What is the treatment approach for patients with functional hypothalamic amenorrhea (FHA) and anorexia?

From the Guidelines

The treatment approach for patients with functional hypothalamic amenorrhea (FHA) and anorexia should prioritize a multidisciplinary approach focusing on weight restoration, nutritional rehabilitation, and psychological support, with the primary goal of achieving and maintaining a healthy body weight, which often leads to spontaneous resumption of menses. This approach is supported by recent studies, including a narrative review published in 2025 1, which highlights the importance of addressing nutritional and energy deficiencies to protect bone health in women with FHA.

Key Components of Treatment

• Weight restoration: aiming for a BMI of at least 18.5-19 kg/m²
• Nutritional rehabilitation: starting with a caloric intake of approximately 30-40 kcal/kg/day, gradually increasing to 70-100 kcal/kg/day for weight gain of 0.5-1 kg per week
• Psychological interventions: particularly cognitive behavioral therapy (CBT)
• Hormonal therapy: considering transdermal oestradiol therapy with cyclic oral progestin for adolescents and women who have not had a return of menses after an adequate trial of nutritional, psychological, and/or modified exercise intervention, as recommended by Gordon et al. (2017) 1
• Bone health protection: using hormone replacement therapy over combined oral contraception to prevent the risk of reduced bone mineral density and osteoporosis, as suggested by Gordon et al. (2017) 1

Additional Considerations

• Regular monitoring of weight, menstrual function, bone density, and psychological status is necessary throughout treatment
• Adequate calcium (1200-1500 mg/day) and vitamin D (800-1000 IU/day) supplementation is recommended for all patients
• Recovery from FHA with anorexia can take months to years, and relapse prevention strategies are crucial for long-term success
• The use of combined oral contraceptives should be limited to its contraceptive action or for other non-contraceptive benefits in specific medical situations, as it may inhibit IGF-1 production and decrease osteoblastic activity, as noted by Behary and Comninos (2022) 1

From the Research

Treatment Approach for Functional Hypothalamic Amenorrhea (FHA) and Anorexia

The treatment approach for patients with FHA and anorexia involves a multidisciplinary approach, addressing both organic and psychological aspects. Key considerations include:

• A comprehensive assessment of nutrition status, anthropometry, eating disorders, fat tissue, and leptin levels 2
• Dietary intervention focusing on increasing the caloric content of the diet to restore energy balance and menstrual function 3
• Ensuring adequate kilocalories are provided throughout the day to avoid a negative energy balance 3
• Increasing body fat percentage above 22% to restore menstrual function 3
• Reducing the intensity of physical activity or training volume, while not giving up physical activity altogether 3
• Ensuring adequate intake of micronutrients, reducing stress, and incorporating cognitive-behavioral therapy 3

Psychological Aspects

Psychological aspects of FHA and anorexia are crucial in the treatment approach. Studies have shown that:

• Individuals with FHA demonstrate low self-esteem, depressive mood, anxiety, and inability to cope with daily stress 4
• Adolescents with FHA and anorexia nervosa share common psychopathological aspects, such as maturity issues, social insecurity, and introversion 4
• Nutritional counseling plays a significant role in the treatment of anorexia nervosa and bulimia nervosa, and can be applied to FHA as well 5

Management and Prevention

Management and prevention of FHA are essential to prevent adverse outcomes in bone density, cardiovascular risk profile, psychological well-being, and fertility. Studies suggest that:

• Modification of nutritional intake and exercise are crucial in the management of FHA 6
• Advancements in the understanding of the pathophysiological basis of FHA will aid in the development of novel therapeutic approaches 6
• A comprehensive approach to the management of patients with FHA, including consultation with a gynecologist, psychotherapist, and nutritionist, is necessary 2