August 2017 Issue
Clinical Nutrition: Functional Hypothalamic Amenorrhea
By Caroline Young Bearden, MS, RD, LD, RYT
Vol. 19, No. 8, P. 12
Nutrition is an important part of treatment.
Nutrition intervention is now recommended as part of treatment for functional hypothalamic amenorrhea (FHA), according to the Endocrine Society's new clinical guidelines. In March, the society published its updated guidelines for FHA in The Journal of Clinical Endocrinology & Metabolism.
FHA often is seen in women who follow a diet low in calories and/or fat, which warrants the guidelines' inclusion of specialized dietary instructions and counseling from a nutrition professional.1
Generally, there are two types of amenorrhea: primary and secondary. The former is when a woman doesn't receive her period by age 16, despite otherwise normal growth and development. But FHA is a common cause of secondary amenorrhea, or cessation of a period for three months or more once a young woman already has started menstruating.2
Historically, there have been three separate causes of FHA, including weight loss, stress, and overexercise. However, Jennifer Kawwass, MD, reproductive endocrinology and fertility specialist at Emory Hospital in Atlanta, says she usually sees all three causes combined. "Many women have a small combination of each of these factors that are likely cumulative in their effect."
Without amenorrhea, the hypothalamus releases gonadotropin-releasing hormone (GnRH), stimulating the pituitary gland to release gonadotropins (reproductive hormones), which include luteinizing hormone (LH) and follicle-stimulating hormone (FSH). They signal ovaries to release hormones necessary for a normal reproductive cycle.3
In FHA, there's a disturbance of the hypothalamic-pituitary-ovarian axis, and gonadotropins are suppressed. This results from changes in GnRH secretion in the hypothalamus. Decreased gonadotropin secretions reduce estradiol production in the ovaries. Therefore, clinical indicators of FHA include low FSH, LH, and estradiol.
In addition, patients with FHA often have high cortisol levels, low serum insulin levels, low insulinlike growth factor, low leptin, high grehlin, and low total triiodothyronine.4
Women at highest risk of developing FHA are those who restrict calories, exercise excessively, have type-A personalities, or have an eating disorder, Kawwass says. "The stress that causes FHA can be physical, nutritional, or mental."
There's no minimum body fat percentage and/or BMI to avoid FHA, because some women develop FHA at "normal" body fat percentages and BMIs. Therefore, FHA must be treated on a case-by-case basis using a process of elimination.5
Moreover, athletes are three times more likely to develop FHA than nonathletes.6
Tracy Brown, RD, LD, an attuned eating coach, says she most often sees the condition in adolescents and young women.
"Typically, though, [I see] women of childbearing age who are engaged in high-intensity sports or exercise and athletes in sports that promote leanness," Brown says.
How to Diagnose
To diagnose FHA, doctors go through a process of elimination once the patient presents with amenorrhea. The new guidelines recommend a pregnancy test, physical exam, and general lab tests. They also recommend evaluation for inpatient treatment if patients have slow heart rates, low blood pressure, or electrolyte imbalances, all of which are common in anorexia nervosa and can be life-threatening.1
According to Kawwass, reproductive and thyroid hormone tests are performed to rule out other causes of disruption in the menstrual cycle and additional types of amenorrhea.
Plus, it's important to rule out genetic diseases that can cause amenorrhea, such as Prader-Willi syndrome, characterized by obesity and retardation, and organic diseases of the hypothalamus, such as sarcoidosis, symptoms of which include fatigue and confusion, before the final diagnosis. Sometimes, brain imaging is conducted, Kawwass says, to rule out anatomic causes of low LH, FSH, and estradiol.
Consequences of FHA
FHA puts women in a chronic state of low estrogen, which can increase risk of bone disease and heart disease and is linked to low libido, vaginal dryness, and moodiness, Kawwass says.
Since estrogen is important for bone metabolism, hypoestrogenism is linked to an increased risk of osteopenia and osteoporosis.
Hypoestrogenism also can cause disruptions in the cardiovascular system, including endothelial dysfunction and interference with vasodilation of blood vessels. The cardiovascular system can be impacted by an energy deficit commonly seen in FHA in addition to metabolic disturbances, leading to impaired lipid profiles and issues with glucose metabolism.
Some research has found sex hormones to have an effect on women's moods, because low estrogen is linked to disturbances in brain activity (such as normal production of the neurotransmitter serotonin). Studies have found FHA to be associated with higher levels of depression and anxiety.
What's more, FHA can have serious consequences on reproductive health. Chronic, untreated amenorrhea can increase the risk of infertility and cause muscle atrophy in the uterus. If a woman with FHA becomes pregnant, her chances of miscarrying and having a preterm birth increase.2
Fortunately, FHA is reversible. Kawwass says the best treatment is to get to the root of the problem—the underlying stressors. Other forms of treatment include hormone replacement and leptin therapy.
And while oral contraceptives will cause menstruation to return, they mask FHA, Kawwass says. The other issues like bone loss are corrected only through treatment of the underlying problem, which typically involves reducing stress and exercise, and nutritional rehabilitation.7 "Treatment is often recommended in conjunction with a dietitian, psychologist, and reproductive endocrinologist," Kawwass says.
Nutrition's Role in Treatment
Current research supports taking a multifaceted approach that includes nutrition intervention to best treat FHA. One five-year retrospective study of female athletes with menstrual disturbances showed that nonpharmacologic therapies such as increased dietary intake resulted in return of menses.8
"Adequate nutrition, [including sufficient] caloric and fat intake, are integral parts of recovery from FHA," Kawwass says.
Specifically, the priority should be to ensure patients consume enough calories to support their weight to maintain a menstrual cycle, Brown says. And if restoring weight is necessary, she says she helps patients increase overall caloric intake.
According to the new guidelines and current research, there aren't specific numbers of calories or fat grams to recommend patients consume because each woman has her own threshold based on her physiology and physical activity.
"Their weight may need to surpass their premenstrual cycle-lost weight to attain and maintain a monthly cycle," Brown says.
While there are no specific foods Brown recommends, she says adequate fat and carbohydrate intake is key and that these are the most underconsumed macronutrients by this population.
For bone health, it's necessary for patients to take vitamin D (400 to 1,000 IU) and calcium (~1,200 mg) supplements.7 "There are some dietitians that may recommend [vitamin] B-complex and adaptogenic herbs [plant extracts that are purported to enhance the body's reaction to stress] to support adrenal health; however, I recommend this be done in coordination with the patient's MD," Brown says.
Kawwass says, "Cognitive behavioral therapy [CBT] has been shown to be effective, along with reducing stress and exercise, decreasing caloric restriction, and increasing fat in the diet." In one randomized controlled trial of two groups of women, one that participated in 16 CBT sessions and one that was under observation, showed a return of menses in the CBT intervention group after a 20-week period. Much of the CBT sessions included evaluation and education on nutrition, exercise habits, and beliefs.9
Strategies for RDs
It's important to give patients with FHA concrete and attainable goals that don't stray too far from their current lifestyle, Kawwass says, adding that dietitians should explain why they're recommending lifestyle changes to treat FHA.
She also emphasizes the importance of working in conjunction with a psychologist, therapist, and/or a psychiatrist.
Brown, who says she works in tandem with a doctor and a therapist (especially when therapy involves patients with disordered eating or mental health issues), starts treating FHA by addressing her patients' relationship to weight, food, and exercise.
"[I address] how the person [was led] to undereat, overexercise, or experience stressors more than their system can handle," Brown says. "[The goal is] to improve nutrient intake, encourage eating a variety of foods, and not restricting carbohydrates or fat … and decreasing or ceasing exercise is likely necessary."
Brown also recommends assessing protein needs beyond the standard 0.8 g/kg to 1.2 to 1.6 g/kg of body weight for athletes who may continue to participate in their sport.
Patients will need to work with their dietitian to develop meal plans that will promote healing and satisfaction, Brown says. "Because relationships with food and exercise, as well as nutrition, play such a key role in the development of FHA, it only makes sense to include the dietitian as part of the treatment team to help address the misconceptions and distortions around fueling oneself properly for activity; heal their maladaptive relationship to food, weight, and exercise; and encourage overall self-care."
— Caroline Young Bearden, MS, RD, LD, RYT, is an Atlanta-based dietitian, freelance health care journalist, and certified yoga instructor. She serves as a part-time dietitian and marketing and communications specialist at the National Peanut Board, as a PRN dietitian at Ridgeview Institute in the women's unit for trauma and eating disorders, and as a yoga teacher at CorePower Yoga. She blogs at thewholeyogiRD.com.
1. Endocrine Society experts issue Clinical Practice Guideline on hypothalamic amenorrhea. Endocrine Society website. https://www.endocrine.org/news-room/current-press-releases/endocrine-society-experts-issue-clinical-practice-guideline-on-hypothalamic-amenorrhea. Published March 22, 2017.
2. Blelak KM. Amenorrhea. Medscape website. http://emedicine.medscape.com/article/252928-overview. Updated June 28, 2017.
3. Hypogonadotropic hypogonadism. Medline Plus website. https://medlineplus.gov/ency/article/000390.htm. Updated July 24, 2015.
4. Meczekalski B, Katulski K, Czyzyk A, Podfigurna-Stopa A, Maciejewska-Jeske M. Functional hypothalamic amenorrhea and its influence on women's health. J Endocrinol Invest. 2014;37(11):1049-1056.
5. Mallinson RJ, Williams NI, Olmsted MP, Scheid JL, Riddle ES, De Souza MJ. A case report of recovery of menstrual function following a nutritional intervention in two exercising women with amenorrhea of varying duration. J Int Soc Sports Nutr. 2013;10:34.
6. Practice Committee of the American Society for Reproductive Medicine. Current evaluation of amenorrhea. Fertil Steril. 2006;86(5 Suppl 1):S148-S155.
7. Klein DA, Poth MA. Amenorrhea: an approach to diagnosis and management. Am Fam Physician. 2013;87(11):781-788.
8. Arends JC, Cheung MY, Barrack MT, Nattiv A. Restoration of menses with nonpharmacologic therapy in college athletes with menstrual disturbances: a 5-year retrospective study. Int J Sport Nutr Exerc Metab. 2012;22(2):98-108.
9. Michopoulos V, Mancini F, Loucks TL, Berga SL. Neuroendocrine recovery initiated by cognitive behavioral therapy in women with functional hypothalamic amenorrhea: a randomized, controlled trial. Fertil Steril. 2013;99(7):2084-2091.