Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline

Catherine M. Gordon; Kathryn E. Ackerman; Sarah L. Berga; Jay R. Kaplan; George Mastorakos; Madhusmita Misra; M. Hassan Murad; Nanette F. Santoro; Michelle P. Warren


J Clin Endocrinol Metab. 2017;102(5):1413-1439. 

In This Article

Method of Development of Evidence-based Clinical Practice Guidelines

The Clinical Guidelines Subcommittee of the Endocrine Society deemed an enhanced understanding and management of FHA to be a priority area in need of practice guidelines and appointed a task force to formulate evidence-based recommendations. The task force followed the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group, an international committee with expertise in the development and implementation of evidence-based guidelines.[1] A detailed description of the grading scheme has been published elsewhere.[2] The task force used the best available research evidence to develop the recommendations. The task force also used consistent language and graphical descriptions of both the strength of a recommendation and the quality of evidence. In terms of the strength of a recommendation, strong recommendations use the phrase "we recommend" and the number 1, and weak recommendations use the phrase "we suggest" and the number 2. Cross-filled circles indicate the quality of the evidence, such that ⊕○○○ denotes very low quality evidence;⊕⊕○○, low quality;⊕⊕⊕○, moderate quality; and ⊕⊕⊕⊕, high quality. The task force has confidence that persons who receive care according to the strong recommendations will derive, on average, more good than harm. Weak recommendations require more careful consideration of the person's circumstances, values, and preferences to determine the best course of action. Linked to each recommendation is a description of the evidence and the values that the task force considered in making the recommendation; in some instances, there are remarks, a section in which the task force offers technical suggestions for testing conditions, dosing, and monitoring. These technical comments reflect the best available evidence applied to a typical person being treated. Often this evidence comes from the unsystematic observations of the task force and their values and preferences; therefore, one should consider these remarks as suggestions.

In this guideline, the task force made several statements to emphasize the importance of shared decision making, general preventive care measures, and basic principles of FHA treatment. They labeled these "Ungraded Good Practice Statement." Direct evidence for these statements was either unavailable or not systematically appraised, and thus considered out of the scope of this guideline. The intention of these statements is to draw attention and remind providers of these principles; one should not consider these statements as graded recommendations.[3]

The Endocrine Society maintains a rigorous conflict-of-interest review process for developing clinical practice guidelines. All task force members must declare any potential conflicts of interest by completing a conflict-of-interest form. The Clinical Guidelines Subcommittee reviews all conflicts of interest before the Society's Council approves the members to participate on the task force, and periodically during the development of the guideline. All others participating in the guideline's development must also disclose any conflicts of interest in the matter under study, and majority of these participants must be without any conflicts of interest. The Clinical Guidelines Subcommittee and the task force have reviewed all disclosures for this guideline and resolved or managed all identified conflicts of interest.

Conflicts of interest are defined as remuneration in any amount from commercial interests; grants; research support; consulting fees; salary; ownership interests [e.g., stocks and stock options (excluding diversified mutual funds)]; honoraria and other payments for participation in speakers' bureaus, advisory boards, or boards of directors; and all other financial benefits. Completed forms are available through the Endocrine Society office.

The Endocrine Society provided the funding for this guideline; the task force received no funding or remuneration from commercial or other entities.