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Treating the Underlying Cause of Functional Hypothalamic Amenorrhea

Dr. Vitaly Kushnir outlines treatments for functional hypothalamic amenorrhea, including general health improvements, hormones for low estrogen, and medications for fertility conditions.

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So it is important when treating Functional Hypothalamic Amenorrhea to try to get at the root cause of the disorder. Obviously, if somebody has a brain tumor then surgery would be the treatment. But for the vast majority of patients it’s due to an imbalance in their energy levels, and this can be either due to not enough nutrition; and for these people gaining weight and increasing their caloric intake can help resolve the whole problem. For those people who have excessive exercise and are training for marathons or doing ballet, or whatever it is, decreasing energy expenditure by doing less of those physical activities can help as well. So that’s the first level, and the goal should be to achieve some small degree of weight gain.

The second level is what’s called cognitive behavioral therapy and this has been shown to be successful for girls who have Functional Hypothalamic Amenorrhea and in some cases even for women who have fertility problems.

In terms of protecting the bones, again it’s weight gain that’s probably the most important thing to correct this energy deficit. For some women it makes sense to go on some form of estrogen supplementation, either in the form of hormone replacement therapy or birth control pills; but it’s not uniformly for everyone. So this has to be really individualized to the specific condition.

Now once we get to fertility treatment, the treatments are really varied and it depends on a variety of different factors – how old the woman is when she’s presenting and what are the associated conditions – so it can be quite complicated to help patients who have infertility and Functional Hypothalamic Amenorrhea and it’s also important to recognize in some of these patients that there is an overlap between polycystic ovary syndrome and Functional Hypothalamic Amenorrhea; not all the patients have these but a significant proportion do. So it is extremely important to identify these people because the treatment for them is a bit different from those who have only Functional Hypothalamic Amenorrhea, or non-obese thin PCOS patients. Those who have both conditions are even more complex.

So, in those patients who still have menstrual cycles, sometimes fertility drugs like clomiphene can work, although for patients who have no menstrual cycles and who have very low estrogen levels and very low FH LSH levels normally clomiphene does not help with ovulation. The treatments like injectable gonadotropins can be much more effective and we use medications like menipure, for example, to help induce ovulation in these women. Sometime IVF becomes necessary and this really depends on the individual situation.

One of the important things to realize when embarking on fertility treatment is that even if these women become pregnant through fertility treatments, they are at a much higher risk during subsequent pregnancy for a variety of different things, particularly if the woman does not gain enough weight during pregnancy. And this can lead to a variety of problems as during pregnancy, during a healthy pregnancy, a woman is supposed to gain a good number of pounds or kilograms and if it doesn’t happen this can put the pregnancy at risk. Specific problems is that the foetus doesn’t grow because there is not enough nutrition and the foetus is sort of competing with the mother for the small number of calories available. And this can increase the risk of miscarriages, for example, it can also increase the risk of premature deliveries and the need for cesarean sections.

Occasionally, when patients with Functional Hypothalamic Amenorrhea miscarry they immediately, after the miscarriage, become hypo-estrogenic, and if DNC is performed they can develop problems with the uterus as a consequence of the hypo-estrogenism and the surgery. So it’s important to recognize it before it happens because once they develop Asherman’s adhesions or adhesions inside the uterus it becomes difficult to achieve a pregnant again. So it’s a very complicated condition with many different facets and it’s important to really be evaluated and treated by someone who is knowledgeable about Functional Hypothalamic Amenorrhea both for the woman’s general wellbeing, but also for fertility treatment. And it can be an ongoing condition that needs sometimes quite a bit of care, of ongoing care.