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Functional hypothalamic amenorrhea: Evaluation and management

Kathryn E Ackerman, MD, MPH
Madhusmita Misra, MD, MPH
Section Editors
Robert L Barbieri, MD
William F Crowley, Jr, MD
Deputy Editor
Kathryn A Martin, MD


Low energy availability (from decreased caloric intake, excessive energy expenditure, or both) and stress are common causes of hypogonadotropic hypogonadism in women. Functional hypothalamic amenorrhea (FHA) is the term used to describe amenorrhea that results from such causes and is diagnosed after excluding other etiologies of amenorrhea. The terms functional hypothalamic amenorrhea and hypothalamic amenorrhea (HA) are often used interchangeably.

FHA is presumed to be a functional disruption of pulsatile, hypothalamic gonadotropin-releasing hormone (GnRH) secretion. The abnormal GnRH secretion characteristic of FHA leads to decreased pulses of gonadotropins, absent midcycle surges in luteinizing hormone (LH) secretion, absence of normal follicular development, anovulation, and low serum estradiol (E2) concentrations. Variable neuroendocrine patterns of LH secretion can be seen. Serum concentrations of follicle-stimulating hormone (FSH) are low or normal and often exceed those of LH, similar to the pattern in prepubertal girls.

This topic will review the evaluation and management of FHA. The pathophysiology and clinical manifestations of FHA, as well as the approach to women with primary and secondary amenorrhea, are presented separately. (See "Functional hypothalamic amenorrhea: Pathophysiology and clinical manifestations" and "Evaluation and management of primary amenorrhea" and "Evaluation and management of secondary amenorrhea".)


Diagnosis — FHA is a disorder that, by definition, excludes organic disease. The diagnosis of FHA is based upon the findings of amenorrhea, low serum gonadotropins and estradiol (E2), and, usually, evidence of a precipitating factor (exercise, low weight, stress). As in every woman with new-onset amenorrhea, other causes should first be excluded before diagnosing this condition. Our approach is consistent with the Endocrine Society's 2017 Clinical Practice Guideline for the diagnosis and treatment of FHA [1]. (See "Functional hypothalamic amenorrhea: Pathophysiology and clinical manifestations" and "Evaluation and management of primary amenorrhea" and "Evaluation and management of secondary amenorrhea".)

Exclude other disorders — Women with FHA usually present with secondary amenorrhea, although some present with primary amenorrhea. The evaluation of both types of amenorrhea includes a thorough history and physical examination, biochemical testing, assessment of estrogen status, and, in some cases, imaging. These are reviewed in detail separately (algorithm 1 and algorithm 2). (See "Evaluation and management of primary amenorrhea" and "Evaluation and management of secondary amenorrhea".)

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Literature review current through: Oct 2017. | This topic last updated: Apr 21, 2017.
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