Full Guideline: Functional Hypothalamic Amenorrhea
JCEM | March 2017
Catherine M. Gordon (Chair), Kathryn E. Ackerman, Sarah L. Berga, Jay R. Kaplan, George Mastorakos, Madhusmita Misra, M. Hassan Murad, Nanette F. Santoro, and Michelle P. Warren
Co-sponsoring Associations: The American Society for Reproductive Medicine, the European Society of Endocrinology, and the Pediatric Endocrine Society. This guideline was funded by the Endocrine Society.
The 2017 guideline addresses:
- Diagnosing functional hypothalamic amenorrhea (FHA)
- Evaluating causal and concomitant conditions, including mental disorders
- Deciding which laboratory and imaging tests should be performed
- Treating FHA and concomitant conditions with lifestyle changes and hormone therapy, and providing fertility treatments for women with FHA
Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline
Essential Points
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.
Summary of Recommendations
+ 1.0 Diagnosing, differential diagnosis, and evaluation
- 1.1 We suggest that clinicians only make the diagnosis of functional hypothalamic amenorrhea (FHA) after excluding the anatomic or organic pathology of amenorrhea. (Ungraded Good Practice Statement)
- 1.2 We suggest diagnostic evaluation for FHA in adolescents and women whose menstrual cycle interval persistently exceeds 45 days and/or those who present with amenorrhea for 3 months or more. (2|⊕⊕⚪⚪)
- 1.3 We suggest screening patients with FHA for psychological stressors (patients with FHA may be coping with stressors, and stress sensitivity has multiple determinants). (2|⊕⊕⊕⚪)
- 1.4 Once clinicians establish the diagnosis of FHA, we suggest they provide patient education about various menstrual patterns occurring during the recovery phase. We suggest clinicians inform patients that irregular menses do not require immediate evaluation and that menstrual irregularity does not preclude conception. (Ungraded Good Practice Statement)
+ 2.0 Evaluation
