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.”
