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Treatment for Functional Hypothalamic Amenorrhea (FHA)
Step 1: Behavioral changes to correct the energy imbalance and restore normal Hypothalamic-GnRH func
- Diet/ weight GAIN
- DECREASE exercise
- Adequate calcium intake for bone health, 600 mg 2x daily, 8 hrs apart
- INCREASE in cholesterol (if your levels are low), since cholesterol is used to synthesize reproductive hormones.
- Adequate Vitamin D intake (lab value > 50 ng/ml)
- 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.
Step 2: Consider psychological support, such as Thomistic Psychology or Cognitive Behavior Therapy
- Research has well-documented that women with FHA have a higher occurrences of disordered eating (excessive dieting, preoccupation with food), and eating disorders such as anorexia nervosa and bulimia.
- Women diagnosed with FHA are more likely to have depression, anxiety, obsessive-compulsive disorders, and perfectionism.
- Thomistic Psychology is somewhat similar to Cognitive Behavioral Therapy (CBT) but the patient is taken to the next step and encouraged to continually focus on God. Even if you are not Christian, Thomistic Psychology is for you, as this method is based on the ancient philosophical teaching of Aristotle.
- CBT has been shown to be successful in treating many psychological conditions, including but not limited to: anxiety, depression obsessive compulsive disorder and eating disorders. Therefore a trial of CBT will almost always be encouraged.
Step 3: Hormone Replacement Pharmacotherapy
- Estrogen Replacement: I will begin by replacing your estrogen using bioidentical estradiol in the form of a transdermal patch (a patch placed on the skin). Typically we start with a 0.025 to a 0.05 mg patch, which you will wear continuously and change 2x/week. This will help build up and thicken your endometrial lining.
- Progesterone Replacement: I would typically start with 200 mg of bioidentical progesterone which you will take at bedtime for 10 days every time you start a new box of the estrogen patch (ie: every 4 weeks. Thus, for 10 days, you will wear the patch (changing 2x weekly) and also take progesterone at bedtime. See more information about bioidentical progesterone below.
- If you are trying to bet pregnant, we will follow protocols on my Infertility & Recurrent Pregnancy Loss webpage.
Step 4: Imaging
Brain MRI: occasionally a brain MRI may be warranted to ensure there is no other more serious reason that is causing or contributing to your anovulation. We are specifically looking for tumors that could be in the pituitary gland or in the hypothalamus region.
DEXA Scan: (Dual-Energy X-ray Absorptiometry), also called a Bone Scan or a Bone Densitometry is an imaging modality where a very small dose of ionizing radiation (like having an x-ray) will be used to produce a image of your bones, specifically your wrist, femur and spine. This is recommeneded because women with FHA often have had low estrogen for long periods of time because they have not been ovulating. Thus, she will be at risk of developing early
Step 5: Referral to a Specialist
If I am unable to bring on withdrawal bleeds after a 2-3 month trial of hormone replacement therapy, I will refer you to a specialist who will likely offer you FSH and/or LH replacement therapy. Prescribing FSHand LH is beyond my scope of training.
For women who are > 18 yrs old, an endocrinologist who specializes in treating Functional Hypothalamic Amenorrhea will be recommended.
For a teen who is < 18 yrs old, I will refer you to a pediatric-endocrinologist who specializes in treating Functional Hypothalamic Amenorrhea.
What is the Difference between a Withdrawal Bleed and a true Menstrual Period?
A withdrawal bleed is a bleed that is brought on from the "withdrawal" of progesterone. Thus, the precipitous fall in progesterone levels when the Prometrium is stopped, will cause the endometrial lining to shed.
A true menstrual period is brought about by a healthy functioning Hypothalamic-Pituitary- Ovarian Axis (HPO-Axis). You may wish to read more about this on my Education page, or you may wish to revisit the FHA page.
Although, hormone replacement will bring on withdrawal bleeds quite efficiently, our goal will be to reset the HPO-Axis, which is more effectively done by Step 1 and Step 2 above.
Discussion about Low Dose Naltrexone (LDN)"
Naltrexone (off-label use):
- Naltrexone is commonly used to help people with addictions avoid alcohol use and or opioid use.
- This medication is an opioid-receptor antagonist (blocks opioid receptors).
- Thus, we call this an "off-label" use of this medication, which is somewhat common to do in mainstream medicine.
- Many NaPro patients report wonderful success using naltrexone to treat PMS.
I do occasionally use the full 50 mg dose of naltrexone only in very severe cases. Most often I will recommend "Low-Dose Naltrexone" (LDN) for you namely b/c there has been some discussion among the medical community that if a patient has been on full dose naltrexone for many years, this may present a conundrum if the patient needs opioid medications to control severe pain, such as after a surgery or after a significant injury has been sustained. The concern is twofold:
- If the pt is left on the 50 mg of naltrexone, it may be very difficult to manage his/her pain, because the naltrexone is blocking the pain receptors.
- Whereas, if the patient is taken off the naltrexone and given an opioid medication to control his/her pain, a regular dose of the opioid (eg; Percocet) may be too much, and the patient may be at a higher risk of respiratory depression (breathing stops) due to a normal dose of an opioid medication now being too potent, because the patient's opioid receptors have undergone a process called down-regulation, which occurs after long term opioid use.
My recommended treatment for most cases:
We would start at a very low dose and slowly titrate up to 8 mg and see how you feel. The 8 mg dose may be enough for most women. Again, in rare cases, we may continue uptitration to the full 50 mg dose. Naltrexone can only be purchased with a prescription. The Low doses capsules (4 mg to 8 mg) are only available through a compounding pharmacy. You can view a list of
compounding pharmacies that I frequently work with here.
A typical treatment titration regimen would be:
Rx# 1: naltrexone 4 mg:
- take one pill daily x 10 days (4 mg daily total)
- take two pills daily x 10 days (8 mg daily total)
#30 pills total for Rx # 1.
Rx#2: naltrexone 8 mg:
- take two pills daily x 10 days (16 mg daily total)
- take four pills daily x 10 days (32 mg daily total)
#60 pills total for Rx #2.
Rx#3: naltrexone 50 mg (available at either retail pharmacy or compounded)
- take one pill daily
#30 pills total for Rx #3.
*** If we agree on using the full dose, I will document you have been educated to the risks as noted above, and you would like to take this risk. Also, we would plan to use the full dose for only 4-6 mos.
What about a GnRH Pump?
You may come across a treatment for FHA called a GnRH-pump. However, I don't believe this offered in the United States at this point in time. Please do let me know if you find out this is offered somewhere. If you are interested in enrolling in a Clinical Trial (a research study), please let me know and I will search the ClinicalTrials.gov website for you.
GnRH is a medication that cannot be delivered orally, vaginally, nor as an injectable, namely because endogenous GnRH is released by the hypothalamus in a pulsatile fashion, which must be mimicked in order to permit the return of FSH and LH release from the pituitary gland. A continuous infusion of GnRH will actually inhibit the release of GnRH via a negative feedback loop.
Treatment for significant Reduction in Bone Mineral Density:
TERIPARATIDE (rPTH):
- Teriparatide is commonly used and effective in post-menopausal women with decreased bone density.
- In adult women with FHA, who are incurring bone fractures and/or delayed fracture healing due to a decreased bone mineral density, short term use of teriparatide is an option.
- However, it should be noted that this medication carries a Black Box Warning in that is has been shown to be associated with an increased incidence of osteosarcoma in rats.
Mediations to AVOID for women with FHA and low BMD:
The Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guidelines (2017) recommend AGAINST the use certain medications for women with FHA and decreased bone mineral density:
BISPHOSPHONATES:
- Bisphosphonates are commonly used with efficacy in post-menopausal women with decreased bone mineral density.
- This medication is well known to incorporate itself into bone and be retained for years, hence the risk of femur fractures with long term use.
- Some animal trials have demonstrated a risk to the unborn child.
- Pre-pregnancy administration of bisphosphonates may result in the drug moving out of the mother's skeleton during pregnancy, across the placenta and be exposed to the to the growing child in utero.
- Animal studies have shown bisphosphonates to be teratogenic (cause serious harm) to the growing fetus.
DENOSUMAB:
- Denosumab is a human monoclonal antibody directed against the receptor activator of nuclear factor-kB ligand.
- This mediation works well, in post-menopausal women, by limiting bone resorption via inhibition of osteoclast maturation.
- However, animal studies have also reported transplacental transfer and the potential for fetal teratogenicity.