Endocrine Society Releases Guidelines for Functional Hypothalamic Amenorrhea

In advance of the Endocrine Society’s annual meeting this year in Orlando, Florida, the group has announced a new Clinical Practice Guideline for functional hypothalamic amenorrhea (FHA). The guideline, entitled, "Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline," is set to appear in the May 2017 issue of The Journal of Clinical Endocrinology and Metabolism.

The condition impacts women of reproductive age, and often female athletes or women with eating disorders, and can halt menstruation. It is the result of reduced release of GnRH, a hormone originating in the hypothalamus that controls the menstrual cycle, and a press release associated with the announcement places “ballet dancers, figure skaters, runners and others who burn more calories through exercise than they consume in their diet” at risk for it, and the report adds stress to the list of potential contributing factors.

In adolescents, the condition can delay puberty, and in chronic forms it can contribute to bone loss and osteoporosis, raising risk of fracture.

The guidelines break into three sets of suggestions regarding diagnosis, evaluation, and treatment. Recommendations in the report are weighted into four tiers by the quality of their supporting evidence, ranging from “very low quality” to “high quality.” They recommend seeking diagnosis “in adolescents and women whose menstrual cycle interval persistently exceeds 45 days and/or those who present with amenorrhea for 3 months or more,” and also screening potential FHA patients for psychological stressors.

After excluding pregnancy as a possible cause of halted menstruation, the guidelines recommend a further “diagnosis of exclusion,” to eliminate other possible causes, as well as laboratory tests to gauge blood count, hormone levels, and electrolytes. The guidelines also recommend obtaining a detailed personal history “with a focus on diet; eating disorders; exercise and athletic training; attitudes such as perfectionism and high need for social approval; ambitions and expectations for self and others; weight fluctuations; sleep patterns; stressors; mood; menstrual pattern; fractures; and substance abuse.” They also recommend a thorough family history that explores such grounds.

Other evaluative recommendations include MRI, bone mineral density measurements, and “progestin challenge in patients with FHA to induce withdrawal bleeding (as an indication of chronic estrogen exposure) and ensure the integrity of the outflow tract.”

In treatment, the report calls for a range of support, including psychological support. It discourages the use of oral contraceptives “for the sole purpose of regaining menses or improving BMD,” as well as against using bisphosphonates, denosumab, testosterone, and leptin to improve BMD in adolescents and women with the condition.

The guidelines also suggest physicians monitor FHA patients for abnormally slowed heart rate, low blood pressure, and electrolyte imbalance, underscoring the importance of such observation given a heightened mortality rate for those patients with the condition in conjunction with an eating disorder, particularly anorexia nervosa.

The report was cosponsored by American Society for Reproductive Medicine, the European Society of Endocrinology, and the Pediatric Endocrine Society, and was lead by Catherine M. Gordon of the Cincinnati Children’s Hospital in Ohio. It can be read online in advance of upcoming print publication.