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QUESTION: I have hypothalamic amenorrhea and am currently taking estrogen and progesterone. I'm lean and physically active, but cause is unknown.

If I stop treatment to see if cycling occurs naturally, how long do I need to be off the meds before testing blood levels.  Some have said one month is sufficient.  Others say three.  Note, my HA was primary, though there was no physical obstruction...meds work fine, but I've been on OCs or estrogen/progesterone with a few breaks since I was 18.

Also, is being on some kind of medicine for life essentially, common for HA?

ANSWER: Hello Arielle from the U.S. (New York),

The cause of hypothalamic amenorrhea is that the hypothalamus is not working correctly.  What is causing the hypothalamus to not work is the mystery, and may not be able to be found.  It can be genetic, or body fat content or primarily in the hypothalamus.  Unless it is body fat, which can be altered by increasing the body fat (this is the cause in super athletes or marathon runners or aneorexics), the only treatment is to either substitute the hormones that are missing, as in fertility treatments, or give the end hormones (estrogen/progesterone) but some method.  The birth control pill is the most common method.  If you take it as estrogen and progesterone, you need to make sure the dosage is appropriate for your age (our metabolism changes with age), and not simply the hormone replacement regimens which are meant for menopausal women (lower metabolism and requirement).  Unfortunately, unless the hypothalamus kicks in on its own, you have to get estrogen and progesterone by some method because they are essential for your body.  Without them, you will age faster and your body will deteriorate in several ways.

If you want to test and see if your hypothalamus kicks in on its own, you stop the estrogen/progesterone at the time that you are supposed to in order to have a period, and go one cycle to see if you have a period.  I would recommend that you not go longer than 35 days.  If you don't have a resultant period on your own, then it is probably not working.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
info@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.  I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy).  Contact me at ejrmd@montereybayivf.com if you are interested in continuous access to me.

---------- FOLLOW-UP ----------

QUESTION: Thanks a lot for the response.

Why do you suggest 35 days as the maximum time off?  And is there a particular frequency this can be tested (e.g., every yr or two)?

How can one really determine that the cause is weight/exercise?

Re dose, I've have been using .1 mg transdermal estradiol patch/wk + 200 mg progesterone 12 days about every 5 wks.

ANSWER: Hello Again,

I suggest 35 days because most people that ovulate will have a period by cycle day #35 and if not, are either pregnant or have an ovulatory dysfunction so waiting longer is a waste of time.  This sets a time limit so that precious time is not wasted waiting for nothing.  So, this is basically recommended only for time reasons and NOT medical reasons.  The medical mantra is that a woman should have a period at least every 3 months to decrease the risk of hemorrhage and/or endometrial cancer, but that recommendation is not for women trying to get pregnant.

Hormone testing helps to distinguish what might be occurring.  If the FSH and LH are sub-normal, then the hypothalamus is not working correctly (hypo hypo), but this doesn't help to determine what is causing the hypothalamus to not work.  If you are underweight, from a total body fat perspective, then the only way to determine if this is the cause is to gain weight (or stop the intense exercise) and see what happens (basically trial and error).

0.1 mg estradiol patch is HRT (hormone replacement therapy) dosing and meant to replace estrogen in MENOPAUSAL (OLDER) WOMEN.  It is NOT the replacement dose for a young woman whose metabolism is probably twice the menopausal women's level and therefore has a higher estrogen requirement.  The progesterone dosage is fine.  That is why I prefer the birth control pill for women needing to cycle, and not wanting to get pregnant, that are hypo hypo.  In women wanting to get pregnant, the strategy has to be changed completely because the ovaries have to be induced to ovulate.  Ovulatory medications called gonadotropins, basically FSH and LH, are used for this purpose.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
info@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.  I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy).  Contact me at ejrmd@montereybayivf.com if you are interested in continuous access to me.



---------- FOLLOW-UP ----------

QUESTION: Thanks very much for this info.

Re dose, if one is using transdermal patches, doesn't this bypass concerns about metabolic breakdown?

It's also possible to test estradiol levels, but I realize this fluctuates even on patches, notwithstanding that they  are supposed to offer timed release.  Isn't the presence of what appears to be a normal menstrual outflow sufficient evidence that hormone levels are appropriate?

Answer
Hello Again,

When you use supplemental hormone in any form (pills, injections, creams, patches), then that immediately invalidates the physiologic testing of the hormone levels in your body because the hormone goes directly to the blood stream to get to the end organs so you see, the testing reveals nothing about what is supposed to happen.  It is only reading the available hormone in the blood.

Menstrual bleeding is dependent on the thickness of the endometrium and the hormonal support (or withdrawal).  You are correct that if you have a bleed it can indicate a normal cycle, but you must also consider that you can get bleeding with insufficient hormone as well, such that the endometrium becomes extremely thinned out exposing the small blood vessels and leading to a bleed.  We call this "dysfunctional bleeding" and it does not indicate that there is a normal cycle.  It indicates exactly the opposite.  The key to interpretation is if you have REGULAR cycles i.e. a bleed for 3-7 days every month at approximately the same cycle length.  This regularity is certainly an indication that the cycle is working correctly.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
info@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.  I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy).  Contact me at ejrmd@montereybayivf.com if you are interested in continuous access to me.

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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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