Endocrine Society experts issue Clinical Practice Guideline on hypothalamic amenorrhea

March 22, 2017

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Guideline addresses condition that halts menstruation in some athletes, women with eating disorders

Washington, DC - Female athletes and women who have eating disorders are prone to developing a condition called hypothalamic amenorrhea that causes them to stop menstruating. The Endocrine Society today issued a Clinical Practice Guideline advising healthcare providers on ways to diagnose and treat this condition.

The guideline, titled “Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline,” was published online and will appear in the May 2017 print issue of The Journal of Clinical Endocrinology & Metabolism (JCEM), a publication of the Endocrine Society.

Hypothalamic amenorrhea occurs when the hypothalamus in the brain slows or stops releasing GnRH, the hormone that controls the menstrual cycle. It often affects adolescent girls or women with low body weight, a low percentage of body fat, a very low calorie or fat intake, and emotional stress. Ballet dancers, figure skaters, runners and others who burn more calories through exercise than they consume in their diet can be at risk for developing hypothalamic amenorrhea.

“This energy imbalance needs to be addressed to effectively treat hypothalamic amenorrhea and typically requires behavioral modifications,” said Catherine M. Gordon of Cincinnati Children’s Hospital Medical Center in Cincinnati, Ohio, and the chair of the task force that authored the guideline. “Referring patients to a nutritionist for specialized dietary instructions is an extremely important part of their care. Menstrual cycles can often be restored with increased calorie consumption, improved nutrition or decreased exercise activity.”

Hypothalamic amenorrhea raises the risk of other health problems, such as delayed puberty in adolescents and infertility in adult women. Chronic hypothalamic amenorrhea can contribute to bone loss, and some patients develop stress fractures and are at high risk to develop osteoporosis.

To diagnose hypothalamic amenorrhea, healthcare providers must rule out other conditions that can halt menstruation, including benign tumors in the pituitary gland and adrenal gland disorders. The guideline recommends that providers first exclude pregnancy as a cause and then perform a full physical exam to evaluate for other potential causes. General laboratory tests, including a complete blood count and electrolytes, also are part of the recommended screening process.

Recommendations from the guideline include:

  • Hypothalamic amenorrhea is a “diagnosis of exclusion,” which requires healthcare providers to rule out other conditions that could be interrupting the menstrual cycle.
  • As part of their initial evaluation, women diagnosed with hypothalamic amenorrhea should have a series of laboratory tests to check levels of hormones including estrogen, thyroid hormones and prolactin. The workup can help identify factors preventing menstruation.
  • Hypothalamic amenorrhea patients should be evaluated for inpatient treatment if they have an abnormally slow heart rate, low blood pressure, or an electrolyte imbalance. Careful monitoring is needed in these cases because there is a high mortality rate associated with hypothalamic amenorrhea in the setting of eating disorders, particularly anorexia nervosa.
  • Select patients presumed to have hypothalamic amenorrhea should undergo a brain MRI to check for damage to or abnormalities of the pituitary gland or pituitary hormone deficiencies, if they exhibit select signs or symptoms, including a history of severe or persistent headaches; persistent vomiting that is not self-induced; changes in vision, thirst or urination not attributable to other causes; neurological signs suggesting a central nervous system abnormality; or other clinical signs or test results that suggest pituitary hormone deficiency or excess.

The Society’s public education arm, the Hormone Health Network, offers more information on hypothalamic amenorrhea and women’s reproductive health.

Other members of the Endocrine Society task force that developed this guideline include: Kathryn E. Ackerman of Boston Children’s Hospital and Massachusetts General Hospital in Boston, Mass.; Sarah L. Berga and Jay R. Kaplan of Wake Forest School of Medicine in Winston-Salem, N.C.; George Mastorakos of Areteio Hospital in Athens, Greece; Madhusmita Misra of Massachusetts General Hospital in Boston, Mass.; M. Hassan Murad of The Mayo Clinic in Rochester, Minn.; Nanette F. Santoro of the University of Colorado School of Medicine in Aurora, Colo.; and Michelle P. Warren of Columbia University Medical Center in New York, N.Y.

The Society established the Clinical Practice Guideline Program to provide endocrinologists and other clinicians with evidence-based recommendations in the diagnosis, treatment, and management of endocrine-related conditions. Each guideline is created by a task force of topic-related experts in the field. Task forces rely on evidence-based reviews of the literature in the development of guideline recommendations. The Endocrine Society does not solicit or accept corporate support for its guidelines. All Clinical Practice Guidelines are supported entirely by Society funds.

The Clinical Practice Guideline was co-sponsored by the American Society for Reproductive Medicine, European Society of Endocrinology and the Pediatric Endocrine Society.

The guideline will be published online at https://academic.oup.com/jcem/article/3077281/Hypothalamic-Amenorrhea-An-Endocrine-Society.

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