Endocrine Abstracts

‘Functional’ hypothalamic amenorrhoea (FHA) is a common cause of secondary amenorrhoea. A focused history should include a full menstrual history (including hormonal contraception); diet, weight and exercise (including any eating disorder); any significant stressors; the woman’s current situation in relation to contraception and fertility plans; a personal or family history of a lack of sense of smell (suggesting Kallmann syndrome); and any family history of delayed menarche, menstrual or fertility problems. Symptoms of acne or hirsutism, hot flushes or galactorrhoea suggest other diagnoses. The clinical examination should include height, weight and visual fields. Typical laboratory results supporting a diagnosis of FHA include a low/normal LH, normal FSH, normal prolactin, normal/low TSH, normal/low FT4, and low oestradiol. It may also be helpful to check a 9 am cortisol, coeliac screen and vitamin D. A ‘Provera test’ can be used to assess oestrogen status. Usually there is no need for a pituitary MRI scan or a transvaginal ultrasound scan. A DEXA scan is unlikely to change management. Clear explanations are vital, including the cause of FHA, from a physiological and evolutionary perspective, research evidence about the interactions between genetic and environmental causes, reassurance about ovarian function, discussion about future fertility options, and why oestrogen is important for bone health. Initial approaches to treatment are psychological and dietary. Resumption of natural menses is best for bone health, together with vitamin D3 treatment if required and adequate dietary calcium, but not bisphosphonates. If menses do not resume, oestradiol treatment with a cyclical progestogen is recommended. Transdermal oestradiol has the best evidence for improving bone mass, but a variety of other factors may influence patient choice, including social acceptability, stigma and prescription charges. Oestrogen treatment should be paused for a few months at appropriate intervals to reassess the endogenous menstrual cycle.