The Endocrine Society has released a clinical practice guideline for the diagnosis and treatment of patients with functional hypothalamic amenorrhea (FHA). The guideline has been published in the Journal of Clinical Endocrinology and Metabolism.

A task force appointed by the Endocrine Society commissioned 2 systematic reviews and used the best available evidence from other published systematic reviews and individual studies to develop the guideline.

“Investigations should include assessment of systemic and endocrinologic etiologies, as FHA is a diagnosis of exclusion,” the study authors wrote. “A multidisciplinary treatment approach is necessary, including medical, dietary, and mental health support. Medical complications include, among others, bone loss and infertility, and appropriate therapies are under debate and investigation.”

Continue Reading

A summary of the recommendations is as follows:

Diagnosis and evaluation

Clinicians should only make the diagnosis for FHA after excluding the anatomic or organic pathology of amenorrhea.
Adolescents and women whose menstrual cycle interval persistently exceeds 45 days or who present with amenorrhea for more than 3 months should undergo diagnostic evaluation for FHA.
Patients with FHA should be screened for psychological stressors.
Clinicians should provide patient education about menstrual patterns occurring during the recovery phase once a diagnosis of FHA has been established.


Clinicians should obtain a personal detailed history in patients suspected with FHA. The history should include diet, eating disorders, exercise and athletic training, attitudes including perfectionism and need for social approval, ambitions and expectations for self and others, weight fluctuations, sleep patterns, stressors, mood, menstrual pattern, fractures, and substance abuse. Clinicians should also obtain a family history regarding eating and reproductive disorders.
In patients with suspected FHA, pregnancy should be excluded and a full physical should be performed, including a gynecologic examination.
The following screening laboratory tests should be obtained in women or adolescents with suspected FHA: β-human chorionic gonadotropin, complete blood count, electrolytes, glucose, bicarbonate, blood urea nitrogen, creatinine, liver panel, and sedimentation rate or C-reactive protein levels.
The following laboratory tests should be obtained for the initial endocrine evaluation for patients with FHA: serum thyroid-stimulating hormone, free thyroxine, prolactin, luteinizing hormone, follicle-stimulating hormone, estradiol, and anti-Mullerian hormone.
A progestin challenge should be administered in patients with FHA after excluding pregnancy to induce withdrawal bleeding and ensure the integrity of the outflow tract.
A brain MRI should be performed in adolescents and women with presumed FHA and a history of severe or persistent headaches, persistent vomiting, lateralizing neurologic signs, clinical signs or laboratory results that suggest pituitary hormone deficiency or excess, or change in vision, thirst, or urination.
Clinicians should obtain a baseline bone mineral density measurement with dual-energy X-ray absorptiometry from any adolescent or woman with more than 6 months of amenorrhea.
Mullerian tract anomalies should be evaluated in cases of primary amenorrhea, and diagnostic options include physical examination, progestin challenge test, abdominal or transvaginal ultrasound, or MRI.
In patients with FHA and underlying polycystic ovary syndrome, clinicians should determine a baseline bone mineral density measurement by dual-energy X-ray absorptiometry in those with more than 6 months of amenorrhea and earlier in those with a history of severe nutritional deficiency, other energy deficiency states, or skeletal fragility. Patients treated with exogenous gonadotropins for infertility should also undergo clinical monitoring for hyperresponse.