FUNCTIONAL HYPOTHALAMIC AMENORRHOEA ...an upsurging trend.pptx

A hidden problem in adolescents,often overlooked,FHA is indeed a marker of stress that helps us to undermine the overall physical,mental and social ill-being of the individual.Need to address a holistic approach is emphasised to restore the optimal functioning of the HPO axis.

1. DR.ANINDITA JANA,MD. A REVIEW OF THE UPSURGING TREND OF FUNCTIONAL HYPOTHALAMIC AMENORRHOEA IN ADOLESCENT GIRLS DUE TO STRESS IN COVID-I9 PANDEMIC PERIOD---ITS CAUSE,DIAGNOSIS AND MANAGEMENT ’

2. COVID-19 PANDEMIC…. THE INDIRECT YET SINISTER EFFECTS AS WE ARE ALL AWARE THE PANDEMIC AND ITS ENSUING STRICT CONTAINMENT MEASURES APPLIED GLOBALLY TO CURB TRANSMISSION BY PHYSICAL DISTANCING AND CLOSED PUBLIC SPACES FORCED ALL TO “STAY AT HOME ‘ AD0LESCENTS THE UNSPOKEN SUFFERERS THE AGE GROUP SPANNING 10-19 YEARS,CONSTITUTE 16% OF THE WORLD”S POPULATION. THOUGH ALL AGE GROUPS ARE AFFECTED,ADOLESCENTS ARE THE WORST-HIT.

3. AMENORRHOEA IN TEENS NO MENSTRUAL BLEEDING FOR 3 MONTHS OR MORE IN A GIRL WITH PREVIOUSLY NORMAL PERIODS NO MENSTRUAL BLEEDING FOR 6 MONTHS OR MORE IN A GIRL WITH IRREGULAR PERIODS. RED FLAG SIGN

4. FUNCTIONAL HYPOTHALAMIC AMENORRHOEA Anovulation due to the suppression of Hypothalamic-Pituitary-Ovarian (HPO) axis No organic cause Related to stress WEIGHT LOSS Due to: consuming too few calories AND/OR exercising too much Upsurge in adolescent girls with previously normal cycles during the lockdown period DUE TO PHOBIA OF WEIGHT-GAIN,OVERZEALOUS HEALTHY-LIFESTYLE,NEGATIVE EFFECTS OF SOCIAL-MEDIA. Diagnostic incidence 15.3% higher in 2020 compared with previous years(RR 1.15).The RR increased steadily from March 2020 onwards exceeding 1.5 by the end of the year.* Primarily related to young females with Eating Disorders esp.Anorexia nervosa,Bulimia Nervosa,Avoidant /Restrictive food intake Disorder,Rumination Disorder,Pica showing a dramatic increase in this set-up. AMENORRHOEA:THE FIRST WARNING SIGN THAT OFTEN BRINGS AN ADOLESCENT GIRL TO A DOCTOR WITH UNDERLYING MENTAL HEALTH DISORDERS . In contrast to Adolescent Obesity which is well- highlighted,the Adolescent Weight-loss related disorders are less spoken- off,are a hidden burden and often go unnoticed till they take serious tolls on the growing body and mind. Eating Disorders are disabling and potentially fatal and difficult to treat ,as most sufferers are in a state of Denial;associated with considerable stigma which might obstruct help-seeking behaviour due to poor general awareness of the society.

5. ASSESSMENT OF FUNCTIONAL HYPOTHALAMIC AMENORRHOEA DIAGNOSED BY EXCLUSION OF ALL ORGANIC CAUSES OF SECONDARY AMENORRHOEA:: EXCLUDE:---Pregnancy Disorders of Pituitary: Prolactinoma,Sheehan’s Syndrome, Cushing’s Syndrome, Empty Sella Ovarian: PCOD Thyroid Dysfunction: Hypothyroidism Adrenal :Adrenal tumours , Congenital Adrenal Hyperplasia THOROUGH HISTORY-TAKING AND GENERAL SURVEY, LABORATORY TESTS :TSH,PROLACTIN,ESTRADIOL,FSH,LH,DHEAS IMAGING STUDIES:USG ABDOMEN,MRI BRAIN PROGESTERONE CHALLENGE:NO WITHDRAWAL BLEED EVALUATING CAUSAL AND CONCOMITANT CONDITIONS

6. FUNCTIONAL HYPOTHALAMIC AMENORRHOEA(FHA) HYPOGONADOTROPIC HYPOGONADISM RELATED TO AN ABERRATION OF THE PULSATILE RELEASE OF GnRH FROM THE HYPOTHALAMUS. SPECTRUM MAY VARY FROM A LOWER MEAN FREQUENCY,COMPLETE ABSENCE TO A FAIRLY NORMAL APPEARING LH PUSATILITY. REDUCED ESTRADIOL PRODUCTION IN THE OVARY.

7. GnrH SUPPRESSION DECREASED IGF-I DECREASED T3 REDUCED LEPTIN Response to stress INCREASED CORTISOL INCREASED GHRELIN KISSPEPTIN SIGNALLING ANTERIOR PITUITARY FSH,LH SUPPRESSION OVARIAN SUPPRESSION ESTRADIOL ABSENCE OF MENSES

8. CONSEQUENCES OF HYPOESTROGENISM IN ADOLESCENCE CARDIOVASCULAR-- - Impaired endothelial function, rise in TG, Total and LDL Cholesterol :-Increased risk of Atherosclerosis and Heart attack in later life. CENTRAL NERVOUS SYSTEM----- Memory and concentration loss, low self-esteem, depression, anxiety, inability to cope with stress SKELETAL SYSTEM---- Osteopenia, Osteoporosis, increased risk of fractures (Due to increased bone resorption in absence of estrogen) Decline in BMD in Adolescence when its supposed to reach its peak may not be reversible in Exercise-induced Hypogonadotrophic Hypogonadism. REPRODUCTIVE---- Infertility(poor/absent follicular development, impaired ovulation, insufficient luteal-phase progesterone)

9. MANAGEMENT::MULTIDISCIPLINARY APPROACH INPATIENT TREATMENT----INDICATED IN ANOREXIA NERVOSA WITH SEVERE WEIGHT LOSS,BRADYCARDIA,HYPOTENSTON AND ELECTROLYTE DISTURBANCES. CORRECTION OF ENERGY IMBALANCE---- MAINSTAY OF TREATMENT: 5% increase in current body weight recommended for spontaneous resumption of menses . PSYCHOLOGICAL SUPPORT---overcoming DENIAL COGNITIVE BEHAVIOUR THERAPY(BEST OPTION TILL DATE) ANTIDEPRESSANTS HRT----COMBINED ORAL CONTRACEPTIVE PILLS. (NOT AN APPROPRIATE MANOEUVRE) SHORT-TERM TRANSDERMAL ESTROGEN REPLACEMENT CALCIUM AND VITAMIN D SUPPLEMENTS EXOGENEOUS LEPTIN . GnRH PUMPS,KISSPEPTIN

10. CONCLUSION UPSURGE OF FHA IN ADOLESCENT GIRLS WITH SUSCEPTIBLE PSYCHOGENETIC MAKE-UP IN RECENT PANDEMIC SITUATION IS ATTRIBUTED TO STRESS LEADING TO SUPPRESSION OF HPO AXIS. TIMELY INTERVENTION IS ESSENTIAL AS HYPOESTROGENISM HAS PROFOUND SHORT-TERM AND LONG-TERM CONSEQUENCES. COMBINED MODALITY APPROACH INVOLVING PHYSICIAN,ENDOCRINOLOGIST,NEUROPSYCHIYATRIST,PSYCHOLOGIST,NUTRITIONIST/DIETICIAN WITH COUNSELLING OF PARENTS & FAMILY. SPONTANEOUS RESUMPTION OF MENSES OCCURS IN MOST CASES FOLLOWING WEIGHT GAIN AND RELIEVING STRESS. CBT IS A SUCCESSFUL OPTION OF TREATMENT.USE OF COC DISCOURAGED AS IT MASKS THE PRIMARY GOAL OF TREATMENT. MULTIDISCIPLINARY APPROACH TO IMPROVE THE OUTCOME. GOAL OF THE FUTURE :NEW DRUGS THAT PROVE TO BE MORE EFFECTIVE THAN HRT AND SATISFACTORILY RE-ESTABLISH THE HPO AXIS TO ITS ORIGINAL TUNE.

11. REFERENCES 1) Niamph P et al,The Impact of Covid-19 Pandemic on Women’s Reproductive Health Front Endocrinol,22 mar 2021 2) Maxim T et al,Incidence and Outcomes of Eating Disorders during the Covid-19 Pandemic. Cambridge University Press,27 jul 2021 3) Hornberger , L.L.Lane and THE COMMITTEE ON ADOLESCENCE,Identification and Management of Eating Disorders in Children and Adolescents , Pediatrics2021. 4) Podfigurna A. et al.Functional Hypothalamic Amenorrhoea:A Stress-based Disease Endocrines 2021 5 ) Meule A Et al,Inpatient Treatment of Anorexia Nervosa in Adolecsents,A 1-Year Follow-up Study, Euro . Eat. Disorders Review 2021 6) Roberts R.E. et al,Current Understanding of Hypothalamic Amenorrhoea, Thera.Adv . Metab . 2020

12. REFERENCES contd …. 7)Stephan Z et al,The Hidden Burden of the Eating Disorders during The COVID_19 Pandemic,The Lancet,Vol 9,Issue 1,Jan 01,2022. 8)Holly Augustino et al,Trends in the Incidence of New-Onset Anorexia Nervosa and Atypical Anorexia Nervosa Among Youth during The Covid-19 Pandemic JAMA Netw open2021;4(12) 9) Meczekalski B. et al,Functional Hypothalmic Amenorhoea and its influence on Women’s Health,Journal of Endocrinological Investigation,2014;37(11):1049_58 10)Riccardo Dalle Grave et a,lCognitive Behavioural Therapy forAnorexia Nervosa:An Update.Curr Psychiatry Rep.2016 Jan 11)Gordon M.et al,Functional Hypothalamic Amenorrhea:An Endocrine Society Clinical Practice Guideline,The Journal of Clinical Endocrinol & Metabol Vol102,Issue 5,May 2017:1413-39

13. DR.ANINDITA JANA M.D. CONSULTANT GYNAECOLOGIST AND OBTETRICIAN, KULTIKARI,W.B.721135, Email:[email protected] THANK YOU