1. Chapter 11. PSYCHOLOGICAL STRESS AND FUNCTIONAL AMENORRHEA Reid L. Norman, PhD Professor, Pharmacology and Neuroscience, TTUHSC

2. Learning Objectives The definition of functional hypothalamic amenorrhea (FHA)The definition of functional hypothalamic amenorrhea (FHA) The causes of FHAThe causes of FHA The importance of seeking medical attention for this conditionThe importance of seeking medical attention for this condition The long-term medical consequences of low estrogen levelsThe long-term medical consequences of low estrogen levels

3. Functional hypothalamic amenorrhea FHA is the absence of menstrual cycles for more than six months without any anatomic or pathologic causeFHA is the absence of menstrual cycles for more than six months without any anatomic or pathologic cause In FHA, there is no organic problem, rather, the system is not functioning properly because there is insufficient GnRH release from the hypothalamusIn FHA, there is no organic problem, rather, the system is not functioning properly because there is insufficient GnRH release from the hypothalamus

4. Stress Hans Selye (1939) was the first to recognize that stress negatively impacted the reproductive systemHans Selye (1939) was the first to recognize that stress negatively impacted the reproductive system Refeinstein (1946) was also among the first to link disrupted menstrual cycles with “overt or latent psychological disturbances” even before GnRH was identifiedRefeinstein (1946) was also among the first to link disrupted menstrual cycles with “overt or latent psychological disturbances” even before GnRH was identified

5. Psychological stress Chronic psychological stress is thought to be a major contributor to FHAChronic psychological stress is thought to be a major contributor to FHA Other factors contributing to this effect are:Other factors contributing to this effect are: DietingDieting ExerciseExercise Body image concernsBody image concerns Performance pressurePerformance pressure Unrealistic expectationsUnrealistic expectations

6. Acute stress Acute psychological stress stimulates ACTH and cortisol and can inhibit LH releaseAcute psychological stress stimulates ACTH and cortisol and can inhibit LH release This effect can be blocked by naloxone, an opioid antagonistThis effect can be blocked by naloxone, an opioid antagonist Implicates endorphins as mediators of the inhibitory effect of stress on gonadotropin secretionImplicates endorphins as mediators of the inhibitory effect of stress on gonadotropin secretion

7. Low energy availability One school of thought is that this is the reason for FHA in most instances, particularly in athletesOne school of thought is that this is the reason for FHA in most instances, particularly in athletes Contributing factor are the same as listed beforeContributing factor are the same as listed before Dieting – reduces energy intakeDieting – reduces energy intake Exercise – increases energy expenditureExercise – increases energy expenditure Body image concerns - psychologicalBody image concerns - psychological Performance pressure - psychologicalPerformance pressure - psychological Unrealistic expectations - psychologicalUnrealistic expectations - psychological

8. FHA Women with this condition haveWomen with this condition have More dysfunctional attitudesMore dysfunctional attitudes Did not cope with ordinary stressesDid not cope with ordinary stresses More interpersonal dependenceMore interpersonal dependence Increased stress hormone levelsIncreased stress hormone levels

9. Consequences of FHA if untreated OsteoporosisOsteoporosis Increased cardiovascular diseaseIncreased cardiovascular disease DepressionDepression Psychological diseasePsychological disease DementiaDementia

10. Treatment Can be treated with hormonal therapyCan be treated with hormonal therapy Treats the symptoms of low estrogenTreats the symptoms of low estrogen Does not address the underlying problemDoes not address the underlying problem Behavioral problems should be treated with psychological therapyBehavioral problems should be treated with psychological therapy