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Dear Dr. Ramirez,

I was diagnosed with hypothalamic amenorrhea this past year.  My relevant history:

-From 2002-2003, over the course of 1 yr, I lost 55-60 pounds to a BMI of 16.5 and body fat of apprx 5-10%
-Sometime that year, I stopped having a natural period
-I was placed on OCPs, which I stopped in May of 2012; of note, my weight had increased slowly over the course of those yrs by 20 lbs (BMI of 20, BF 15-20%)
-However, I continued to exercise 5-6 times per week, with an emphasis on running (marathons)
-My personality and career are also high-stress

Work-up to date:
-Low estrogen (10, then 22)
-Low LH and FSH
-Nl TSH
-Nl CBC/Chem 13
-Nl brain MRI

Modifications to date:
-Since mid-March, I have stopped long-distance training (I now run 1-2x/wk, max 4-5 miles per run)
-I have started yoga
-I have gained more weight (BMI 22-23)

My RE would like to proceed w/ a semen analysis, HSG, and then FSH/LH injects coupled w/ IUI.  My concern is that this latter measure seems a bit aggressive as I am not in a rush to have a child and would like to regain my natural period given risks of prolonged hypoestrogenism.

My questions are:
(1) Do you have any recommendations re: re-establishing a natural period? I have heard some talk of an extended clomid protocol being useful in this regard.
(2) Based on your experience, do you have a time range for resuming a natural period after reversal of factors which may have triggered hypothalamic amenorrhea?
(3) Do you recommend psychotherapy (specifically cognitive behavioral therapy) to supplement treatment for hypothalamic amenorrhea?

Thank you in advance!

Answer
Hello Sophia from the U.S. (California),

If your hypothalamic amenorrhea is secondary (due to an outside source such as exercise), then your are currently following a good regimen to get your cycles back to normal.  Basically, the hypothalamus needs to return to normal function thereby inducing the ovaries to ovulate each month.  That will make your cycles regular and allow you to potentially get pregnant naturally.

If your hypothalamus is not working, on the other hand, the only way to get the ovaries to ovulate is to give hypothalamic hormone which is what the injection medications are.  Clomid only works if the hypothalamus is working because it indirectly stimulates the hypothalamus.

If you are not in a hurry to get pregnant, then you can wait and see if things return to normal on its own.  I would give yourself 3-6 months for your cycles to return.

I don't think that psychotherapy is indicated, nor do I think that it will help with the hormonal problem.  The decision on what to do next depends on whether or not pregnancy is desired.  If pregnancy is not desired, then increasing your weight and reducing exercise is a good start.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate

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Edward Joseph Ramirez, MD, FACOG

Expertise

I am a specialist in infertility and advanced gynecological care. I can answer questions about infertility, gynecology related ills, menopause...virtually anything that affects women's health. PLEASE tell me where you are writing from as I am always interested.

Experience

I have been practicing as an Ob/Gyn and Infertility Specialist for over 23 years. Gynecology, advanced laparoscopic surgery, basic infertility, IUI's, IVF, reproductive surgery, and ovulation induction are all areas of my expertise. I am Board Certified. I have been doing In Vitro Fertilization in my clinic for 19 years.

Organizations
American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, Society of Assisted Reproductive Technology, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists,Resolve-National Chapter, Open Path - Northern California, Board of Directors Monterey Medical Society

Publications
American Journal of Obstetrics and Gynecology, Wall Street Journal, Monterey Herald, SERMO, Women's Health and Fertility Blog

Education/Credentials
Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco

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