Amenorrhea, or lack of a menstrual cycle, is a common condition that presents in clinical practice. The menstrual cycle is a 5th vital sign for women. A lack of a cycle is not something that should be brushed aside and should be given immediate attention. Today I'm going to introduce a condition known as functional hypothalamic amenorrhea (FHA). Let's dig in and find out what it is, how it's diagnosed, how it affects fertility, and discuss a few treatment options.
What is FHA?
Functional hypothalamic amenorrhea (FHA) is a type of secondary amenorrhea and accounts for 25-35% of all secondary amenorrhea in women. Secondary amenorrhea is defined as the absence of menses in a woman who has previously had functioning menstrual periods. Excessive exercise, lack of adequate nutrition, psychological stress, or a combination of these are the key factors that lead to FHA. High-level athletes (specifically those participating in ballet, running, gymnastics, and figure skating) are at greater risk of developing FHA from excessive exercise and inability to meet the energy needs of the body. Improper signaling between the brain and the ovaries leads to low estrogen levels in the body and this in turn can lead to symptoms such as amenorrhea, low bone mineral density, vaginal atrophy, infertility, and pain with intercourse.
How is it diagnosed?
FHA is a diagnosis of exclusion, meaning that it is a diagnosis reached by ruling out other conditions of menstrual irregularities. If we were to run a blood test on a woman with FHA, we usually see low levels of hormones such as Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH), as well as low estradiol. FSH and LH are hormones produced in the brain that are essential for the growth of follicles in the ovaries, ovulation, and fertility. We typically like to test hormones on day 3 of the menstrual cycle however in a woman that is not menstruating it does not matter what day the hormones are tested as we do not have a reference point.
Your healthcare practitioner may also recommend administrating a progesterone challenge after excluding pregnancy. This involves giving progesterone orally or vaginally for about 10 days to see if you get any vaginal bleeding. A progesterone challenge will help the practitioner identify whether your brain to body signaling is functioning normally and confirm that there is no obstruction to the genital tract.
How does it affect fertility?
Anovulation (lack of ovulation) is a characteristic feature of FHA, therefore women are not able to get pregnant naturally. The diagnosis of FHA may not be made until a woman is trying to conceive or is having difficulties conceiving. Many women may not have bothersome symptoms of estrogen deficiency, which makes it trickier to screen for. Without estrogen, a lot of the reproductive functions are affected, such as the inability to stimulate ovarian follicles and release it from the ovary into the fallopian tube for fertilization. The endometrial lining in the uterus is also not thick enough to support a healthy embryo. Women with FHA who have a low BMI are at an increased risk of miscarrying. In particular, women with a BMI <18.5 are 72% more likely to miscarry in the first trimester. Low BMI is one of the main risk factors for preterm delivery (<37 weeks gestational age). On average, women need approximately 22% body fat to maintain their period and 17% body fat to get their period. It's important to work with a regulated healthcare provider who can assess and estimate your energy requirements based on your lifestyle.
Can the oral contraceptive pill (OCP) help?
While women with FHA may be prescribed the OCP, the underlying cause of amenorrhea still needs to be addressed. OCPs do not prevent further bone loss associated with FHA and should not be used for that purpose. While hormonal contraceptives may mask underlying pathology, they should be considered for patients at risk of pregnancy because ovulation may precede menstruation.
What are your treatment options?
Treatment will vary from person to person, depending on the underlying cause, whether that is psychological stress, excessive exercise, or inadequate nutrition. Therefore, nutrition repletion, stress reduction, weight gain, and behaviour change can all be part of the management plan. A multidisciplinary team including a clinician, nutritionist or registered dietitian, and therapist can yield optimal results. Cognitive behavioural therapy (CBT) is a successful treatment option for FHA due to psychological stress and has resulted in a return of regular menses. CBT has also been shown to lower cortisol levels, increase leptin (our satiety hormone), and Thyroid Stimulating Hormone (TSH) levels.
A healthcare provider who can accurately diagnose and provide appropriate recommendations is key to successful outcomes. A Naturopathic Doctor who focuses in the area of women's health can help you with your health goals. If you're interested in learning how we can work together to get to the root cause of your concern(s), contact me today.