Evaluation of the anovulatory patient. When to proceed, when to refer

The anovulatory patient presents the primary care physician with what is often a diagnostic and therapeutic challenge. To meet this challenge and avoid doing a disservice to the patient, the physician needs to have both a firm understanding of the disease process and an adequate understanding of available treatment methods. Anovulation must be considered before it can be recognized. Once it is suspected, a thorough yet judicious approach to diagnosis must be undertaken. In these days of diagnosis-related groups (DRGs) and prospective reimbursement, a thoughtful, logical, cost-effective approach to the diagnosis of anovulation is more critical than ever. Finally, once the diagnosis is achieved, investigation of the etiologic factor can proceed in an orderly, stepwise fashion. There is no place for a shotgun approach in the work-up of the anovulatory patient. Even more important to the primary care physician is a firm understanding of when to refer. While straightforward aspects of the patient evaluation are best accomplished at the local level (indeed, the tertiary care center could not and should not try to cope with total referral), complex diagnostic and therapeutic regimens should be handled by the reproductive endocrinologist. Patients with hyperprolactinemia, those who have failed ovulation induction with clomiphene citrate (Clomid), those with suspected outflow tract anomalies, and hypoestrogenic patients surely should be evaluated and treated in consultation with the specialist. This approach of careful, efficient initial assessment coupled with appropriate use of the reproductive endocrinologist and tertiary referral center leads to optimum care of the anovulatory patient.