea (i.e. >6 months)
  • Weight/BMI
  • ßeta HCG
  • FSH, LH, prolactin, oestradiol, TSH

Delayed Puberty

  • Short stature screen
  • TFTs, renal function, FBC, ESR, or CRP, Anti TTG
  • Urinalysis
  • Chromosones (Karytope) in girls only (Turner Syndrome)
  • Bone age

3. Additional referral information Useful for processing the referral

  • Consider pelvic USS (day 1-4 menstrual cycle)(TVS preferable) TVS USS may not be appropriate in virginal young girls
  • If suspected hypopituitarism then check other anterior pituitary hormones e.g. prolactin, TSH, T4, morning (08:00-09:00) cortisol, ACTH, IGF1, growth hormone
  • Consider 08:00 17 (OH) progesterone for Congenital Adrenal Hyperplasia


  • History of marijuana use (including partner) or other relevant medications that contribute to infertility e.g. illicit drugs, steroids, chemotherapy

Delayed puberty

  • LH/FSH, Oestrogen or testosterone (highly desired)

4. Request

Last updated: 21 June 2023