February Dutch Webinar on Secondary Amenorrhea

hello everyone and welcome to the February Dutch webinar I'm Noah Reed vice president of sales and marketing for precision analytical creators of the Dutch test today we are excited to bring you an expert in women's health Dr Tori Hudson Dr Hudson is here to explain secondary amenorrhea and give you tips to treat your patients who may be struggling with it today's webinar is one of many educational resources available through Dutch visit us at dutchtest.com and find a vast library of videos and educational resources to help you understand hormones and treat your patients complex hormone-related issues coming soon we will also be launching a full online education course with in-depth topics to help providers become hormone experts and profoundly change the lives of their patients this free course will only be available to registered Dutch providers so sign up today and be one of the first to gain access to this amazing new course signing up as a Dutch provider is easy just click the link we've posted in the chat and complete the become a provider form on our website if you sign up today you'll also receive 50 off your first five test kits plus patient referrals and access to even more valuable education now a few housekeeping notes before we get started with today's webinar you can find today's slides in the handout section of the control panel on your screen this webinar is also being recorded and everyone who registered will receive the recording via email tomorrow if you have questions along the way add them to the questions section of the control panel as well we will conduct a short q a after the presentation if time allows lastly please keep in mind that the contents of this webinar are for educational and informational purposes only the information is not to be interpreted as or mistaken for clinical advice please consult a medical professional or health care provider for medical advice diagnosis or treatment patients can find a list of Dutch providers in their area on our website through find a provider button at the top of the page and now let me introduce today's speaker Dr Tori Hudson is a naturopathic physician who graduated from the National College of natural naturopathic medicine in 1984 and has since served at the college in many capacities including Professor medical director and academic Dean she is currently an adjunct clinical professor at am Southwest College of naturopathic medicine in Bastyr University Dr Hudson has been in practice for more than 38 years she's the medical director of her Clinic a women's time in Portland Oregon and is the director of product research and education for vitalica she is also the founder and co-director of naturopathic Education and Research Consortium a non-profit organization for accredited accredited naturopathic residencies in May of 2021 she received the Freddy Kronberg excellence in research and education in Botanicals for Women's Health award from the American Botanical Council this prestigious award is presented to the researcher educator or clinician who furthers the scientific study education and clinical use of medicinal plants in phytomedicines for women's health conditions Dr Hudson is also nationally a nationally recognized author speaker educator researcher and clinician who serves on several editorial boards advisory panels in a consult a consultant to the natural products industry thank you for joining us today Dr Hudson we're all ready when you are all right my pleasure thank you so much and I just want to thank the the Dutch test team overall for inviting me to speak week and I just really also want to commend you all for at Dutch for offering practitioners content that you know may or may not directly uh be relevant to Dutch testing I I appreciate that and just in the spirit of women's health and education of consumers clinicians and my motto how do we help more women more of the time so I appreciate that you all are up to that um in all kinds of ways let me I'm speaking to you from Portland Oregon by the way um and this is my normal time would I be eating my my dark chocolate right after lunch but which is now currently my source of cadmium and Lead apparently um and I'm sure you all have been reading about that so I've been enjoying trying to figure find out where I can get the best chocolate with the least Academy and the least lid um I think this has already been read to you by the Dutch test folks and the disclosures um he mentioned vitalica I am co-owner of itanica as well and I do serve on the scientific advisory Boards of of a few different entities um but let's start with our topic of amenorrhea and by the way I'm going to go in and out of my video uh so don't be alarmed if you can't see me um I'll be coming back and forth so amenorrhea as it turns out is kind of one of the most challenging problems in gynecologic endocrinology and the reason why it is is because there's just an array of potential diseases and disorders that involve multiple organ systems and in some cases carry morbid or even lethal consequences so it can be complex but if we are attentive and methodical we as practitioners and stick with the process that I'm going to outline today in the workup which is it all starts with the workup a diagnosis can be made from this presenting symptom of secondary amenorrhea and by the way by there are different there's also primary amenorrhea and that's when you someone does not have a Menses by age 14 in the absence of growth or development of secondary sexual characteristics or no Menses by 16 regardless of the presence of normal growth and development and secondary sex characteristics that's also primary inventory and we're not going to talk about primary amenity today we're talking about secondary which is the Menses has occurred at some point in their past even if it was just a little bit even if it was one time but now it's not occurring and it has not been occurring for three months if they have a history of raider Cycles or it's not occurring for six months if it's been a history of irregular Cycles all that is the definition of secondary amenorrhea and you can see the preference up above and especially women with infertility 20 percent of those cases of infertility are caused by secondary amenorrhea foreign so let's start with how do we understand some basic principles uh and if we understand I'm going to assume that we all understand sort of basic principles of menstruation uh then we can see these discrete compartmental systems on which that menstrual function depends so our evaluation today is going to segregate the causes of secondary amen or into these four compartments compartment one is where there's some problem with the outflow track it could be that the Oz you know the cervix is stenosed it could be in the case of secondary of course the case of primary they they could be absent some some congenital absence of major uh significance but in secondary elementary it's more that that Oz would become stenos closed off and the blood actually cannot Escape um or the uterus itself is not um there's something that has occurred over time where it's been damaged um such that it can't receive that estrogen stimulation in particular uh but also progesterone compartment two is problems in the ovary compartment threes problems in the anterior pituitary and compartment four is disorders of the central nervous system the hypothalamic uh factors in particular the history and the physical exam should seek to evidence for starting with sort of start with the stress aspect but don't assume that or presume that or just say oh she's stressed that's why we include that um but then we need to go on because there also might be some family history of some uh some genetic meaning there might be uh we should look for problems with the focus on nutritional status are they do they have do we have reason to think that thou amrish do we have reason to think that they are on Extreme uh diets do we have reason to think they have disordered eating or anorexia or bulimia especially anorexia do we have information about their excessive exercise and the combination of excessive exercise and eating disorder are sort of the most wicked combination of the two um and then are they having you know normal or abnormal growth and development of breasts for example uh and um that's I think and I think that covers it let me just look at all this there might be some uh medication uh that could be Happening Here For example even a young woman can get breast cancer can be uh or or or some other Cancer and a local pelvic radiation and or systemic anti-hormonal therapy or chemotherapy all those can cause secondary amenorrhea and um and essentially premature menopause um that is one of the causes of secondary amenorrhea so medication history is important um her her specific menstrual history is very important how old was she did she ever have regular Menses if so when was that when did they stop um does she have some other chronic illness um that might might be related we'll talk a little bit about that like do do we know she already has hypothyroidism as one small example there's also the issue uh in terms of their her uh review of systems we want to know if she has galactorrhea or nipple discharge this is an important sign and whether it's spontaneous or whether it occurs only when the the nipple and breast are compressed and expressed and it can be an important sign whether it's one breast or both breasts and whether it's persistent or intermittent all that has potential is important to know now hormonal secretions that are uh you might say benign meaning non-cancerous these hormonal secretions that cause uh galactorrhea usually come from multiple duct openings which you can actually see when you're looking at the nipple how many of those duct openings is that galactorrhea being is coming from uh because a pathologic discharge usually comes from a single duct and only one breast so that would be a breast cancer or perhaps a papilloma which can be benign but and if they have both amenorrhea and galactorrhea we actually proceed with the evaluation of the amenorrhea first and then we add the other evaluation of galactria after that our amen re-evaluation is done the physical exam you know we're looking secondary sex characteristics we're looking for evidence of hirsutism acne hair loss something on the skin not just acne but something called acanthosis nigricans which is a dark discoloration and the body folds increases usually it happens in the armpits uh and the groin or armpits or the groin uh and or the neck region so here uh groin and neck region um and then we want to know how much she weighs and how what her height is and assessor body mass index um does she have proper sexual maturity I think that's everything on this list let's see um and then we're going to get to testing so this next section of before we get to Therapeutics this this is a little bit weighty in here with evaluation and workup and you're going to need to refer to these slides you clinicians who are hopefully going to adopt this work up um because it's it's not a it's it's not going to be easy to grasp just with a one-time through there is a very important chapter in a very important book called uh Clinic was it called so I'm looking at a clinical uh gynecologic endocrinology and fertility by Leanne spirov I think the last Edition was a few years ago it's still that amenorrhea chapter is golden you probably I recommend that my residence actually read that chapter four times uh before they really kind of get the drift of it all is usually takes about four times uh and then of course it takes you know having one two three four patients that you're walking through it before you kind of get comfortable so these are the tests that we're talking about um at different points along the algorithm here that I'm going to lay out in the next few moments what you notice is there's no salivary testing or urinary testing on here and that's because the algorithms for a clinical diagnosis of a uh of a medical condition that's underlying the cause of secondary amen or it does not include any of those kinds of tests uh now that you could certainly do other functional medicine testings such as a dust test to for some other aspect of their health or their medical history their family history breast cancer for example but to diagnose their cause of secondary amenorrhea we need to really focus on knowing how and when to use these tests and the meaning of the results of these tests so step one starts with are they pregnant and you can decide if you want to conclude that you're comfortable with their answer to your questions about sexual activity with the uh an intercourse with a male partner I.E sperm exposure uh and or or uh if the history is adequate or if you should do a pregnancy test and sometimes that's a delicate situation but the Baseline testing is determine if they're pregnant or not a TSH test you don't need to do all the other hoopla for thyroid for this algorithm and a serum prolactin level that is uh that's the initial step um and if she has an elevated TSH and by elevated I mean actually beyond the 4.5 reference range um it would be very rare but not absolutely impossible but very rare for a gray Zone TSH like a 3.0 TSH to cause secondary amenor yet now if she so what which I would call sort of sub-optimal but not hypothyroid now maybe that gray zone between 2 and 4.5 TSH could along with her being underweight along with her being highly stressed then maybe we could we could see the influence that she's more more vulnerable to that sub-optimal TSH of course if she's so if she's hypothyroid we treat her hypothyroidism as the treatment for her secondary amenorrhea obviously if she's pregnant we go from there elevated prolactin levels um we um have to decide when when we do imaging and so there are some cutoffs with some numbers you can look up uh versus monitoring just the serum prolactin but it's elevated uh definitely I think the number is above 100 don't quote me on that but I believe that's the case uh we want need to determine if there's a tumor involved and imaging with a what they call a cone down x-ray of the celestica is what is I think the still standard of care if all these are normal she's not pregnant she's not hypothyroid she doesn't have elevated serum prolactin then we go on to what is called a progesterone challenge test or progestational challenge test so that the purpose of this it's very important to understand this the purpose of a progesterone challenge test is to assess the level of endogenous estrogen and the competence of her outflow tract and there are three different ways to do that that are accepted in uh what you might call standard of care conventional algorithm and work up and evaluation of secondary amenorrhea one is a synthetic progestin called medroxyprogesterone acetate or MPA 10 milligrams a day for five days another is you could use oral micronized progesterone three to four hundred milligrams a day for five to seven days frankly I in this case I wouldn't get fussy oh you want to use bioidentical versus synthetic it's only for a few days and actually progesterone at three to four hundred milligrams might more likely cause immediate side effects like sedation or groggy or dizzy or lightheaded or drunken feeling might more likely cause that within the few days than would these MPA and the mpa at is stronger even that 10 milligrams versus 400 milligrams is stronger so you do get I think a better test you might say one can use parental progesterone I don't do that so I stick with either one or number two um within two to seven days after the conclusion of the progestational medication the patient will either bleed or she won't bleed now if she bleeds we get to make a diagnosis of an ovulation and we we know that's reliable and securely established because she's having a withdrawal bleed after this progesterone challenge even if she just has a few tiny blood spots following a progesterone challenge that it does in fact imply at least a marginal level of endogenous estrogen and it implies the presence of a functional outflow tract and a uter and we now know that there is a uterus line by reactive endometrium sufficient that it gets it can be stimulated by her endogenous estrogen we've confirmed all of that and with this confirmation of the presence of estrogen at least some minimal function of her ovary her pituitary and her hypothalamus has been established published by this simple test with this positive withdrawal bleed in response to the progestogen challenge and in the absence of galactorrhea and in the presence of a normal prolactin normal th we don't have to do any further evaluation necessary because this combination of things effectively rules out a significant pituitary tumor and we know she's not ovulating now her estrogen her ovarian estrogen production is good what's not good is she's not ovulating so then we can further understand that is it because she's stressed is she because she has PCOS so there is a little bit more work to do there but we had our history uh that that hopefully leads us in the right directions uh you notice what's not on here is progesterone cream or progesterone trokies please do not use those for this test called The progestational Challenge test they are not adequate they are not proven entities to accomplish the uh the reliable information that we need there are a couple rare there are some rare situations associated with a negative withdrawal bleed despite the presence of adequate endogenous estrogen so that I'm about to confuse you but one of those is PCOS PCOS women have adequate estrogen they have adequate uh hypothalamic pituitary ovarian axis orchestration happening but what they do have is insulin resistance and Hyper androidism and that's interfering with the maturation of their follicles and and ovulation so that's not so rare but the second situation is the endometrium is decidualized by high progesterone levels associated with a very specific adrenal enzyme deficiency um if there's no bleed after the progesterone challenges not even a spot that then the problem is either the target organ is a problem meaning the uterus uh or there's um some some kind of the estrogen proliferation of the endometrium has not occurred so now we're trying to figure out what's that about so when there's no bleed with the progesterone challenge this is step two um this step is designed to clarify the situation is the problem the uterus is the problem um the orchestration with the hpo axis uh and orally in order to sort this begin to sort this out now we give a basically orally active estrogen in a quantity and duration that's certain to stimulate the endometrial proliferation and with a progestogen is is certain to cause a withdrawal bleed providing that she has a reactive uterus and a good outflow tract so that is why we give I would say one of these two methods you can give either an oral estrogen CE stands for conjugated equine estrogen that's Premarin which 1.25 is double your average dose or you can do bioidentical estradiol two milligrams is twice your average menopausal dose I should State and you do that for 21 days and then you bring on the mpa for the last five days another way to do it is a birth control pill I would recommend a 30 microgram pill not a 20 and definitely not a 10. you remember where the goal is to to clarify the situation we have to give enough active estrogen uh in enough amounts and duration to stimulate that endometrial proliferation so don't use a cream don't use a vaginal estrogen use one of these two methods please the purpose of these is a test we're testing these we're using these hormones as tests not as treatment so if there is no withdrawal bleed with so how we got to this step is there was no withdrawal relief from the progestogen talons now there's no withdrawal bleed with giving estrogen and a progestin so if this means the diagnosis of a defect in compartment one systems can be made so we look back at compartment one compartment one is a problem in the uh outflow track or the uterus itself so no withdrawal bleed with progestogen no withdrawal bleed with estrogen and progestogen the problem is either is in the compartment one if withdrawal bleeding does occur with this step too now we can assume that compartment one systems have normal function capacities they can receive estrogen and they can exit the lining of the the uterus and the tissue in the blood if it's properly stimulated by the estrogen so if the patient has normal external and internal genitalia by exam and in the absence of a history of infection or trauma we actually then go on to step three because she had a withdrawal bleed with this Purpose with this regimen the purpose of uh so if she bled after our estrogen stimulation again we now know that her endogenous estrogen is actually not adequate to stimulate the endometrium but now we need to know why um and because she it wasn't we proved it wasn't adequate in step one because she did not have a withdrawal bleed we got to get step two we even gave her estrogen it still didn't occur so in order to produce estrogen the ovaries have to contain a normal follicular apparatus and sufficient pituitary gonadotropins to stimulate that apparatus so this step step three is designed to determine which of these true crucial components is functioning improperly the gonadotropins or the follicular activity so it's designed to determine whether the lack of estrogen is due to a fault in the follicle which is compartment one or is it a a problem in this CNS pituitary axis axis sorry which is compartments three and four so what do we do now we test her FS her serum FSH and LH and I know what too often occurs someone does has secondary a mineral we just throw a bunch of tests at them throw estrogen progesterone FSH LH thyroid what didn't I mention who who other functional medicine tests we just throw the gamut atom because we actually kind of don't know what we're doing if we do that would be my assertion and this so we going through this step we might have never even gotten to needing those tests this this methodical algorithm pays off in efficiency of diagnosis accurate diagnosis and uh cost of testing cost of of knowing what's going on we reduce our costs okay so step three continued the so so what if her outcome is an FSH that's elevated n and Elevate LH is elevated and what I elevated here we mean greater than 20. um the association between high levels of gonadotropins and ovarian failure is very reliable but there are some situations in which high gonadotropins can be accompanied by ovaries that contain follicles so there are some rare tumors that can produce gonadotropins even that's actually associated with the lung cancer oddly enough there's a handful of reports of a single gonadotropin deficiency maybe a high level of one and maybe undetectable or Baseline normal of the other and there might so there might be this homozygous mutation in the gonadotropin genes I've never seen either of these two situations by the way in uh 38 years and then there are situations uh rare where a high FSH and a low LH could occur and this would make us suspect a gonadotropin secreting pituitary adenoma but these are all rare tumors that are FSH secreting um and most of these case reports are actually in men so what we're looking for is this FSH in particular above 20. I.E is it in the menopausal range I put POF premature ovarian failure uh I should update that the premature ovarian insufficiency is a more commonly used term these days so what if she has an elevated FSH and a normal LH from our test well during that perimenopausal period it's actually normal for FSH levels to begin to rise even before bleeding has cease and that is a very labile number FSH in perimenopause so this is true whether it's perimenopause at the normal age or it's perimenopause prematurely and during that perimenopausal period those remaining follicles you might say are the least sensitive of all the follicles because they remain in place and fail to respond for gonadotropins for all these many years so as these remaining follicles begin to respond to that Rising FSH level during perimenopause the production of inhibin is also maybe inadequate because that is responsible for a negative feedback as well so the patient can have elevated levels of FSH despite continued bleeding or very recent onset of their amenorrhea so we kind of need to pay attention to this situation because a period of post-menopausal levels of FSH can be followed by a pregnancy so that's why we want to measure both FSH and LH so that we can understand if she's truly perimenopausal or not which is associated with high FSH but normal LH and then we have the elevated FSH uh LH in what's called resistant or insensitive ovaries um I think I might let you read a little bit about that because that condition is rare they can sometimes they even have to do laparotomy to look to find follicles deep within the ovary it's maybe possible that ultrasound can be used to see if there's a low number of follicles but this is where she has elevated gonadotropins despite the presence of ovarian follicles remember we get into these tests and these interpretations because of our earlier steps and in particular uh yeah our earlier steps and then secondary amen area due to premature ovarian failure or premature menopause can be due to autoimmune disease so this is where maybe thyroid antibody testing could be helpful but also does she already have myasthenia gravis or ITP or rheumatoid arthritis or Vitiligo or autoimmune hemolytic anemia or true adrenal insufficiency I'm not talking about you know a functional medicine test that shows uh adrenal this and that I'm talking about true adrenal insufficiency measured by challenged you know they have to get these shots to challenge their adrenals to really diagnose that um but a classic case of premature menopause or POF or POI can precede adrenal failure so monitoring adrenal function is my the important and then the final situation associated with high gonadotropins and normal ovarian follicles include galactosemia and an enzymatic deficiency in both ovaries and the adrenal glands this person though would present with absent secondary sexual development it might be hypertensive okay what about this situation she has normal gonadotropin so this is the one you're going to see um and you're going to maybe scratch your head well those are normal so normal FSH normal LH this is hypothalamic amenorrhea and there's no other test that you need to know because we've gone through all the other steps and now we do know and remember we got here because um of our previous in the patients with normal exam in the absence of History error infection she had a withdrawal bleed from the birth control not from the progestogen but from the birth control pills when she was properly stimulated by estrogen but we want to know why isn't she producing enough of her own so if we get to this place in the algorithm boom we get to diagnose hypothalamic amenorrhea and then there's low FSH or normal FSH LH that's one final step to distinguish between pituitary or CNS hypotherm cause of amenorrhea and that is where we have to come back to that x-ray evaluation of the Celica turcica I don't think I said that right okay what about congenital abnormalities those are limited to secondary amenorrhea which presents in the puberty time period in a study of almost 300 women with secondary amenorrhea that the chart kind of breaks down like this so you see uh there might be so Turner syndrome is something you'll probably see certainly premature menopause is definitely something you'll see uh and um and ovulation is the most common is it stress is it uh is it PCOS uh not very often is it actually hypothyroid okay now we're going to go to um our natural treatment interventions but again I'm gonna perhaps annoyingly stress we have to make an accurate diagnosis from these tests this algorithm to know that we're treating the right thing you don't just say Throw Vitex or Maca or black cohosh or seed cycling or whatever else you can come ideas you might have at a secondary amenorrhea person without knowing the cause because the causes are very different they're treated very differently and each of them is associated with future different risk of future health problems PCOS associated with future risk of type 2 diabetes heart disease hypothalamic amenorrhea if not treated properly associated with osteoporosis and fractures premature ovarian insufficiency associated with under with if it's not treated at adequately risk for osteoporosis fractures heart disease possibly Alzheimer's disease and just premature aging of everything skin bones eyes everything let alone quality of life issues in all of these that I'm mentioning so we need to understand that underlying cause with our methodical work up and coming to and going through those evaluation steps and coming to what is the underlying cause or causes and now we get to manage that underlying cause any complications associated with that she's PCOS we need to be mindful of the long-range plan too preventing diabetes and heart disease especially if she's obese uh so prevention prevention prevention in addition so don't just set your eyes on oh I want her to have a menstrual period we need to set aside on the menstrual period as a reflection of her endocrine health quality of life issues that she's having that she doesn't want to have like infertility acne hirsutism depression and prevention of Big Time future diseases that we can actually reduce the risk of so these uh at least the first six bullet points would look familiar to naturopathic Physicians those are our there are principles I also have the Tori Hudson United say principles of resonance and choice resonance being what's right for this what's the right treatment plan relative to not just the disease and the condition but there are other health issues there their way of life their finances their abilities to take things and do things that's all about resonance and then ultimately with enough with the right education they get to choose what they're comfortable with then there's also uh perhaps some you know other things we're going to have to kind of uh addressed especially if if it's relating if her condition PCOS POI or hypothalamic amenorrhea are going to affect her fertility so there might be conversations and addressing her emotions about that there might need to be some other child bearing or child rearing options that need to be discussed either with you or someone else she she might have this be having secondary amenorrhea as I mentioned much earlier due to medication one some of those medications related to Cancers and certain cancer treatments do increase the risk of premature menopause so we have that is essentially then a side effect of that cancer treatment and then we are going to need to give her treatment options we're going to talk about I have listed here just in a hormonal contraception and menopausal hormone therapy and you might ask well why aren't why isn't Botanicals and Lifestyle on this list she's prematurely menopausal that means she stopped having her period because of due to premature ovarian insufficiency which we learn from our algorithm and work up and tests and she the standard of care for her is that she be on menopausal hormone therapy or birth control pills until she's 51. that is the standard of care if you don't do that you are risking her future osteoporosis heart disease fractures Alzheimer's disease premature aging dying a few years earlier than she would die normally have died and a few years earlier than she would die if compared to taking hormone therapy so that's why Botanicals and nutraceuticals are not the on this list that's not to say you can't do them in addition bone prevention heart disease prevention while other quality of life issues for sure um but the primary treatment for POI should be some proven Doses and delivery of estrogen and progestogens I'm stressing proven because she does have a uterus you give her estrogen we got to give her proven doses of progestogen to protect her uterine lining so here are some uh might we investigate environmental exposures autoimmune genetic causes yeah we might we might do that um so there are some examples ex means examples of hormone regimens that are accepted and within standards of care proven to uh be uh protect your uterine lining from endometrial cancer proven to provide estrogen support for the aging process all the things that I mentioned those are all accepted regimens um and it looks like um even the estrogen patch the point one patch which is the double the average dose patch is superior to a 30 microgram birth control pill in improving bone mineral density in women with POI that's a little bit surprising but that there is some evidence to show that now could you try something non-hormonal for a period of time just to see if this is the cause POI I would not do that for any longer six months Max now she might already have been a menorate for six months so she's already put in her six months of estrogen deficiency you might say so with that I don't really want to go another six months that's a whole year that's going to cost her in her future so I might say okay let we'll go three months um and to see if we can get a menstrual cycle going with these things um so that's kind of a tough call but the the main message is don't go too long um with non-hormonal proven treatments to prevent these big time future diseases uh in a POI case these are just some other things you might consider exploring if you want to explore environmental exposures could if there's an expire environmental exposure could you reduce her exposure or and could you probably you could but could you get it out of her system or get it out of the sphere of influence on her menstrual cycle in any amount of time let alone a short amount of time that's questionable um just again a note about you got to keep your eye on the long range plan also for POI the osteoporosis the heart disease the Alzheimer's and that when we haven't even gotten to hot flashes insomnia night sweats vaginal atrophy Etc insulin resistance dyslipidemia uh and and more okay premature ovarian feather this is a a repeat I think but maybe a little bit more specific so she's prematurely menopausal POI could you do something for a few months my vote would be hang heavy on the Maca and but I have some other ideas there all the while thinking okay yes we're going to do that but we gotta help protect our bones her heart or brain so we can do fish oils and minerals and vitamin D and exercise and soy and all those things to also think of her future while we're also addressing the now but don't go too long uh that's a repeat I'm sorry I have repeat slides in here another repeat um okay what about um when she has an ovulatory amenorrhea unrelated to PCOS hypothyroid or hyperpolactinemia so my what who who might this was where I'd be looking is stress really the cause it could be um and she's not she doesn't fit the criteria of hypothalamic amenorrhea in our algorithm but I'm not going to just assume stress from the get-go even if I've heard some horrible story I'm still going to go through my algorithm progesterone precursor herbs do they have a role here certainly not for a progesterone challenge they might have a role in our short-term plan uh that could stimulate ovulation black coha should actually be on there but they don't although it doesn't contain diasogenin but adheres on this there's a study uh in PCOS patients let's see I don't think I have it here black cohosh 10 days out of the month 40 milligrams extract stimulated ovulation uh and then I just have these traditional Botanicals and their role as tonics as sedatives improving muscular tone um all those might have a role short term uh especially in the an ovulatory patient who's doesn't have PCOS doesn't have hypothyroid doesn't have hyperprolactinemia um black collage can be used certainly in a POI patient who's hasn't had a period for six months she's but she's less than age 40 so she's prematurely perimenopausal but we could take three months and see if we could get things going with black cohosh Tribulus pastry rhodiola is an herb not for everyone's familiar with in terms of an ovulation uh support herb and this was just a small study these were women who had secondary amenorrhea but we don't know the causes the paper didn't have the causes um but nonetheless it's what foreign out of about 25 out of 40 women became regular administrators and 11 of them became pregnant and then Vitex good old Chase tree berry uh that uh can be used in PCOS to help stimulate ovulation but remember the core problem of PCOS is insulin resistance hyperandrogenism so you have that has to be the core of your treatment plan so we'll come back to that but I'll talk about Vitex or chase tree berry for elevated prolactin we know that the basic function of Chase tree berry and the reproductive situation anyways it seems to stimulate the release of luteinizing hormone from the pituitary gland and mildly inhibits FSH and by doing so it has this indirect ability to modulate Progesterone so meaning if you stimulate ovulation now she has a corpus luteum that produces the progesterone that's what has to happen to have endogenous progesterone production but it's also Vitex can modulate the secretion of prolactin and I'll show you a little bit more about that this small study is showing that six of the women had a secondary amenorrhea and using a simple Chase tree they developed one or more menstrual cycles and this nice old-fashioned 40 drops of Chase tree berry tincture 15 out of 20 had the onset of menstrual cycles after having secondary amenorrhea uh flax seeds this study basically just shows that you can have more the women who took a certain amount 10 grams of flax seeds a day for three months had more ovulatory Cycles than women who weren't having ovulatory cycles and weren't having regular Menses not I I'm not a fan of the seed cycling because I don't these seeds don't work that in a short-term way just like Vitex doesn't work short term you need a few months typically two three four months to see vitax work I don't think you need only two weeks to see this seed work in two weeks to see that seed work that just doesn't make sense to me so I'm I kind of discourage that line of thinking but this study flax seeds 10 grams every day uh does seem to yield more ovulatory Cycles in women with secondary amenorrhea due to anovulation so chronic and ovulation here you see the flax seeds you could do cyclic progesterone either a oral that's OMP or lower dose a cream much lower dose you're not stimulating ovulation by the way by doing that you're merely helping to promote the withdrawal bleed we're going to use rhodiola and perhaps a Vitex and the flax seeds to stimulate ovulation Simplex F I apologize I try not to do proprietary things but that's a multi-glandular formula that has several bovine Source glands in it that I was one of the few glandulars I've hold on to over the years because I've seen it work um and then PCOS make sure you understand what are the criteria for diagnosing PCOS it's very specific uh and at the exclusion of other etiologies of her secondary amenorrhea so make sure you understand that and then there's some the this is the Rotterdam criteria and then there's um the Androgen excess Society has a little bit different criteria so it PCOS is the most common endocrine disorder of reproductive age women worldwide and there are high-risk groups um obesity is one example um premature uh adrenal dysfunction first degree relatives with PCOS type 1 or type 2 gestational diabetes uh they're but then the PCOS might be the cause of secondary amenorrhea but what's the cause of PCOS well we know it's hyperinsulinism and Hyper androidism but we might want to ask the question as naturopathic functional medicine alternative medicine people what's the cause of that and might there be environmental exposures or genetics and there is does seem to be a strong genetic link um so the treatment goals are to help her menstruate regularly um and meaning to ovulate regularly in this case provide endometrial protection because she's producing her normal amount of estrogen not too much estrogen she's just not producing normal amounts of progesterone because she's not ovulating either at all or certainly not regularly we also want to reduce her androgens and treat symptoms of excess like the acne the hirsutism the hair loss the body hair anywhere restore the fertility if desired and then there's Health maintenance issues reducing a risk of future problems all those are on our to-do list for PCOS patient and I've outlined here a sample of treatment plan just a sample think of it as a sample and but I have broken it down to what I consider fundamental like the things I pretty much probably am always going to do in a PCOS patient and I didn't I think we had time to go over the studies on these but there is quite a bit of data on n-acetylcysteine at this dose usually and PCOS so you might want to check that out it's kind of probably the most uh uh the supplement that has yeah it's just certainly the supplement has the most data in PCOS and it's right up there with a supplement that has the most data and any women's health condition and then here's that uh study I referred to the 40 milligram standardized extract 10 days a month um and then I have my top add-ons and the biggie in my book is the myoinositol four grams a day I almost always do that with I almost always do NAC and myoinositol so I might even if they don't have a very significant acne or hirsutism we know the underlying cause is on the list is hyper androgenism so I really want that myoinositol in there because that's really what that targets these other players Nettles root green tea um licorice Road they they are minor players in lowering androgens and saw palmetto I don't think actually in my estimation doesn't lower Androgen it lowers the effect of conversion of testosterone to dihydrotestosterone at the hair follicle and then we consider some of these other things and I definitely have on my consideration list metformin and and possibly spironolactone as well but metformin gets at the underlying cause of insulin resistance what about hyperprolactinemia um we want to for sure have ruled on our due diligence to make sure there's no tumor Vitex is our main player here 20 milligrams a day for three months I think I already mentioned that but lowering prolactin levels and uh it can be uh here's just again this bull lowers prolactin due to its dopaminergic effects increases serum progesterone improves pregnancy rates now these are women in with psos not specifically hyper prolactone or not only hyperprolactinemia but B6 also keep in mind this is just a very small uh study three women treated with B6 the gala who had a hyperpolactinemia and galactorrhea as a result um the uh it was able to actually uh lower or S cease the galactorrhea and lower the serum prolactin what's a little bothersome is the dosing that was used these can be doses fraught with side effects worry some side effects I would try to hang with the 200 and hope that there's going to be no peripheral neuropathy here's my sample treatment plan the dopamine is a monoamine derived from tyrosine and or alphenylalanine so that is why the l-tyrosine is in there in someone with hyperprolactinemia and then a little you know anorexia nervous well hypothalamic amenorrhea is I has lifelong consequences including osteoporosis and fractures if she's not given estrogen by the way but if she has anorexia as the cause of her hypothermic amen array that of course is a very complex situation uh and my treatment plans here my non-hormonal treatments plans here I want to stress the same thing that I stress for POI is don't go too long without giving her estrogen but my main players here are going to be Maca Vitex rhodiola polyglander support but she might also be depressed or anxious so we can have lots of other natural therapies to address that um and um and working again if she's anorexic we've got to bring a team of experts uh on board for that and this looks like a duplicate basically of the information before that here's some information from up to date uh on standard of care guidelines for hypothalamic amenorrhea you really have to consider hormones within a few months uh because the consequences are just too great if we naively go on and on and on um Baseline bone density I think is a good idea both in the POI case and the hypothalamic amenorrhea case uh you can use similar guidelines that we did for POI in terms of estrogen but the 0.1 estradiol patch the double the average menopause dose that you do once a week or there are patches that are twice a week and then we would typically if she wants to bleed we would cycle our oral micronized progesterone don't use a patch with progesterone cream don't use a patch with progesterone trokies those are not proven to protect the endometrium from the estrogen no matter what ideas you might believe or come up with about absorption it's just not proven um and there are is my last my last slide but I think there's another last slide here but I just want to point out that I do give seminars uh four times a year not me but me and a team of fabulous teachers and Educators and clinicians on a range of topics we have them quarterly the next one is the menopause hormone boot camp uh in April so you would go to The Institute of women's health and see what we've got going on um this is these are currently virtual only seminars and just a wealth of information very compatible with uh things that you are learning from the Dutch test library and then um I think he mentioned this but here's also a reminder that new providers get 50 off up to five testing kits and some other all goodies that are listed there so maybe that's actually decent time management on my part I must say so maybe we have some questions yeah wonderful time management thank you so much for a great presentation we do have a few questions that we can get to uh probably won't be able to get to all of them just bumping up against that one o'clock time hour but the very first and easy question is you mentioned a book at the beginning we had quite a few of our uh attendees ask what that book is and where they can get it one more time uh well it's a big old fat textbook um and it's I'm pretty sure it's called clinical gynecologic endocrinology [Music] and infertility and there's two authors Leon spiroff is one author and there's another author and like I said I think the it's not published yearly or every other year but the last Edition that's available I would look on online and you can purchase it if you just type in clinical gynecologic endocrinology and infertility Leon spiroff thank you very much next question would be any herbals that you use to help with an LH surge you mean they're not having an LH surge correct uh yeah I think uh I'm sorry if that wasn't glean from my information there but I would go with Vitex um possibly Rhodiola perfect uh the next question that we'll get to is does your treatment approach change at all if amenorrhea occurred after coming off birth control for 22 years no she well you mean okay I was so hoping to avoid that one but but I understand the question um so um going off of birth control pills is not the cause of her secondary amenorrhea that's the fundamental thing you have to accept she has an underlying cause the birth control pills were masking that cause someone probably she and either she had the problem way back when and was just put on birth control pills without a proper evaluation she had periods great she had contraception great and now she went off and boom the problem is back that's one scenario or during the course of taking the birth control pills she acquired PCOS or that her PCOS evolved for example uh or perhaps she now has POI but the birth control pills were not the cause something else is the cause so it behooves us to know what that is wonderful thank you uh the next question this will be the last one that we get to today is there a limit or a starting uh for a starting treatment for premature or ovarian failure example uh they stopped having a Menses at age 46 but now at 50 years old no hormonal treatment for four years should they start treatment because they're less than 51. okay so actually uh stopping your menses at age 46 is not premature ovarian insufficiency premature menopause or POI is stopping your menses before the age of 40 due to that cause remember there might be other causes so it the cutoff is age 40. she's become menopausal apparently at age 46 that's within the normal time range uh becoming menopausal before age 40 is premature between the ages of 40 and 45 is early she's at 46 she doesn't need to go on hormones to protect bones heart brain but if it was before 40 or between 40 and 45 I would vote she should and if she was 43 she would take hormones until she was about 51. if she was less than 40 she would take hormones until she's about 51. she's 46 and she she stopped Menses at 46 and if I remember she's Now 51 or 50. so she could she could go on hormones if you had a good reason quality of life issues or osteoporosis prevention because she's at high risk mother had a hip fracture or she has a sucky bone density uh or she already has osteoporosis those would be the three buckets she could as long as she's within 10 years of her last menstrual period due to menopause you can safely initiate systemic hormonal therapy and that's that in about 500 times more in details are in the menopause hormone boot camp in April because it's a really important question I'm glad you brought it out so I could clarify again the ages but that below 40 40 to 45 and then after 45 is a very they're three very different scenarios that your patient she's become menopausal at a fine normal age she can go on estrogen because she's within four years of that last menstrual period if she if you have a good reason for her to go on it's less than 10 years okay thank you for getting forgetting that question thank you all again for joining us today uh make sure you check your inboxes tomorrow for a link to the recording and to download the slides if you do have any additional questions about today's content or for general questions about the Dutch Test please email our customer support team at info dutchtest.com thank you and have a great rest of your day thanks everybody bye-bye

hello everyone and welcome to the February Dutch webinar I&#39;m Noah Reed vice president of sales and marketing for precision analytical creators of the Dutch test today we are excited to bring you an expert in women&#39;s health Dr Tori Hudson Dr Hudson is here to explain secondary amenorrhea and give you tips to treat your patients who may be struggling with it today&#39;s webinar is one of many educational resources available through Dutch visit us at dutchtest.com and find a vast library of videos and educational resources to help you understand hormones and treat your patients complex hormone-related issues coming soon we will also be launching a full online education course with in-depth topics to help providers become hormone experts and profoundly change the lives of their patients this free course will only be available to registered Dutch providers so sign up today and be one of the first to gain access to this amazing new course signing up as a Dutch provider is easy just click the link we&#39;ve posted in the chat and complete the become a provider form on our website if you sign up today you&#39;ll also receive 50 off your first five test kits plus patient referrals and access to even more valuable education now a few housekeeping notes before we get started with today&#39;s webinar you can find today&#39;s slides in the handout section of the control panel on your screen this webinar is also being recorded and everyone who registered will receive the recording via email tomorrow if you have questions along the way add them to the questions section of the control panel as well we will conduct a short q a after the presentation if time allows lastly please keep in mind that the contents of this webinar are for educational and informational purposes only the information is not to be interpreted as or mistaken for clinical advice please consult a medical professional or health care provider for medical advice diagnosis or treatment patients can find a list of Dutch providers in their area on our website through find a provider button at the top of the page and now let me introduce today&#39;s speaker Dr Tori Hudson is a naturopathic physician who graduated from the National College of natural naturopathic medicine in 1984 and has since served at the college in many capacities including Professor medical director and academic Dean she is currently an adjunct clinical professor at am Southwest College of naturopathic medicine in Bastyr University Dr Hudson has been in practice for more than 38 years she&#39;s the medical director of her Clinic a women&#39;s time in Portland Oregon and is the director of product research and education for vitalica she is also the founder and co-director of naturopathic Education and Research Consortium a non-profit organization for accredited accredited naturopathic residencies in May of 2021 she received the Freddy Kronberg excellence in research and education in Botanicals for Women&#39;s Health award from the American Botanical Council this prestigious award is presented to the researcher educator or clinician who furthers the scientific study education and clinical use of medicinal plants in phytomedicines for women&#39;s health conditions Dr Hudson is also nationally a nationally recognized author speaker educator researcher and clinician who serves on several editorial boards advisory panels in a consult a consultant to the natural products industry thank you for joining us today Dr Hudson we&#39;re all ready when you are all right my pleasure thank you so much and I just want to thank the the Dutch test team overall for inviting me to speak week and I just really also want to commend you all for at Dutch for offering practitioners content that you know may or may not directly uh be relevant to Dutch testing I I appreciate that and just in the spirit of women&#39;s health and education of consumers clinicians and my motto how do we help more women more of the time so I appreciate that you all are up to that um in all kinds of ways let me I&#39;m speaking to you from Portland Oregon by the way um and this is my normal time would I be eating my my dark chocolate right after lunch but which is now currently my source of cadmium and Lead apparently um and I&#39;m sure you all have been reading about that so I&#39;ve been enjoying trying to figure find out where I can get the best chocolate with the least Academy and the least lid um I think this has already been read to you by the Dutch test folks and the disclosures um he mentioned vitalica I am co-owner of itanica as well and I do serve on the scientific advisory Boards of of a few different entities um but let&#39;s start with our topic of amenorrhea and by the way I&#39;m going to go in and out of my video uh so don&#39;t be alarmed if you can&#39;t see me um I&#39;ll be coming back and forth so amenorrhea as it turns out is kind of one of the most challenging problems in gynecologic endocrinology and the reason why it is is because there&#39;s just an array of potential diseases and disorders that involve multiple organ systems and in some cases carry morbid or even lethal consequences so it can be complex but if we are attentive and methodical we as practitioners and stick with the process that I&#39;m going to outline today in the workup which is it all starts with the workup a diagnosis can be made from this presenting symptom of secondary amenorrhea and by the way by there are different there&#39;s also primary amenorrhea and that&#39;s when you someone does not have a Menses by age 14 in the absence of growth or development of secondary sexual characteristics or no Menses by 16 regardless of the presence of normal growth and development and secondary sex characteristics that&#39;s also primary inventory and we&#39;re not going to talk about primary amenity today we&#39;re talking about secondary which is the Menses has occurred at some point in their past even if it was just a little bit even if it was one time but now it&#39;s not occurring and it has not been occurring for three months if they have a history of raider Cycles or it&#39;s not occurring for six months if it&#39;s been a history of irregular Cycles all that is the definition of secondary amenorrhea and you can see the preference up above and especially women with infertility 20 percent of those cases of infertility are caused by secondary amenorrhea foreign so let&#39;s start with how do we understand some basic principles uh and if we understand I&#39;m going to assume that we all understand sort of basic principles of menstruation uh then we can see these discrete compartmental systems on which that menstrual function depends so our evaluation today is going to segregate the causes of secondary amen or into these four compartments compartment one is where there&#39;s some problem with the outflow track it could be that the Oz you know the cervix is stenosed it could be in the case of secondary of course the case of primary they they could be absent some some congenital absence of major uh significance but in secondary elementary it&#39;s more that that Oz would become stenos closed off and the blood actually cannot Escape um or the uterus itself is not um there&#39;s something that has occurred over time where it&#39;s been damaged um such that it can&#39;t receive that estrogen stimulation in particular uh but also progesterone compartment two is problems in the ovary compartment threes problems in the anterior pituitary and compartment four is disorders of the central nervous system the hypothalamic uh factors in particular the history and the physical exam should seek to evidence for starting with sort of start with the stress aspect but don&#39;t assume that or presume that or just say oh she&#39;s stressed that&#39;s why we include that um but then we need to go on because there also might be some family history of some uh some genetic meaning there might be uh we should look for problems with the focus on nutritional status are they do they have do we have reason to think that thou amrish do we have reason to think that they are on Extreme uh diets do we have reason to think they have disordered eating or anorexia or bulimia especially anorexia do we have information about their excessive exercise and the combination of excessive exercise and eating disorder are sort of the most wicked combination of the two um and then are they having you know normal or abnormal growth and development of breasts for example uh and um that&#39;s I think and I think that covers it let me just look at all this there might be some uh medication uh that could be Happening Here For example even a young woman can get breast cancer can be uh or or or some other Cancer and a local pelvic radiation and or systemic anti-hormonal therapy or chemotherapy all those can cause secondary amenorrhea and um and essentially premature menopause um that is one of the causes of secondary amenorrhea so medication history is important um her her specific menstrual history is very important how old was she did she ever have regular Menses if so when was that when did they stop um does she have some other chronic illness um that might might be related we&#39;ll talk a little bit about that like do do we know she already has hypothyroidism as one small example there&#39;s also the issue uh in terms of their her uh review of systems we want to know if she has galactorrhea or nipple discharge this is an important sign and whether it&#39;s spontaneous or whether it occurs only when the the nipple and breast are compressed and expressed and it can be an important sign whether it&#39;s one breast or both breasts and whether it&#39;s persistent or intermittent all that has potential is important to know now hormonal secretions that are uh you might say benign meaning non-cancerous these hormonal secretions that cause uh galactorrhea usually come from multiple duct openings which you can actually see when you&#39;re looking at the nipple how many of those duct openings is that galactorrhea being is coming from uh because a pathologic discharge usually comes from a single duct and only one breast so that would be a breast cancer or perhaps a papilloma which can be benign but and if they have both amenorrhea and galactorrhea we actually proceed with the evaluation of the amenorrhea first and then we add the other evaluation of galactria after that our amen re-evaluation is done the physical exam you know we&#39;re looking secondary sex characteristics we&#39;re looking for evidence of hirsutism acne hair loss something on the skin not just acne but something called acanthosis nigricans which is a dark discoloration and the body folds increases usually it happens in the armpits uh and the groin or armpits or the groin uh and or the neck region so here uh groin and neck region um and then we want to know how much she weighs and how what her height is and assessor body mass index um does she have proper sexual maturity I think that&#39;s everything on this list let&#39;s see um and then we&#39;re going to get to testing so this next section of before we get to Therapeutics this this is a little bit weighty in here with evaluation and workup and you&#39;re going to need to refer to these slides you clinicians who are hopefully going to adopt this work up um because it&#39;s it&#39;s not a it&#39;s it&#39;s not going to be easy to grasp just with a one-time through there is a very important chapter in a very important book called uh Clinic was it called so I&#39;m looking at a clinical uh gynecologic endocrinology and fertility by Leanne spirov I think the last Edition was a few years ago it&#39;s still that amenorrhea chapter is golden you probably I recommend that my residence actually read that chapter four times uh before they really kind of get the drift of it all is usually takes about four times uh and then of course it takes you know having one two three four patients that you&#39;re walking through it before you kind of get comfortable so these are the tests that we&#39;re talking about um at different points along the algorithm here that I&#39;m going to lay out in the next few moments what you notice is there&#39;s no salivary testing or urinary testing on here and that&#39;s because the algorithms for a clinical diagnosis of a uh of a medical condition that&#39;s underlying the cause of secondary amen or it does not include any of those kinds of tests uh now that you could certainly do other functional medicine testings such as a dust test to for some other aspect of their health or their medical history their family history breast cancer for example but to diagnose their cause of secondary amenorrhea we need to really focus on knowing how and when to use these tests and the meaning of the results of these tests so step one starts with are they pregnant and you can decide if you want to conclude that you&#39;re comfortable with their answer to your questions about sexual activity with the uh an intercourse with a male partner I.E sperm exposure uh and or or uh if the history is adequate or if you should do a pregnancy test and sometimes that&#39;s a delicate situation but the Baseline testing is determine if they&#39;re pregnant or not a TSH test you don&#39;t need to do all the other hoopla for thyroid for this algorithm and a serum prolactin level that is uh that&#39;s the initial step um and if she has an elevated TSH and by elevated I mean actually beyond the 4.5 reference range um it would be very rare but not absolutely impossible but very rare for a gray Zone TSH like a 3.0 TSH to cause secondary amenor yet now if she so what which I would call sort of sub-optimal but not hypothyroid now maybe that gray zone between 2 and 4.5 TSH could along with her being underweight along with her being highly stressed then maybe we could we could see the influence that she&#39;s more more vulnerable to that sub-optimal TSH of course if she&#39;s so if she&#39;s hypothyroid we treat her hypothyroidism as the treatment for her secondary amenorrhea obviously if she&#39;s pregnant we go from there elevated prolactin levels um we um have to decide when when we do imaging and so there are some cutoffs with some numbers you can look up uh versus monitoring just the serum prolactin but it&#39;s elevated uh definitely I think the number is above 100 don&#39;t quote me on that but I believe that&#39;s the case uh we want need to determine if there&#39;s a tumor involved and imaging with a what they call a cone down x-ray of the celestica is what is I think the still standard of care if all these are normal she&#39;s not pregnant she&#39;s not hypothyroid she doesn&#39;t have elevated serum prolactin then we go on to what is called a progesterone challenge test or progestational challenge test so that the purpose of this it&#39;s very important to understand this the purpose of a progesterone challenge test is to assess the level of endogenous estrogen and the competence of her outflow tract and there are three different ways to do that that are accepted in uh what you might call standard of care conventional algorithm and work up and evaluation of secondary amenorrhea one is a synthetic progestin called medroxyprogesterone acetate or MPA 10 milligrams a day for five days another is you could use oral micronized progesterone three to four hundred milligrams a day for five to seven days frankly I in this case I wouldn&#39;t get fussy oh you want to use bioidentical versus synthetic it&#39;s only for a few days and actually progesterone at three to four hundred milligrams might more likely cause immediate side effects like sedation or groggy or dizzy or lightheaded or drunken feeling might more likely cause that within the few days than would these MPA and the mpa at is stronger even that 10 milligrams versus 400 milligrams is stronger so you do get I think a better test you might say one can use parental progesterone I don&#39;t do that so I stick with either one or number two um within two to seven days after the conclusion of the progestational medication the patient will either bleed or she won&#39;t bleed now if she bleeds we get to make a diagnosis of an ovulation and we we know that&#39;s reliable and securely established because she&#39;s having a withdrawal bleed after this progesterone challenge even if she just has a few tiny blood spots following a progesterone challenge that it does in fact imply at least a marginal level of endogenous estrogen and it implies the presence of a functional outflow tract and a uter and we now know that there is a uterus line by reactive endometrium sufficient that it gets it can be stimulated by her endogenous estrogen we&#39;ve confirmed all of that and with this confirmation of the presence of estrogen at least some minimal function of her ovary her pituitary and her hypothalamus has been established published by this simple test with this positive withdrawal bleed in response to the progestogen challenge and in the absence of galactorrhea and in the presence of a normal prolactin normal th we don&#39;t have to do any further evaluation necessary because this combination of things effectively rules out a significant pituitary tumor and we know she&#39;s not ovulating now her estrogen her ovarian estrogen production is good what&#39;s not good is she&#39;s not ovulating so then we can further understand that is it because she&#39;s stressed is she because she has PCOS so there is a little bit more work to do there but we had our history uh that that hopefully leads us in the right directions uh you notice what&#39;s not on here is progesterone cream or progesterone trokies please do not use those for this test called The progestational Challenge test they are not adequate they are not proven entities to accomplish the uh the reliable information that we need there are a couple rare there are some rare situations associated with a negative withdrawal bleed despite the presence of adequate endogenous estrogen so that I&#39;m about to confuse you but one of those is PCOS PCOS women have adequate estrogen they have adequate uh hypothalamic pituitary ovarian axis orchestration happening but what they do have is insulin resistance and Hyper androidism and that&#39;s interfering with the maturation of their follicles and and ovulation so that&#39;s not so rare but the second situation is the endometrium is decidualized by high progesterone levels associated with a very specific adrenal enzyme deficiency um if there&#39;s no bleed after the progesterone challenges not even a spot that then the problem is either the target organ is a problem meaning the uterus uh or there&#39;s um some some kind of the estrogen proliferation of the endometrium has not occurred so now we&#39;re trying to figure out what&#39;s that about so when there&#39;s no bleed with the progesterone challenge this is step two um this step is designed to clarify the situation is the problem the uterus is the problem um the orchestration with the hpo axis uh and orally in order to sort this begin to sort this out now we give a basically orally active estrogen in a quantity and duration that&#39;s certain to stimulate the endometrial proliferation and with a progestogen is is certain to cause a withdrawal bleed providing that she has a reactive uterus and a good outflow tract so that is why we give I would say one of these two methods you can give either an oral estrogen CE stands for conjugated equine estrogen that&#39;s Premarin which 1.25 is double your average dose or you can do bioidentical estradiol two milligrams is twice your average menopausal dose I should State and you do that for 21 days and then you bring on the mpa for the last five days another way to do it is a birth control pill I would recommend a 30 microgram pill not a 20 and definitely not a 10. you remember where the goal is to to clarify the situation we have to give enough active estrogen uh in enough amounts and duration to stimulate that endometrial proliferation so don&#39;t use a cream don&#39;t use a vaginal estrogen use one of these two methods please the purpose of these is a test we&#39;re testing these we&#39;re using these hormones as tests not as treatment so if there is no withdrawal bleed with so how we got to this step is there was no withdrawal relief from the progestogen talons now there&#39;s no withdrawal bleed with giving estrogen and a progestin so if this means the diagnosis of a defect in compartment one systems can be made so we look back at compartment one compartment one is a problem in the uh outflow track or the uterus itself so no withdrawal bleed with progestogen no withdrawal bleed with estrogen and progestogen the problem is either is in the compartment one if withdrawal bleeding does occur with this step too now we can assume that compartment one systems have normal function capacities they can receive estrogen and they can exit the lining of the the uterus and the tissue in the blood if it&#39;s properly stimulated by the estrogen so if the patient has normal external and internal genitalia by exam and in the absence of a history of infection or trauma we actually then go on to step three because she had a withdrawal bleed with this Purpose with this regimen the purpose of uh so if she bled after our estrogen stimulation again we now know that her endogenous estrogen is actually not adequate to stimulate the endometrium but now we need to know why um and because she it wasn&#39;t we proved it wasn&#39;t adequate in step one because she did not have a withdrawal bleed we got to get step two we even gave her estrogen it still didn&#39;t occur so in order to produce estrogen the ovaries have to contain a normal follicular apparatus and sufficient pituitary gonadotropins to stimulate that apparatus so this step step three is designed to determine which of these true crucial components is functioning improperly the gonadotropins or the follicular activity so it&#39;s designed to determine whether the lack of estrogen is due to a fault in the follicle which is compartment one or is it a a problem in this CNS pituitary axis axis sorry which is compartments three and four so what do we do now we test her FS her serum FSH and LH and I know what too often occurs someone does has secondary a mineral we just throw a bunch of tests at them throw estrogen progesterone FSH LH thyroid what didn&#39;t I mention who who other functional medicine tests we just throw the gamut atom because we actually kind of don&#39;t know what we&#39;re doing if we do that would be my assertion and this so we going through this step we might have never even gotten to needing those tests this this methodical algorithm pays off in efficiency of diagnosis accurate diagnosis and uh cost of testing cost of of knowing what&#39;s going on we reduce our costs okay so step three continued the so so what if her outcome is an FSH that&#39;s elevated n and Elevate LH is elevated and what I elevated here we mean greater than 20. um the association between high levels of gonadotropins and ovarian failure is very reliable but there are some situations in which high gonadotropins can be accompanied by ovaries that contain follicles so there are some rare tumors that can produce gonadotropins even that&#39;s actually associated with the lung cancer oddly enough there&#39;s a handful of reports of a single gonadotropin deficiency maybe a high level of one and maybe undetectable or Baseline normal of the other and there might so there might be this homozygous mutation in the gonadotropin genes I&#39;ve never seen either of these two situations by the way in uh 38 years and then there are situations uh rare where a high FSH and a low LH could occur and this would make us suspect a gonadotropin secreting pituitary adenoma but these are all rare tumors that are FSH secreting um and most of these case reports are actually in men so what we&#39;re looking for is this FSH in particular above 20. I.E is it in the menopausal range I put POF premature ovarian failure uh I should update that the premature ovarian insufficiency is a more commonly used term these days so what if she has an elevated FSH and a normal LH from our test well during that perimenopausal period it&#39;s actually normal for FSH levels to begin to rise even before bleeding has cease and that is a very labile number FSH in perimenopause so this is true whether it&#39;s perimenopause at the normal age or it&#39;s perimenopause prematurely and during that perimenopausal period those remaining follicles you might say are the least sensitive of all the follicles because they remain in place and fail to respond for gonadotropins for all these many years so as these remaining follicles begin to respond to that Rising FSH level during perimenopause the production of inhibin is also maybe inadequate because that is responsible for a negative feedback as well so the patient can have elevated levels of FSH despite continued bleeding or very recent onset of their amenorrhea so we kind of need to pay attention to this situation because a period of post-menopausal levels of FSH can be followed by a pregnancy so that&#39;s why we want to measure both FSH and LH so that we can understand if she&#39;s truly perimenopausal or not which is associated with high FSH but normal LH and then we have the elevated FSH uh LH in what&#39;s called resistant or insensitive ovaries um I think I might let you read a little bit about that because that condition is rare they can sometimes they even have to do laparotomy to look to find follicles deep within the ovary it&#39;s maybe possible that ultrasound can be used to see if there&#39;s a low number of follicles but this is where she has elevated gonadotropins despite the presence of ovarian follicles remember we get into these tests and these interpretations because of our earlier steps and in particular uh yeah our earlier steps and then secondary amen area due to premature ovarian failure or premature menopause can be due to autoimmune disease so this is where maybe thyroid antibody testing could be helpful but also does she already have myasthenia gravis or ITP or rheumatoid arthritis or Vitiligo or autoimmune hemolytic anemia or true adrenal insufficiency I&#39;m not talking about you know a functional medicine test that shows uh adrenal this and that I&#39;m talking about true adrenal insufficiency measured by challenged you know they have to get these shots to challenge their adrenals to really diagnose that um but a classic case of premature menopause or POF or POI can precede adrenal failure so monitoring adrenal function is my the important and then the final situation associated with high gonadotropins and normal ovarian follicles include galactosemia and an enzymatic deficiency in both ovaries and the adrenal glands this person though would present with absent secondary sexual development it might be hypertensive okay what about this situation she has normal gonadotropin so this is the one you&#39;re going to see um and you&#39;re going to maybe scratch your head well those are normal so normal FSH normal LH this is hypothalamic amenorrhea and there&#39;s no other test that you need to know because we&#39;ve gone through all the other steps and now we do know and remember we got here because um of our previous in the patients with normal exam in the absence of History error infection she had a withdrawal bleed from the birth control not from the progestogen but from the birth control pills when she was properly stimulated by estrogen but we want to know why isn&#39;t she producing enough of her own so if we get to this place in the algorithm boom we get to diagnose hypothalamic amenorrhea and then there&#39;s low FSH or normal FSH LH that&#39;s one final step to distinguish between pituitary or CNS hypotherm cause of amenorrhea and that is where we have to come back to that x-ray evaluation of the Celica turcica I don&#39;t think I said that right okay what about congenital abnormalities those are limited to secondary amenorrhea which presents in the puberty time period in a study of almost 300 women with secondary amenorrhea that the chart kind of breaks down like this so you see uh there might be so Turner syndrome is something you&#39;ll probably see certainly premature menopause is definitely something you&#39;ll see uh and um and ovulation is the most common is it stress is it uh is it PCOS uh not very often is it actually hypothyroid okay now we&#39;re going to go to um our natural treatment interventions but again I&#39;m gonna perhaps annoyingly stress we have to make an accurate diagnosis from these tests this algorithm to know that we&#39;re treating the right thing you don&#39;t just say Throw Vitex or Maca or black cohosh or seed cycling or whatever else you can come ideas you might have at a secondary amenorrhea person without knowing the cause because the causes are very different they&#39;re treated very differently and each of them is associated with future different risk of future health problems PCOS associated with future risk of type 2 diabetes heart disease hypothalamic amenorrhea if not treated properly associated with osteoporosis and fractures premature ovarian insufficiency associated with under with if it&#39;s not treated at adequately risk for osteoporosis fractures heart disease possibly Alzheimer&#39;s disease and just premature aging of everything skin bones eyes everything let alone quality of life issues in all of these that I&#39;m mentioning so we need to understand that underlying cause with our methodical work up and coming to and going through those evaluation steps and coming to what is the underlying cause or causes and now we get to manage that underlying cause any complications associated with that she&#39;s PCOS we need to be mindful of the long-range plan too preventing diabetes and heart disease especially if she&#39;s obese uh so prevention prevention prevention in addition so don&#39;t just set your eyes on oh I want her to have a menstrual period we need to set aside on the menstrual period as a reflection of her endocrine health quality of life issues that she&#39;s having that she doesn&#39;t want to have like infertility acne hirsutism depression and prevention of Big Time future diseases that we can actually reduce the risk of so these uh at least the first six bullet points would look familiar to naturopathic Physicians those are our there are principles I also have the Tori Hudson United say principles of resonance and choice resonance being what&#39;s right for this what&#39;s the right treatment plan relative to not just the disease and the condition but there are other health issues there their way of life their finances their abilities to take things and do things that&#39;s all about resonance and then ultimately with enough with the right education they get to choose what they&#39;re comfortable with then there&#39;s also uh perhaps some you know other things we&#39;re going to have to kind of uh addressed especially if if it&#39;s relating if her condition PCOS POI or hypothalamic amenorrhea are going to affect her fertility so there might be conversations and addressing her emotions about that there might need to be some other child bearing or child rearing options that need to be discussed either with you or someone else she she might have this be having secondary amenorrhea as I mentioned much earlier due to medication one some of those medications related to Cancers and certain cancer treatments do increase the risk of premature menopause so we have that is essentially then a side effect of that cancer treatment and then we are going to need to give her treatment options we&#39;re going to talk about I have listed here just in a hormonal contraception and menopausal hormone therapy and you might ask well why aren&#39;t why isn&#39;t Botanicals and Lifestyle on this list she&#39;s prematurely menopausal that means she stopped having her period because of due to premature ovarian insufficiency which we learn from our algorithm and work up and tests and she the standard of care for her is that she be on menopausal hormone therapy or birth control pills until she&#39;s 51. that is the standard of care if you don&#39;t do that you are risking her future osteoporosis heart disease fractures Alzheimer&#39;s disease premature aging dying a few years earlier than she would die normally have died and a few years earlier than she would die if compared to taking hormone therapy so that&#39;s why Botanicals and nutraceuticals are not the on this list that&#39;s not to say you can&#39;t do them in addition bone prevention heart disease prevention while other quality of life issues for sure um but the primary treatment for POI should be some proven Doses and delivery of estrogen and progestogens I&#39;m stressing proven because she does have a uterus you give her estrogen we got to give her proven doses of progestogen to protect her uterine lining so here are some uh might we investigate environmental exposures autoimmune genetic causes yeah we might we might do that um so there are some examples ex means examples of hormone regimens that are accepted and within standards of care proven to uh be uh protect your uterine lining from endometrial cancer proven to provide estrogen support for the aging process all the things that I mentioned those are all accepted regimens um and it looks like um even the estrogen patch the point one patch which is the double the average dose patch is superior to a 30 microgram birth control pill in improving bone mineral density in women with POI that&#39;s a little bit surprising but that there is some evidence to show that now could you try something non-hormonal for a period of time just to see if this is the cause POI I would not do that for any longer six months Max now she might already have been a menorate for six months so she&#39;s already put in her six months of estrogen deficiency you might say so with that I don&#39;t really want to go another six months that&#39;s a whole year that&#39;s going to cost her in her future so I might say okay let we&#39;ll go three months um and to see if we can get a menstrual cycle going with these things um so that&#39;s kind of a tough call but the the main message is don&#39;t go too long um with non-hormonal proven treatments to prevent these big time future diseases uh in a POI case these are just some other things you might consider exploring if you want to explore environmental exposures could if there&#39;s an expire environmental exposure could you reduce her exposure or and could you probably you could but could you get it out of her system or get it out of the sphere of influence on her menstrual cycle in any amount of time let alone a short amount of time that&#39;s questionable um just again a note about you got to keep your eye on the long range plan also for POI the osteoporosis the heart disease the Alzheimer&#39;s and that when we haven&#39;t even gotten to hot flashes insomnia night sweats vaginal atrophy Etc insulin resistance dyslipidemia uh and and more okay premature ovarian feather this is a a repeat I think but maybe a little bit more specific so she&#39;s prematurely menopausal POI could you do something for a few months my vote would be hang heavy on the Maca and but I have some other ideas there all the while thinking okay yes we&#39;re going to do that but we gotta help protect our bones her heart or brain so we can do fish oils and minerals and vitamin D and exercise and soy and all those things to also think of her future while we&#39;re also addressing the now but don&#39;t go too long uh that&#39;s a repeat I&#39;m sorry I have repeat slides in here another repeat um okay what about um when she has an ovulatory amenorrhea unrelated to PCOS hypothyroid or hyperpolactinemia so my what who who might this was where I&#39;d be looking is stress really the cause it could be um and she&#39;s not she doesn&#39;t fit the criteria of hypothalamic amenorrhea in our algorithm but I&#39;m not going to just assume stress from the get-go even if I&#39;ve heard some horrible story I&#39;m still going to go through my algorithm progesterone precursor herbs do they have a role here certainly not for a progesterone challenge they might have a role in our short-term plan uh that could stimulate ovulation black coha should actually be on there but they don&#39;t although it doesn&#39;t contain diasogenin but adheres on this there&#39;s a study uh in PCOS patients let&#39;s see I don&#39;t think I have it here black cohosh 10 days out of the month 40 milligrams extract stimulated ovulation uh and then I just have these traditional Botanicals and their role as tonics as sedatives improving muscular tone um all those might have a role short term uh especially in the an ovulatory patient who&#39;s doesn&#39;t have PCOS doesn&#39;t have hypothyroid doesn&#39;t have hyperprolactinemia um black collage can be used certainly in a POI patient who&#39;s hasn&#39;t had a period for six months she&#39;s but she&#39;s less than age 40 so she&#39;s prematurely perimenopausal but we could take three months and see if we could get things going with black cohosh Tribulus pastry rhodiola is an herb not for everyone&#39;s familiar with in terms of an ovulation uh support herb and this was just a small study these were women who had secondary amenorrhea but we don&#39;t know the causes the paper didn&#39;t have the causes um but nonetheless it&#39;s what foreign out of about 25 out of 40 women became regular administrators and 11 of them became pregnant and then Vitex good old Chase tree berry uh that uh can be used in PCOS to help stimulate ovulation but remember the core problem of PCOS is insulin resistance hyperandrogenism so you have that has to be the core of your treatment plan so we&#39;ll come back to that but I&#39;ll talk about Vitex or chase tree berry for elevated prolactin we know that the basic function of Chase tree berry and the reproductive situation anyways it seems to stimulate the release of luteinizing hormone from the pituitary gland and mildly inhibits FSH and by doing so it has this indirect ability to modulate Progesterone so meaning if you stimulate ovulation now she has a corpus luteum that produces the progesterone that&#39;s what has to happen to have endogenous progesterone production but it&#39;s also Vitex can modulate the secretion of prolactin and I&#39;ll show you a little bit more about that this small study is showing that six of the women had a secondary amenorrhea and using a simple Chase tree they developed one or more menstrual cycles and this nice old-fashioned 40 drops of Chase tree berry tincture 15 out of 20 had the onset of menstrual cycles after having secondary amenorrhea uh flax seeds this study basically just shows that you can have more the women who took a certain amount 10 grams of flax seeds a day for three months had more ovulatory Cycles than women who weren&#39;t having ovulatory cycles and weren&#39;t having regular Menses not I I&#39;m not a fan of the seed cycling because I don&#39;t these seeds don&#39;t work that in a short-term way just like Vitex doesn&#39;t work short term you need a few months typically two three four months to see vitax work I don&#39;t think you need only two weeks to see this seed work in two weeks to see that seed work that just doesn&#39;t make sense to me so I&#39;m I kind of discourage that line of thinking but this study flax seeds 10 grams every day uh does seem to yield more ovulatory Cycles in women with secondary amenorrhea due to anovulation so chronic and ovulation here you see the flax seeds you could do cyclic progesterone either a oral that&#39;s OMP or lower dose a cream much lower dose you&#39;re not stimulating ovulation by the way by doing that you&#39;re merely helping to promote the withdrawal bleed we&#39;re going to use rhodiola and perhaps a Vitex and the flax seeds to stimulate ovulation Simplex F I apologize I try not to do proprietary things but that&#39;s a multi-glandular formula that has several bovine Source glands in it that I was one of the few glandulars I&#39;ve hold on to over the years because I&#39;ve seen it work um and then PCOS make sure you understand what are the criteria for diagnosing PCOS it&#39;s very specific uh and at the exclusion of other etiologies of her secondary amenorrhea so make sure you understand that and then there&#39;s some the this is the Rotterdam criteria and then there&#39;s um the Androgen excess Society has a little bit different criteria so it PCOS is the most common endocrine disorder of reproductive age women worldwide and there are high-risk groups um obesity is one example um premature uh adrenal dysfunction first degree relatives with PCOS type 1 or type 2 gestational diabetes uh they&#39;re but then the PCOS might be the cause of secondary amenorrhea but what&#39;s the cause of PCOS well we know it&#39;s hyperinsulinism and Hyper androidism but we might want to ask the question as naturopathic functional medicine alternative medicine people what&#39;s the cause of that and might there be environmental exposures or genetics and there is does seem to be a strong genetic link um so the treatment goals are to help her menstruate regularly um and meaning to ovulate regularly in this case provide endometrial protection because she&#39;s producing her normal amount of estrogen not too much estrogen she&#39;s just not producing normal amounts of progesterone because she&#39;s not ovulating either at all or certainly not regularly we also want to reduce her androgens and treat symptoms of excess like the acne the hirsutism the hair loss the body hair anywhere restore the fertility if desired and then there&#39;s Health maintenance issues reducing a risk of future problems all those are on our to-do list for PCOS patient and I&#39;ve outlined here a sample of treatment plan just a sample think of it as a sample and but I have broken it down to what I consider fundamental like the things I pretty much probably am always going to do in a PCOS patient and I didn&#39;t I think we had time to go over the studies on these but there is quite a bit of data on n-acetylcysteine at this dose usually and PCOS so you might want to check that out it&#39;s kind of probably the most uh uh the supplement that has yeah it&#39;s just certainly the supplement has the most data in PCOS and it&#39;s right up there with a supplement that has the most data and any women&#39;s health condition and then here&#39;s that uh study I referred to the 40 milligram standardized extract 10 days a month um and then I have my top add-ons and the biggie in my book is the myoinositol four grams a day I almost always do that with I almost always do NAC and myoinositol so I might even if they don&#39;t have a very significant acne or hirsutism we know the underlying cause is on the list is hyper androgenism so I really want that myoinositol in there because that&#39;s really what that targets these other players Nettles root green tea um licorice Road they they are minor players in lowering androgens and saw palmetto I don&#39;t think actually in my estimation doesn&#39;t lower Androgen it lowers the effect of conversion of testosterone to dihydrotestosterone at the hair follicle and then we consider some of these other things and I definitely have on my consideration list metformin and and possibly spironolactone as well but metformin gets at the underlying cause of insulin resistance what about hyperprolactinemia um we want to for sure have ruled on our due diligence to make sure there&#39;s no tumor Vitex is our main player here 20 milligrams a day for three months I think I already mentioned that but lowering prolactin levels and uh it can be uh here&#39;s just again this bull lowers prolactin due to its dopaminergic effects increases serum progesterone improves pregnancy rates now these are women in with psos not specifically hyper prolactone or not only hyperprolactinemia but B6 also keep in mind this is just a very small uh study three women treated with B6 the gala who had a hyperpolactinemia and galactorrhea as a result um the uh it was able to actually uh lower or S cease the galactorrhea and lower the serum prolactin what&#39;s a little bothersome is the dosing that was used these can be doses fraught with side effects worry some side effects I would try to hang with the 200 and hope that there&#39;s going to be no peripheral neuropathy here&#39;s my sample treatment plan the dopamine is a monoamine derived from tyrosine and or alphenylalanine so that is why the l-tyrosine is in there in someone with hyperprolactinemia and then a little you know anorexia nervous well hypothalamic amenorrhea is I has lifelong consequences including osteoporosis and fractures if she&#39;s not given estrogen by the way but if she has anorexia as the cause of her hypothermic amen array that of course is a very complex situation uh and my treatment plans here my non-hormonal treatments plans here I want to stress the same thing that I stress for POI is don&#39;t go too long without giving her estrogen but my main players here are going to be Maca Vitex rhodiola polyglander support but she might also be depressed or anxious so we can have lots of other natural therapies to address that um and um and working again if she&#39;s anorexic we&#39;ve got to bring a team of experts uh on board for that and this looks like a duplicate basically of the information before that here&#39;s some information from up to date uh on standard of care guidelines for hypothalamic amenorrhea you really have to consider hormones within a few months uh because the consequences are just too great if we naively go on and on and on um Baseline bone density I think is a good idea both in the POI case and the hypothalamic amenorrhea case uh you can use similar guidelines that we did for POI in terms of estrogen but the 0.1 estradiol patch the double the average menopause dose that you do once a week or there are patches that are twice a week and then we would typically if she wants to bleed we would cycle our oral micronized progesterone don&#39;t use a patch with progesterone cream don&#39;t use a patch with progesterone trokies those are not proven to protect the endometrium from the estrogen no matter what ideas you might believe or come up with about absorption it&#39;s just not proven um and there are is my last my last slide but I think there&#39;s another last slide here but I just want to point out that I do give seminars uh four times a year not me but me and a team of fabulous teachers and Educators and clinicians on a range of topics we have them quarterly the next one is the menopause hormone boot camp uh in April so you would go to The Institute of women&#39;s health and see what we&#39;ve got going on um this is these are currently virtual only seminars and just a wealth of information very compatible with uh things that you are learning from the Dutch test library and then um I think he mentioned this but here&#39;s also a reminder that new providers get 50 off up to five testing kits and some other all goodies that are listed there so maybe that&#39;s actually decent time management on my part I must say so maybe we have some questions yeah wonderful time management thank you so much for a great presentation we do have a few questions that we can get to uh probably won&#39;t be able to get to all of them just bumping up against that one o&#39;clock time hour but the very first and easy question is you mentioned a book at the beginning we had quite a few of our uh attendees ask what that book is and where they can get it one more time uh well it&#39;s a big old fat textbook um and it&#39;s I&#39;m pretty sure it&#39;s called clinical gynecologic endocrinology [Music] and infertility and there&#39;s two authors Leon spiroff is one author and there&#39;s another author and like I said I think the it&#39;s not published yearly or every other year but the last Edition that&#39;s available I would look on online and you can purchase it if you just type in clinical gynecologic endocrinology and infertility Leon spiroff thank you very much next question would be any herbals that you use to help with an LH surge you mean they&#39;re not having an LH surge correct uh yeah I think uh I&#39;m sorry if that wasn&#39;t glean from my information there but I would go with Vitex um possibly Rhodiola perfect uh the next question that we&#39;ll get to is does your treatment approach change at all if amenorrhea occurred after coming off birth control for 22 years no she well you mean okay I was so hoping to avoid that one but but I understand the question um so um going off of birth control pills is not the cause of her secondary amenorrhea that&#39;s the fundamental thing you have to accept she has an underlying cause the birth control pills were masking that cause someone probably she and either she had the problem way back when and was just put on birth control pills without a proper evaluation she had periods great she had contraception great and now she went off and boom the problem is back that&#39;s one scenario or during the course of taking the birth control pills she acquired PCOS or that her PCOS evolved for example uh or perhaps she now has POI but the birth control pills were not the cause something else is the cause so it behooves us to know what that is wonderful thank you uh the next question this will be the last one that we get to today is there a limit or a starting uh for a starting treatment for premature or ovarian failure example uh they stopped having a Menses at age 46 but now at 50 years old no hormonal treatment for four years should they start treatment because they&#39;re less than 51. okay so actually uh stopping your menses at age 46 is not premature ovarian insufficiency premature menopause or POI is stopping your menses before the age of 40 due to that cause remember there might be other causes so it the cutoff is age 40. she&#39;s become menopausal apparently at age 46 that&#39;s within the normal time range uh becoming menopausal before age 40 is premature between the ages of 40 and 45 is early she&#39;s at 46 she doesn&#39;t need to go on hormones to protect bones heart brain but if it was before 40 or between 40 and 45 I would vote she should and if she was 43 she would take hormones until she was about 51. if she was less than 40 she would take hormones until she&#39;s about 51. she&#39;s 46 and she she stopped Menses at 46 and if I remember she&#39;s Now 51 or 50. so she could she could go on hormones if you had a good reason quality of life issues or osteoporosis prevention because she&#39;s at high risk mother had a hip fracture or she has a sucky bone density uh or she already has osteoporosis those would be the three buckets she could as long as she&#39;s within 10 years of her last menstrual period due to menopause you can safely initiate systemic hormonal therapy and that&#39;s that in about 500 times more in details are in the menopause hormone boot camp in April because it&#39;s a really important question I&#39;m glad you brought it out so I could clarify again the ages but that below 40 40 to 45 and then after 45 is a very they&#39;re three very different scenarios that your patient she&#39;s become menopausal at a fine normal age she can go on estrogen because she&#39;s within four years of that last menstrual period if she if you have a good reason for her to go on it&#39;s less than 10 years okay thank you for getting forgetting that question thank you all again for joining us today uh make sure you check your inboxes tomorrow for a link to the recording and to download the slides if you do have any additional questions about today&#39;s content or for general questions about the Dutch Test please email our customer support team at info dutchtest.com thank you and have a great rest of your day thanks everybody bye-bye

Transcript for:February Dutch Webinar on Secondary Amenorrhea

Transcript for:
February Dutch Webinar on Secondary Amenorrhea