How to induce menstruation in a female bodybuilder with amenorrhea (absence of menstruation) who is taking growth hormone, testosterone, steroids, and an estrogen blocker?

Managing Amenorrhea in a Female Bodybuilder Using Performance-Enhancing Substances

The most effective approach to induce menstruation in a female bodybuilder with amenorrhea who is using growth hormone, testosterone, steroids, and estrogen blockers is to discontinue these performance-enhancing substances and focus on increasing energy availability through improved nutrition. 1

Understanding the Cause of Amenorrhea

• The current amenorrhea is primarily caused by the use of anabolic androgenic steroids (AAS), testosterone, and estrogen blockers, which profoundly disrupt the hypothalamic-pituitary-gonadal axis 2
• These substances cause significant reductions in luteinizing hormone, follicle-stimulating hormone, and endogenous testosterone levels, leading to menstrual irregularities and amenorrhea 2, 3
• Estrogen blockers (aromatase inhibitors) specifically prevent the conversion of androgens to estrogen, further contributing to the hypoestrogenic state and amenorrhea 4

Primary Treatment Approach

Step 1: Discontinuation of Performance-Enhancing Substances

• Discontinue all anabolic steroids, testosterone, growth hormone, and estrogen blockers as these substances are directly causing the amenorrhea 2, 3
• Be aware that after AAS discontinuation, serum gonadotropin levels may take 13-24 weeks to return to baseline values 2
• Testosterone levels may remain suppressed even longer, potentially for several months after discontinuation 2, 5

Step 2: Nutritional Intervention and Energy Availability

• Increase energy availability through proper nutrition, which is the most effective non-pharmacological approach to restore normal menstrual function 1
• Focus on adequate caloric intake to support both exercise demands and normal physiological functions 1
• Ensure optimal calcium intake between 1000-1300 mg/day and vitamin D levels between 32-50 ng/mL 1

Pharmacological Interventions (If Non-Pharmacological Approaches Fail)

For Inducing Menstruation After Discontinuing Performance Enhancers:

• Estrogen administration with cyclic progesterone can be considered after ruling out contraindications 1
• Consider transdermal estradiol rather than oral estrogen, as oral forms may further suppress IGF-1 production, which is already compromised in athletes 1
• Avoid combined oral contraceptives as they do not restore spontaneous menses and may further compromise bone health due to first-pass effects on hepatic IGF-1 production 1

For Managing Post-Cycle Hypogonadism:

• Human Chorionic Gonadotropin (hCG) may help stimulate endogenous testosterone and estrogen production to restore normal hormonal balance 6, 5
• Selective Estrogen Receptor Modulators (SERMs) like clomiphene may help "restart" the hypothalamic-pituitary-gonadal axis, though they come with potential side effects including mood disorders and musculoskeletal issues 4, 5

Important Considerations and Monitoring

• Recovery time varies significantly based on duration and dosage of performance-enhancing substances used 2, 5
• Monitor for signs of bone health deterioration, as amenorrhea and low estrogen levels can lead to decreased bone mineral density 1
• Be aware that some effects on reproductive health may be long-lasting or potentially permanent, including subfertility 2, 3

Common Pitfalls to Avoid

• Do not attempt to induce menstruation while continuing performance-enhancing substances, as this approach will be ineffective and potentially harmful 1
• Avoid using combined oral contraceptives solely to induce withdrawal bleeding, as this creates a false sense of normalcy without addressing the underlying hormonal disruption 1, 7
• Do not underestimate the recovery time needed; hormonal normalization after stopping anabolic steroids and other substances may take several months 2, 5