quinta-feira, 22 de julho de 2010

Atualização em Amenorréia Hipotalâmica Funcional

Atualização Médica Instantânea - Ginecologia
(post dirigido ao público médico)

Publicação no New England Journal of Medicine de hoje 22 de julho de 2010.

Teaching topics from the New England Journal of Medicine - Vol. 363, No. 4, July 22, 2010

Functional Hypothalamic Amenorrhea

CLINICAL PRACTICE, Functional Hypothalamic Amenorrhea, C.M. Gordon,

Functional hypothalamic amenorrhea is a condition characterized by the absence of menses caused by the suppression of the hypothalamic–pituitary–ovarian axis for which no anatomic or organic disease is identified.

Clinical Pearls

How should bone health be managed in women with functional hypothalamic amenorrhea?
For sustained benefits to bone health, nutritional rehabilitation and a decrease in strenuous activity are recommended strategies. An adequate intake of calcium (1300 mg per day of elemental calcium) and vitamin D (400 to 1000 IU per day) is recommended. Limited data indicate that bisphosphonate treatment reduces bone turnover and increases bone density in adolescents and adults with anorexia nervosa. However, given the potential risks (e.g., long skeletal retention of the drug and possibly teratogenic effects during pregnancy), more data are needed before the use of such drugs in this population can be endorsed.

In a woman with functional hypothalamic amenorrhea is there an ideal body weight at which menses typically resume?
In a 2-year longitudinal study involving 100 adolescents with anorexia nervosa, menses resumed at a mean standard body weight that was 91.6±9.1% of the ideal body weight; within 6 months after achieving that weight, menses resumed in 86% of the girls. However, there were no significant differences in weight, body-mass index, or body-fat percentage in those who resumed menses by 1 year, as compared with those who did not. Of note, the weight needed for restoration of menses was 2.0 kg (4.4 lb) higher than the weight at which menses were lost.

Morning Report Questions
Is treatment with an oral contraceptive pill necessary in women with functional hypothalamic amenorrhea?
Whereas oral contraceptive pills are commonly prescribed in practice with the goal of improving skeletal status, in several studies (including three randomized, controlled trials), the provision of estrogen and progestin did not lead to a significant increase in bone density.

How should infertility be managed in women with functional hypothalamic amenorrhea?
For women with hypothalamic amenorrhea who desire pregnancy, induction of ovulation with pulsatile GnRH or injectable gonadotropins is the treatment of choice. Estrogen-deficient women with hypothalamic amenorrhea often have a poor response to ovulation induction with clomiphene citrate.