FHA Tx

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.

recommended dietitian

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.

Primary Care-Mental Health Appointments

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

osteopenia/osteoporosis,

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.

More Information about Bioidentical Progesterone:

***** Do not take unless under medical supervision *****

Again, only bioidentical hormones supplementation is offered. I commonly prescribe prometrium capsules, which are taken orally. The generic brand is just as good and ot costs much less. Prometrium (micronized progesterone) is truly a bioidendical hormone formulation which can be purchased through a regular retail pharmacy. This medication is generally well-tolerated. Some common side effects are quite pleasant, eg: you may feel more relaxed or sleepy and your might find your mood may improves. Some more unpleasant side effects may be: next-day fatigue, nausea, headaches, or dizziness. Most often the unpleasant side effects can be easily managed by taking the medication right before you lay your head down on the pillow and/or changing to a compounded formulation. Please know prometrium and generic progesterone capsules contain peanut oil, so you CANNOT take this if you have a peanut allergy.

Sometimes the Prometrium or generic micronized progesterone that is purchased will include a package insert which will "warn" of possible birth defects. However, this warning refers to progesterone substitutes that are often prescribed in oral contraception pills, not the bioidentical progesterone we are prescribing. NaPro providers, who were trained at the St. Paul VI Institute, have been safely prescribing micronized progesterone to many, many women to support pregnancies for over 35 yrs and they have not encountered problems.

If the oral medication is not strong enough or if the side effects are bothersome, we can try a vaginal suppository. This will be prescribed for you by a specialty pharmacy called a "compounding pharmacy". You can see a list of compounding pharmacies by viewing Handout #21 here.

Sometimes we will have to use progesterone injections. I will ask you to watch this instructional video and choose someone such as your spouse or a close relative who is willing to administer the injections to you. I would also recommend injections be administered in the upper-outer quadrant of the buttocks (shown in the video) and that you alternate sides. Common side effects of the injections are: soreness, itching and/or mild bruising at the injection site, especially if the injection is done too quickly.

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.

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:

***** Do not take unless under medical supervision *****

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.

Functional Hypothalamic Amenorrhea (FHA)