Amenorrhea

DENVER -- Cognitive-behavioral therapy is an effective treatment for women with stress-induced anovulation, Rebecca M. Ringham reported at an international conference of the Academy for Eating Disorders.

The psychological intervention results not only in restoration of ovarian activity, it also addresses the subthreshold eating disorder symptoms and dysfunctional attitudes that are part and parcel of stress-induced anovulation, also known as functional hypothalamic amenorrhea, according to Ms. Ringham of the Western Psychiatric Institute and Clinic, University of Pittsburgh.

"It may provide an alternative to expensive and risky infertility therapy and may also ameliorate other consequences of amenorrhea, such as increased risk of osteoporosis and heart disease," she said at the conference, which was sponsored by the University of New Mexico.

Functional hypothalamic amenorrhea is anovulation that's not attributable to a discernible organic cause. It entails reduced GnRH/LH drive and other neuroendocrine changes.

Ms. Ringham and her coinvestigators had previously demonstrated that women with functional hypothalamic amenorrhea are distinguishable from women having an organic cause for their amenorrhea as well as from normally menstruating women on the basis of their high levels of subthreshold symptoms of disordered eating, with dysfunctional attitudes, mild undernutrition, and/or excessive energy output.

Capitalizing on this observation, they then developed a version of cognitive-behavioral therapy (CBT) specifically tailored for patients with stress-induced anovulation. It was adapted from the form of CBT used in bulimia nervosa, which on the basis of randomized trials data has become the consensus treatment of choice for that eating disorder.

The treatment program consisted of 16 CBT sessions conducted over a 20-week period. The therapeutic emphasis was placed on changing problematic behaviors and attitudes. Patients were helped to embrace a healthy balanced overall lifestyle pattern, including an improved diet, moderate exercise three to five times per week, development of problem-solving skills, and the restructuring of maladaptive thoughts and beliefs about dieting, weight, and shape, Ms. Ringham explained.

She reported on 16 patients with functional hypothalamic amenorrhea who participated in a randomized trial in which half were assigned to CBT and half to observation.

During 36 weeks of follow-up, six of eight patients in the CBT arm showed full recovery, including a return of normal ovarian activity. This was associated with normalization of hormone profiles--including a significant decrease in serum cortisol--and reduction in subthreshold eating disorder symptoms based upon improved scores on the Bulimia Test-Revised and Beck Depression Inventory.

One CBT-treated patient had partial recovery, and one did not recover. In contrast, only two patients in the control group experienced return of ovarian function.

Session Chair Dr. Kenneth L. Weiner, a psychiatrist at the University of Colorado, Denver, said that when he sees young women who he suspects have stress-induced anovulation, he refers them to an ob.gyn, for an infertility work-up and asks them to gain a little weight. 'And you'd also like them to have a period of CBT, which is a benign intervention?" he asked Ms. Ringham.

"Yes, definitely," she replied. "The women in this study just really responded, even the ones who started out with the attitude, 'I don't need to be doing this.'"

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