Session: S69-Functional Hypothalamic Amenorrhea: Special Topics
Room 134 (Moscone Center)
Functional hypothalamic amenorrhea (FHA) is a reversible form of anovulation. FHA is a diagnosis of exclusion and organic causes must be excluded. The proximate cause is reduced hypothalamic GnRH drive that results in reduced LH pulse frequency and low FSH levels and thus insufficient ovarian stimulation to support ovulation. FHA is elicited by metabolic and psychogenic factors that synergistically activate the limbic-hypothalamic-pituitary-adrenal axis while suppressing the hypothalamic-pituitary-thyroidal axis. Women with FHA display problematic attitudes that compromise coping and heighten stress responses. Thus, FHA is more than an isolated disruption of GnRH drive. Pharmacologic approaches include exogenous sex steroid administration if fertility is not immediately desired or ovulation induction if it is. However, neither approach corrects ongoing hypercortisolism, associated metabolic disturbances, or fosters better coping skills. Further, exogenous sex steroid administration may not fully prevent or reverse health consequences associated with chronic stress and FHA such as osteopenia and cardiovascular disease. There may be maternal and fetal consequences to pregnancy in the presence of hypercortisolism and hypothyroidism. Other putative pharmacologic approaches such as psychotropic use may ameliorate and/or protect the brain from hypercortisolism, but to the best of our knowledge psychotropic use alone has not been shown to restore ovarian function or correct metabolic concomitants. Our findings that women with FHA have both reproductive and metabolic disturbances along with compromised coping responses to stressors led us to design a behavioral intervention targeted to improve problematic attitudes. We conducted a randomized clinical trial of 20 weeks of cognitive behavior therapy (CBT) versus observation. CBT restored ovarian activity, including ovulation, in most women with FHA while most of those randomized to observation remained anovulatory. Importantly, CBT also reversed hypercortisolism and many metabolic concomitants of FHA. CBT is readily available, inexpensive, and promises better acute and chronic health.
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