Evidence Based Answers CLINICAL INQUIRIES from the Family Physicians Inquiries Network

Stephen Gamboa, MD, MPH What’s the best way to manage Harvard Medical School, Boston Sean Gaskie, MD, MPH athletes with ? Sutter Santa Rosa Family Medicine Residency Program, Santa Rosa, Calif

Evidence-based answer Michael Atlas, MLS University of Louisville, Ruling out secondary causes of to increase caloric intake or decrease Louisville, Ky amenorrhea is, of course, the fi rst step. energy expenditure to promote the Once that’s done, you can make a return of normal menses (strength of presumptive diagnosis of hypothalamic recommendation: C, expert amenorrhea and advise the patient consensus).1 Clinical commentary ® I err on the side of hormone Dowdenpromote the return Health of menses. Media For women supplementation who desire , I use hormonal The is Copyrighta fi nely balanced contraception. orchestra of events; amenorrhea meansFor personal If use is not onlya concern, I that something is out of tune. In athletes, prefer to cycle the patient on low-dose amenorrhea signals that the body is and progesterone that are sacrifi cing the menses to provide energy chemically identical to her own hormones. FAST TRACK for more important daily functions.2 I believe this gently prods the body’s Because of the potential own hypothalamic-pituitary axis (HPA) to All female athletes negative long-term consequences of re-engage without overriding the internal with amenorrhea , I err on the side HPA-ovarian drive. should have a of hormone supplementation while pregnancy test, encouraging the patient to modify her Roberta VanZant, MD UICOMP/MMCI Family Residency, eating pattern and exercise routine to Peoria, Ill because pregnancy is the most common cause ❚ Evidence summary • serum to rule out pro- of secondary Little evidence and no specifi c guidelines lactinoma exist to guide the clinician in evaluating • follicle-stimulating hormone to amenorrhea and managing exercise-induced amen- rule out premature ovarian failure orrhea. All athletes with amenorrhea • thyroid-stimulating hormone to should have a pregnancy test, because evaluate for thyroid problems. pregnancy is the most common cause of If all these tests are negative, consid- secondary amenorrhea.1 After ruling it er a progesterone challenge test.3 Typi- out, the clinician may choose to exclude cally, athletes with hypothalamic amen- other causes of secondary amenorrhea orrhea don’t experience withdrawal before presuming a diagnosis of hypo- bleeding after progesterone challenge, thalamic amenorrhea. because of inadequate endogenous es- Useful tests (TABLE) include: trogen stimulation.

CONTINUED

www.jfponline.com VOL 57, NO 11 / NOVEMBER 2008 749

For mass reproduction, content licensing and permissions contact Dowden Health Media.

749_JFP1108 749 10/17/08 1:28:16 PM TABLE

INQUIRIES en with secondary amenorrhea. These

Is it hypothalamic amenorrhea, or something else? women should take adequate calcium and vitamin D. Bisphosphonates are DIFFERENTIAL POTENTIALLY DIAGNOSIS CLINICAL CLUES USEFUL TEST not appropriate for women of repro- ductive age, because of their potential Pregnancy

CLINICAL Sexual history Urine hCG teratogenicity.1 Polycystic Obesity, hirsutism Progesterone challenge syndrome Recommendations Ovarian failure Family history Serum FSH The Committee on Sports Medicine and Thyroid dysfunction Physical exam, history Serum TSH Fitness of the American Academy of Pedi- , Galactorrhea Serum prolactin atrics (AAP) encourages exercise to help psychiatric medications maintain lean body mass and protect Asherman’s syndrome History of pelvic /progesterone against obesity, diabetes, hypertension, instrumentation challenge and cardiovascular disease. Athletes with FSH, follicle-stimulating hormone; hCG, human chorionic gonadotropin; amenorrhea, however, may be at risk for TSH, thyroid-stimulating hormone. sequelae such as , fractures, and dyslipidemia. Amenorrhea during Greater calorie and micronutrient adolescence may inhibit the accretion of intake—plus rest—is best BMD, and the lost density may not be re- A 1999 study in the International Journal gained. Amenorrheic athletes are also at of Sport Nutrition found that chronic en- risk for the “female athlete triad”—dis- ergy defi cit in amenorrheic athletes (N=4) ordered eating, amenorrhea, and osteo- could be reversed in a 20-week program porosis.8 using a sport nutrition supplement, 1 rest The potential negative sequelae of day per week, and a dietician to help with amenorrhea are best prevented with mea- food selection.4 A 2002 review similarly sures that restore physiologic menses.3 recommends 1 rest day per week, increas- For exercise-induced hypothalamic bone ing caloric intake by 200 to 300 Kcal/d, loss, the AAP recommends decreased ex- FAST TRACK and increasing intake of calcium, B vita- ercise, increased caloric intake, or both. ■ The potential mins, iron, and zinc.5 References negative effects Oral contraceptives to prevent 1. Warren MP, Perlroth NE. The effects of intense ex- ercise on the female reproductive system. J Endo- of hypothalamic bone loss? Too little information crinol. 2001;170:3-11. amenorrhea, such Bone loss in amenorrheic athletes may 2. Master-Hunter T, Heiman DL. Amenorrhea: have long-term consequences, even if evaluation and treatment. Am Fam Physician. as bone loss, are 2006;73:1374-1382. amenorrhea is only temporary. Some 3. American College of Obstetricians and Gynecolo- best prevented theoretical and disease-based research gists. Amenorrhea (ACOG Technical Bulletin 128). Washington, DC: American College of Obstetri- with measures to suggests a possible role for oral contra- cians and Gynecologists; 1989. restore menses, ceptives to prevent bone loss in pre- and 4. Kopp-Woodroffe SA, Manore MM, Dueck CA, et al. postmenopausal women,6 but little re- Energy and nutrient status of amenorrheic athletes specifi cally participating in a diet and exercise training inter- search has investigated younger women vention program. Int J Sport Nutr. 1999;9:70-88. increased caloric with hypothalamic amenorrhea. A recent 5. Manore MM. Dietary recommendations and athletic menstrual dysfunction. Sports Med. 2002;32:887- intake and open-label study that did examine bone 901. decreased exercise mineral density (BMD) in women with 6. DeCherney A. Bone sparing properties of oral con- hypothalamic amenorrhea before and af- traceptives. Am J Obstet Gynecol. 1996;174:15-20. 7. Warren MP, Miller KK, Olson WH, et al. Effects of an ter 13 cycles of oral contraceptives found oral contraceptive (norgestimate/ethinyl estradiol) a signifi cant increase in BMD in the spine, on bone mineral density in women with hypotha- 7 lamic amenorrhea and osteopenia: an open-label but not at the hip. extension of a double-blind, placebo-controlled No published study has demon- study. Contraception. 2005;72:206-211. 8. American Academy of Pediatrics Committee on strated clinically signifi cant advantages Sports Medicine and Fitness. Medical concerns in for oral contraceptive therapy in wom- the female athlete. Pediatrics. 2000;106:610-613.

750 VOL 57, NO 11 / NOVEMBER 2008 THE JOURNAL OF FAMILY PRACTICE

750_r2_JFP1108 750 10/21/08 10:19:11 AM