What are the treatment options for hypothalamic amenorrhea?

Updated: Oct 14, 2019
  • Author: Kristi A Tough DeSapri, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG  more...
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Hypothalamic amenorrhea is most common in patients who exercise to excess and/or have eating disorders, caloric restriction, and psychogenic stress. Hypothalamic amenorrhea is best treated using behavioral modification and a multidisciplinary team approach, depending on the root cause.

An interdisciplinary team approach that involves nutritionists, clinicians, counselors, and family members is most effective. [60] After correcting the behavior that leads to hypothalamic amenorrhea, most women resume normal pulsatile release of GnRH and subsequent normal menstrual cycling. [60]

Women with severe anorexia nervosa may not resume normal menstrual cycling after weight gain. [61, 62] A BMI of less than 15 kg/m2 requires immediate intervention by an eating disorder specialist. Hospitalization may be indicated. This group of women may need hormone replacement and monitoring of bone density. [63] Weight gain may be the most important factor in bone recovery. [64] Gonadotropin therapy may be needed for conception.

Patients with hypothalamic amenorrhea caused by excessive exercise may refuse to correct or change their behavior. This is especially true for professional, competitive college, or elite athletes participating in "leanness" sports. Although controversial, consideration should be given to correcting their low estradiol (E2) level by prescribing oral contraceptives. [65, 66] Many athletes may request to use oral contraceptives continuously to limit or avoid menses. [67]

Functional hypothalamic amenorrhea due to stress is a diagnosis of exclusion. An occult eating disorder and caloric restriction must be ruled out as a compounding factor. [68] Behavioral modification is the first-line treatment. Although controversial, consideration should be given to correcting the low E2 by prescribing oral contraceptives. [65, 66] If oral contraceptive therapy is initiated, it can be intermittently stopped to determine if the GnRH pump has regained pulsatile function. An increase in BMI is associated with the best long-term recovery. [69]

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