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Functional Hypothalamic Amenorrhea (FHA)
Important Definitions
Amenorrhea = no menstrual period
Oligomenorrhea = infrequent or scanty menstrual periods, specifically fewer than 6-8 periods a year.
When a woman burns more calories than she takes in by eating, her body will sense a "caloric deficit" and try to conserve its fuel for the more important vital organs, such as the heart, lungs, and kidneys. Your body simply not put energy to maintaining your reproductive system.
This condition is very common in athletes and in women who exercise or diet excessively. FHA is also very common in women who suffer from anxiety, since a constant state of anxiety expends a lot of energy. Another common personality trait is women who are perfectionists and/or who are higher achievers.
Excessive exercise (women athletes), eating disorders (anorexia nervosa, bulimia nervosa), disordered eating (excessive dieting) and emotional stress are the most common causes of Functional Hypothalamic Amenorrhea (FHA) or Functional Hypothalamic oligomenorrhea.
** NOTE: FHA and PCOS often co-exist. Please see the PCOS webpage
FHA Lecture for Medical Providers
On 11/29/2023, Sharon presented a lecture on FHA & NaProTechnology, which includes two patient case presentations, to audience-viewers from MyCatholicDoctor and APP2APPP Virtual Lectures, Inc. The aim of this lecture is to disseminate information and knowledge regarding how to accurately diagnosis and manage FHA using NaProTechnology protocols, augmented by the Creighton Model System (CrMS). Sharon compares the work up she provides for her patients to that which would likely be provided to women through a typical mainstream gynecological office.
The target audience for this lecture is physicians, NPs and PAs. However, my patients are most welcome to view the presentation here to help empower you to take charge of your reproductive health.
Click image to view lecture on YouTube.
Just a bit of Anatomy & Physiology....
- The name, Functional HYPOTHALAMIC Amenorrhea or Functional HYPOTHALAMIC Oligomenorrhea tells you that the location of the problem is in the HYPOTHALAMUS.
- The hypothalamus is an area very deep in the center of your brain that is responsible for making an important hormone called Gonadotropin Releasing Hormone (GnRH).
- When a woman expends more calories than she takes in via her diet, her body will interrupt the pulsatile secretion of GnRH or at times even completely stop its production.
- When GnRH is not secreted or minimally secreted, it will cause low (or normal) FSH and LH, and low estrogen, and likely low progesterone due to the downstream effect shown in the diagram above.
- Appropriate pulsatile-secretion of GnRH is necessary to provide adequate levels of FSH (Follicle Stimulating Hormone), which is turn is required in order to grow a healthy ovarian follicle to mature the woman's egg.
- Adequate levels of LH (Luteinizing Hormone) are required for the egg to be released by the ovary during normal healthy ovulation.
- Thus, normal levels of GnRH, with subsequent adequate levels of FSH, LH, estrogen and progesterone are all required for a healthy ovulation and pregnancy to occur.
Can you handle a little more?
- This picture may look the same as the first image, but look closer. You will see the title "Hypothalamic-Pituitary-Thyroid Axis" is different.
- The hypothalamus is also intimately involved in regulating thyroid hormone function, which is often also affected in women with FHA.
- Thyrotropin Releasing Hormone (TRH) is synthesized and secreted in the hypothalamus.
- When TRH is not being secreted or it is minimally secreted, it will result in low (or normal) Thyroid Stimulating Hormone (TSH) being secreted by the pituitary gland, which is located deep in the brain.
- When TSH is insufficient it will results in low thyroid hormone synthesis by the thyroid gland.
- The thyroid gland (located in your neck region) will use iodine, to make thyroid hormones T3 and T4.
- T4 is made in much greater quantity than T3, but only T3 is "active".
- T4 is converted to T3 in the liver, kidney, brain and muscle cells.
- Almost every cell in the body will take up T3, which will regulate metabolism. "metabolism" is when each cell uses oxygen and glucose, delivered to it via the bloodstream, to make energy to sustain life.
- So, we could say that our thyroid hormones help to regulate our metabolism. In reality, they do much, much more.....
- High T4/T3 (HYPERthyroidism) may result in anxiety, weight loss, insomnia, diarrhea, heavy periods, infertility, recurrent miscarriage, etc..
- Low T4/T3 (HYPOthyroidism) may result in fatigue, depression, dry skin and hair, infrequent or no periods, infertility, recurrent miscarriage, and even permanent brain damage to a growing baby in the womb.
- For this reason, I will keep your thyroid gland functioning well.
The Good News Is.....
Life Style Changes are Often Effective Treatment
- INCREASE caloric intake (attempt to eat 2500 calories daily)
- DECREASE caloric expenditure (decrease your exercise)
- INCREASE in cholesterol (if your levels are low), since cholesterol is used to synthesize reproductive hormones.
- Adequate calcium intake for bone health, 600 mg 2x daily, try to obtain at least 600 mg from natural food sources.
- Adequate Vitamin D3 intake, our goal will be b/t 50-75
- Note: If Vit D is low, your body will not be able to absorb the calcium you ingest, in order to be taken up by your bones to keep them healthy.
What will the NaPro appointment be like?
Your appointments at MyCatholicDoctor with me will be one FULL HOUR in length. Generally speaking, NaPro appts will follow a typical protocol as outlined below. However, every individual is different and your situation may warrant a more expeditious process. Please know, the Creighton Model System (CrMS) is very important. Your CrMS chart will help direct me to what diagnostic tests and imaging tests should be done and what treatment plan would be most appropriate.
First Appt: I will take a comprehensive medical history and provide you with education about normal healthy reproduction and oftentimes about a condition I suspect you may have after we have talked a while.
I will order a pelvic ultrasound which I will ask you to schedule on day 5 of your next menstrual cycle. I will order a series of laboratory tests. Click the "laboratory tests" button below to learn more.
You will be asked to begin charting your menstrual cycles using the Creighton Model System (CrMS). Please choose a Fertility Care Practitioner (FCP) by clicking the "Fertility Care Practitioners webpage" button below to learn more about scheduling an Introductory Session to get started.
Please consider joining me as I pray for you here.
Second Appt: You will be asked to return to the office in 2 mos for a follow-up appointment to review the results of your imaging and laboratory tests. If you are having menstrual cycles (Functional Hypothalamic Oligomenorrhea), together we will also review your Creighton Model System (CrMS ) chart to look for specific biomarkers which will help me make a diagnosis.
Please upload an image of your CrMS chart two days prior to all follow up visits and send to me via the portal.
Please add the length of your post-peak phase and your mucus cycle score (MCS) to the R-hand margin of the chart. Your Fertility Care Practitioner (FCP) will calculate your MCS for you.
During this appointment, you may be asked to begin some supplements and/or medications. We will also discuss drawing a full set of hormone panels. We will make a decision if you should have a peri-ovulatory estradiol panel, a post-Peak estradiol & progesterone panel, or both panels.
Hormone Panels:
- Peri ovulatory estradiol panel: start on CD8, go to the lab EOD for an estradiol draw, until you have one draw post-peak.
- post-Peak estradiol and progesterone panel: P+3, 5, 7, 9, and 11. See Handout #3 on the the Patient Handout webpage.
- Hormone panels require 2 mos of CrMS charting AND the patient must be able to confidently identify her Peak day.
ALL patients with FHA and FHO will be asked to work with a dietitian or a nutritionist to help optimize your reproductive health. ALL patients will also be asked to work with a mental health professional to help decrease anxiety, which is almost always intimately related to FHA/FHO. Mental Health professionals will also address an eating disorder if indicated. Please click the button below to learn more info about working with these professionals.
Third Appt: You will return to the office in 2 mos to review the results of your hormone panels as well as the biomarkers on your CrMS chart. Most often at this time I will have made one or more more diagnoses to identify the root cause of your symptoms. Together we will discuss a treatment plan, which will be implemented.
Follow Up Appts: You will return to the office every 2 months. During this time, I will conduct a comprehensive medical interview to ensure your symptoms have resolved, and to ensure you are responding well and not having any negative responses to the management plan. Depending on the individual patient and your individual diagnosis, I may need to monitor your progress with serial laboratory tests and/or serial imaging.
After 9 months of working with you via diet and Life-style changes, I will begin hormone replacement management, with a priority to protect your bones from early osteopenia/osteoporosis, which can occur due to a prolonged low estrogen state. Please see the section entitled "Hormone Replacement, Supplements & Pharmacotherapy" section which can be viewed by clicking the "Treatments" button below.
At any point in time, if a diagnosis has been made, treatment initiated, and/or you are satisfied with the medical management we have implemented, you can schedule annual or biannual visits, per your choice.
BLEEDING KEY: How do I Measure Period Flow on my CrMS Chart?
I will be asking you to tell me very specifically how much you are bleeding. An example of a "detailed flow" is: M, M, H, L, L, VL/B
TAMPON or PADS:
- Very Heavy (VH): changing a full pad/tampon every 1-2 hours
- Heavy (H): changing a full pad/tampon every 3-4 hours
- Moderate (M): changing a full pad/tampon every 5-7 hours
- Light (L): changing a full pad/tampon every 8-12 hours
- Very Light (VL): changing pad/tampon less than every 12 hours
MENSTRUAL CUP MEASUREMENTS
- Very Heavy (VH): 60 cc in a 24 hours
- Heavy (H): 40 cc in 24 hours
- Moderate (M): 20 cc in 24 hours
- Light (L): 10 cc in 24 hours
- Very Light (VL): 5 cc in 24 hours
**The Diva Cup comes in 20, 30 and 32 ml cups 32 being the largest but other cups may vary. 1 ml = roughly 1 cc
Other important information about your flow:
- Tail End Brown Bleeding (TEBB): brown bleeding at tail end of period.
- Premenstrual bleeding: pink spotting or brown spotting at the prior to a full period starting.
- Intermenstrual bleeding: bleeding between periods.