Endocrine Society Issues Hypothalamic Amenorrhea Guideline

Marcia Frellick

March 30, 2017

The Endocrine Society has issued a new guideline on how to diagnose and treat hypothalamic amenorrhea, a condition that occurs when the hypothalamus slows or stops releasing gonadotrophin-releasing hormone (GnRH), leading to cessation of menstruation.

The condition often affects adolescent girls with low weight, low body fat, and emotional stress — ballet dancers, figure skaters, runners, and others who burn more calories through exercise than they consume are at risk for developing hypothalamic amenorrhea, as are those with eating disorders such as anorexia nervosa.

The guideline was published online March 22 and will appear in the May 2017 issue of the Journal of Clinical Endocrinology & Metabolism.

Treatment — to prevent bone loss, delayed puberty, and infertility, among other complications — requires medical, dietary, and mental-health interventions, says the task force that developed the guideline, chaired by Catherine M Gordon, MD, MSc, of Cincinnati Children's Hospital Medical Center in Ohio.

"This energy imbalance needs to be addressed to effectively treat hypothalamic amenorrhea and typically requires behavioral modifications," Dr Gordon notes in an Endocrine Society press release

A Diagnosis of Exclusion

Healthcare providers should consider a diagnosis of hypothalamic amenorrhea when evaluating adolescents or women who regularly have 45 days between periods or who haven't had a period in at least 3 months, the guideline says.

And it is a "diagnosis of exclusion," the guideline stresses, whereby the onus is on the healthcare provider to first exclude other conditions that could be interrupting the menstrual cycle.

After first ruling out pregnancy as a cause, a full physical exam should be performed, with initial evaluations including checks of estrogen, thyroid hormones, and prolactin.

Referring patients to a nutritionist is also an important part of care. Regular menstrual cycles often can be restored with proper nutrition, more calories, and less exercise, the researchers report.

And providers should rule out other conditions that could be interrupting the menstrual cycle, "including benign tumors in the pituitary gland and adrenal-gland disorders."

Some patients presumed to have the condition should have a brain MRI to check for pituitary-gland damage or low pituitary-hormone levels.

Providers should consider a brain MRI if the patient has had severe or persistent headaches; persistent vomiting that is not self-induced; changes in vision, thirst, or urination not linked to other causes; or signs suggesting central nervous system irregularities.

Inpatient treatment should be considered for hypothalamic amenorrhea patients if they have a slow heart rate, low blood pressure, or an electrolyte imbalance.

In these cases, careful monitoring is important because the mortality rate is high for patients who have hypothalamic amenorrhea as well as eating disorders — particularly anorexia nervosa — according to the researchers.

The task force commissioned two systematic reviews and used the best evidence from other published systematic reviews and individual studies.

The guideline was funded by the Endocrine Society. Cosponsoring bodies include the American Society for Reproductive Medicine, the European Society of Endocrinology, and the Pediatric Endocrine Society.

The Clinical Guidelines Subcommittee and the task force have reviewed all disclosures for this guideline and resolved or managed all identified conflicts of interest.

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J Clin Endocrinol Metab. Published online March 22, 2017.  Abstract



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