Hypothalamic Amenorrhea-an Update on Aetiopathogenesis, Endocrine Profile and Management

Hypothalamic Amenorrhea is one of the most common causes of amenorrhea in women of reproductive age, accounting for almost 50%cases of secondary amenorrhea, while the genetic causes account for a lower percentage of cases of HA presenting as primary amenorrhea. HA is a heterogeneous condition with main characteristics being reduced pulsatile GnRH secretion which is evidenced as reduced circulating LH levels along with decreased frequency and amplitude of LH plasticity. It has been observed in 10% of female athletes. Besides that, affected patients may have more than one etiological factor like low body weight, excessive exercise as well as stress. Other important causes such as heterozygous mutations in genes associated with GnRH migration or GnRH secretion maybe responsible for congenital GnRH deficiency whose presentation is also as HA. Thus pulsatile s/c administration remains the treatment of choice in women desiring pregnancy. Priming with LH followed by FSH initiation may be effective in ovulation induction as well. But since infusion pumps requiring GnRH administration intermittently are not available in all countries Kp54/kp10 offers a better alternative once its efficacy and full therapeutic window has been accurately worked out,besides being very effective in Kp/GPR54 mutations as well as neurokin deficiency as it acts downstream of Kp. Emphasis on weight increase and correcting anetiological factors remains the mainstay in patients presenting with functional HA as secondary amenorrhea and factors which will increase intake as well as reduce energy expenditure will go a long way in correcting the GnRH and thus LH pulsatility. Only if these patients require immediate fertility is hormonal therapy indicated along with ovulation induction.