Hypothalamic Amenorrhea

Functional hypothalamic amenorrhea (FHA) is a reversible form of anovulation due to behavioral and psychological factors that provoke hypothalamic hypercortisolism and a cascade of neuroendocrine adaptations that conserve energy and also divert it away from reproduction with the goal of fostering survival and adaptation in response to actual and perceived challenges. Behavioral interventions such as cognitive behavior therapy (CBT) are designed to address problematic attitudes and behaviors so as to reduce hypothalamic hypercortisolism and restore ovulation and fertility. Because FHA is more than an isolated disruption of GnRH drive, hormone use alone does not reverse the neuroendocrine concomitants of FHA. However, because FHA is reversible, contraception should be provided if needed. Infertility treatment should be undertaken with caution as the associated neuroendocrine constellation of hypothalamic hypothyroidism and hypercortisolism may compromise maternal and fetal health. The role of psychotropics has not been appropriately studied. If sustained, the chronic stress and hypoestrogenism of FHA could have long-term deleterious health consequences including osteoporosis, syndromal psychiatric conditions, and cardiovascular disease.