What are the next steps to induce a period after discontinuing all supplements except growth hormone (GH)?

Inducing Menstruation After Discontinuing Supplements While Continuing Growth Hormone

To induce menstruation in a patient who has discontinued all supplements except growth hormone (GH), the most effective approach is to discontinue growth hormone therapy as it may be contributing to menstrual irregularities through its effects on hormonal balance.

Impact of Growth Hormone on Menstrual Function

• Growth hormone can affect ovarian function both directly through its effects on steroidogenesis and indirectly through gonadotropins and IGF-1 1
• GH receptors have been identified in ovarian cells, suggesting direct modulatory effects on gonadotropin-dependent and independent functions 1
• Anecdotal reports indicate that GH therapy may cause accelerated pubertal development, which can disrupt normal menstrual cycling 2

Assessment Before Intervention

• Evaluate pubertal development using Tanner staging to determine if accelerated development is occurring 2
• Assess bone age through radiography of the left wrist to identify any accelerated bone maturation that may be affecting hormonal balance 2
• Measure serum IGF-1 levels to determine if GH therapy is causing supraphysiological effects that could interfere with normal menstrual function 2

Step-by-Step Approach to Induce Menstruation

1. Consider temporary discontinuation of GH therapy:

   • GH should be temporarily stopped to address hormonal imbalances affecting menstruation 2
   • This is particularly important if there is evidence of accelerated bone maturation or pubertal development 2

2. Monitor hormonal parameters:

   • Check thyroid hormone levels (TSH and free T3) as GH therapy can affect thyroid function 2
   • Evaluate glucose metabolism, as GH affects insulin sensitivity which can impact menstrual regularity 3

3. Reassess GH dosing if therapy must continue:

   • If GH therapy cannot be discontinued, consider reducing the dose 2
   • The standard dosage of 0.045-0.05 mg/kg body weight per day may need adjustment 2

4. Regular monitoring during intervention:

   • Schedule follow-up visits every 3-6 months to assess menstrual function 2
   • Monitor for signs of catch-down growth if GH is discontinued 2

Special Considerations

• If the patient is approaching genetic target height, this may be an appropriate time to consider permanent discontinuation of GH therapy 2
• In late-pubertal adolescents, if height velocity drops below 2 cm per year and/or epiphyseal growth plate closure is evident, GH should be permanently discontinued 2
• Be aware that withdrawal of GH may lead to maintenance of height SDS in only about 27% of patients, with potential reduction in growth velocity in the majority 2

Common Pitfalls to Avoid

• Avoid increasing GH dose as higher doses are not more efficient than lower doses and may worsen hormonal imbalances 2
• Do not overlook the potential impact of GH on sodium and fluid retention, which can affect overall hormonal balance 4
• Remember that GH insufficiency states can disrupt ovarian function, but excessive GH can also interfere with normal menstrual cycling 1