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Functional Hypothalamic Amenorrhea

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Î In cases of primary amenorrhea, ES suggests evaluating Müllerian tract anomalies (congenital or acquired). Diagnostic options include physical examination, progestin challenge test, abdominal or transvaginal ultrasound, and/or MRI, depending on the context and patient preferences. (2|⊕⊕⊕ ) Î In patients with FHA and underlying polycystic ovary syndrome (PCOS), ES suggests: • a baseline BMD measurement by DXA in those with ≥6 months of amenorrhea and earlier in those with history or suspicion of severe nutritional deficiency, other energ y deficit states, and/or skeletal fragility (2|⊕⊕ ); and • clinical monitoring for hyperresponse in those treated with exogenous gonadotropins for infertility. (2|⊕⊕ ) Treatment Î ES recommends that clinicians evaluate patients for inpatient treatment who have FHA and severe bradycardia, hypotension, orthostasis, and/or electrolyte imbalance. (1|⊕⊕⊕ ) Î In adolescents and women with FHA, ES recommends correcting the energy imbalance to improve hypothalamic–pituitary–ovarian (HPO) axis function. This often requires behavioral change. Options for improving energy balance include increased consumption and/or improved nutrition and/or decreased exercise activity. This often requires weight gain. (1|⊕⊕⊕ ) Î In adolescents and women with FHA, ES suggests psychological support, such as cognitive behavior therapy (CBT). (2|⊕⊕ ) Î ES suggests against patients with FHA using oral contraceptive pills (OCPs) for the sole purpose of regaining menses or improving BMD. (2|⊕⊕ ) Î In patients with FHA using OCPs for contraception, ES suggests educating patients regarding the fact that OCPs may mask the return of spontaneous menses and that bone loss may continue, particularly if patients maintain an energy deficit. (2|⊕⊕ ) Î ES suggests short-term use of transdermal E2 therapy with cyclic oral progestin (not oral contraceptives or ethinyl E2) in adolescents and women who have not had return of menses after a reasonable trial of nutritional, psychological, and/or modified exercise intervention. (2|⊕ ) Î ES suggests against using bisphosphonates, denosumab, testosterone, and leptin to improve BMD in adolescents and women with FHA. (2|⊕⊕ ) Î In rare adult FHA cases, ES suggests that short-term use of recombinant parathyroid hormone 1-34 (rPTH) is an option in the setting of delayed fracture healing and very low BMD. (2|⊕ )

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