Evaluation
Î In patients with suspected FHA, ES recommends obtaining a detailed
personal history with a focus on diet; eating disorders; exercise and
athletic training; attitudes, such as perfectionism and high need for
social approval; ambitions and expectations for self and others; weight
fluctuations; sleep patterns; stressors; mood; menstrual pattern;
fractures; and substance abuse. Clinicians should also obtain a thorough
family history with attention to eating and reproductive disorders. (U)
Î In a patient with suspected FHA, ES recommends excluding pregnancy
and performing a full physical examination, including a gynecological
examination (external, and in selected cases, bimanual), to evaluate the
possibility of organic etiologies of amenorrhea. (1|⊕⊕⊕
)
Î In adolescents and women with suspected FHA, ES recommends
obtaining the following screening laboratory tests: β-human chorionic
gonadotropin, complete blood count, electrolytes, glucose, bicarbonate,
blood urea nitrogen, creatinine, liver panel, and (when appropriate)
sedimentation rate and/or C-reactive protein levels. (1|⊕⊕⊕⊕)
Î As part of an initial endocrine evaluation for patients with FHA, ES
recommends obtaining the following laboratory tests: serum thyroid-
stimulating hormone (TSH), free thyroxine (T4), prolactin, luteinizing
hormone (LH), follicle-stimulating hormone (FSH), estradiol (E2), and
anti-Müllerian hormone (AMH). Clinicians should obtain total testosterone
and dehydroepiandrosterone sulfate (DHEA-S) levels in patients with
clinical hyperandrogenism and 8 AM 17-hydroxyprogesterone levels
if clinicians suspect late-onset congenital adrenal hyperplasia (CAH).
(1|⊕⊕⊕⊕)
Î After excluding pregnancy, ES suggests administering a progestin
challenge in patients with FHA to induce withdrawal bleeding (as an
indication of chronic estrogen exposure) and ensure the integrity of the
outflow tract. (2|⊕⊕⊕
)
Î ES recommends a brain magnetic resonance imaging (MRI) (with pituitary
cuts and contrast) in adolescents or women with presumed FHA and a
history of severe or persistent headaches; persistent vomiting that is
not self-induced; change in vision, thirst, or urination not attributable
to other causes; lateralizing neurologic signs; and clinical signs and/or
laboratory results that suggest pituitary hormone deficiency or excess.
(1|⊕⊕⊕
)
Î ES suggests that clinicians obtain a baseline bone mineral density
(BMD) measurement by dual-energy X-ray absorptiometry (DXA) from
any adolescent or woman with ≥6 months of amenorrhea, and that
clinicians obtain it earlier in those patients with a history or suspicion of
severe nutritional deficiency, other energy deficit states, and/or skeletal
fragility. (2|⊕⊕⊕
)
