Endocrine Society issues guidelines to treat Functional Hypothalamic Amenorrhea (FHA).

Functional Hypothalamic Amenorrhea is a term used to describe amenorrhea that results from stress, imbalance between the energy intake and energy consumed by the body. These commonly occurs in athletes, ballet dancers, figure skaters, runners and women who have eating disorders, who burn more calories than what they eat.

In response, the hypothalamus gradually slows down or shuts off completely leading to decrease in pulsatile GnRH release, absent LH surge, absence of follicular development, low serum estrogen and anovulation.

The guidelines were published online on March 22,2017 in Journal of Clinical Endocrinology & Metabolism. The other societies which supports the guidelines are The American Society for Reproductive Medicine, the European Society of Endocrinology, and the Pediatric Endocrine Society.

The guidelines were developed by a task force of 8 medical experts, a medical writer and a methodologist. They looked at 2 systematic reviews and other evidence based guidelines in literature to formulate the current guidelines.

Untreated FHA of long standing can lead to infertility, delayed puberty, osteoporosis and stress fractures.

A diagnosis of HA is suspected in adolescent and women who have persistently 45 days between periods or who have amenorrhea of more than 3 months.

The summary of recommendations are as follows:

FHA is a diagnosis of exclusion. It should only be diagnosed after all the anatomic, organic or endocrine causes of amenorrhea are ruled out. 

The physician should perform a complete physical examination to rule out pregnancy as a cause of amenorrhea. A complete psychological evaluation including the drive to achieve perfectionism and need for social approval, ambitions and expectations for self is also necessary to address the psychosocial aspect of FHA.

A detailed diet history, exercise patterns and athletic training along with menstrual history should be elicited.

Initial Screening Laboratory tests should include serum beta HCG, CBC, electrolytes, liver function test, renal function tests and ESR.

Once the diagnosis is made the patients should be administered full endocrine evaluation including serum thyroid-stimulating hormone, free thyroxine, prolactin, luteinizing hormone, follicle-stimulating hormone, estradiol, and anti-Mullerian hormone.

A progesterone challenge test should be done to rule out structural abnormalities of genital tract.

A consultation with nutritionist is a very important form of treatment as regular cycles can be restored with more calories and proper diet.

A Brain MRI is often advised if patient complaints of persistent headache and visual problems to rule out pituitary adenoma.

Those adolescents or women with more than 6 months of amenorrhea should be tested for BMD with dual-energy X-ray absorptiometry.

These patients need an inpatient treatment if they have electrolyte imbalance, bradycardia or hypotension.

Patients who have had a fair trial with nutritional guidance, psychological treatment and exercise limitation should receive short-term transdermal E2 therapy with cyclic oral progestin.

Bisphosphonates, denosumab, testosterone, and leptin to improve bone mineral density is not advised in patients with FHA.

FHA patients wishing to conceive should undergo a complete fertility evaluation and treatment based on the results. Often cognitive behavioral therapy is very successful and restores ovulation and fertility without any medication.

Catherine M. Gordon of Cincinnati Children’s Hospital Medical Center in Cincinnati, Ohio, and the chair of the task force that authored the guideline said in a press release “This energy imbalance needs to be addressed to effectively treat hypothalamic amenorrhea and typically requires behavioral modifications. Referring patients to a nutritionist for specialized dietary instructions is an extremely important part of their care. Menstrual cycles can often be restored with increased calorie consumption, improved nutrition or decreased exercise activity.”