42 yo U.K. Woman, SWF, Low FSH, Low LH, High TSH, No Periods For 16 Years: What Is Wrong? What Are Her Reproductive Options?

Question:

Dear Doctor, I am a single, white female, aged 42. I have high prolactin and started having no periods at age 26 following cessation of pill. There has been no return of periods despite shrinking of prolactinoma found. Many consultants scratched their heads over the years. I am now using HRT (hormone replacement therapy) to guard against osteoporosis.

I have been told I would just need a little help conceiving, clomide maybe. I went off HRT for 6 months whilst exploring potential IVF (in vitro fertilization) clinics using donor sperm. I looked at adoption but did not proceed as few babies for single white people in the UK. Had ORT (ovarian reserve test) at clinic. FSH at 0.8. e2 under 44. AMH low at 0.83. tsh normal/borderline at 4.36. It was suggested that I get tested for response with gonatrophins, then if follicles appear I can try with donor eggs. Donor eggs and sperm may be a bit too far for me.

Any thoughts? Feels like end of road for me. But as clinic is going to seek advice from endocrinologists, I thought I would start to ask wider. Thank you! J. from the U.K.

Answer:

Hello J.from the U.K.,

There are several problems that you report. Let me take them one at a time.

You mentioned that you hve not had periods since the age of 26 and now your are 42 years old. There must be some explanation for that and the only explanation I can see is that your FSH level is very very low (0.8). I presume the LH (lutenizing hormone) level is similarly low. We call that "hypogonadotrophic hypogonadism". It means that your hypothalamus is dysfunctioning and not producing adequate FSH (follicle stimulating hormone) to stimulate the ovaries to work. The treatment for a woman that wants pregnancy is to give FSH and LH (Menopur or Repronex) to stimulate the ovaries to work. This can be done with a reproductive endocrinologist, not a medical endocrinologist, also known as an infertility subspecialist.

Secondly, I noticed that your TSH (thyroid stimulating hormone) level, albeit is within the normal limits, is higher than we like to see it. In general, and U.S. endocrinologists have now adjusted their tolerances as well, we like to see the TSH at less than 2.2. So your thyroid is functioning but it is a little hypothyroid. A little thryoid replacement hormone (synthroid) would probably help to bring that down.

Thirdly, I presume that your prolactin levels are normal now? If not, then need to be treated to get them down to less than 20.

Now, let's talk about your options to get pregnant assuming all the above findings. The one very significant problem that you have, in addition to those above, is your age. At 42 years old, your natural chances for pregnancy have diminished significantly. For example, a 26 year old would have an 85% chance of pregnancy per year. A 42 year old has a 1% chance of pregnancy per year. Therefore, as a single, white female, you need to think outside the envelope of getting pregnant by natural means i.e. just having intercourse or injecting sperm (IUI). IVF will be the treatment of choice, and the medications used to stimulate your eggs will be FSH and LH so that covers the hypothalamic problem.

You might want to consider a gonadotropin stimulation test (trial of using the meds to see if your ovaries respond), but that is not necessary. If you enter the IVF cycle path and your ovaries don't stimulate, then you just cancel the cycle, so the IVF cycle will be test enough. At 42 years old, in my clinic, your chances of pregnancy would be 44% per cycle. That's significantly better than your natural chances. You certainly have the option of using donor eggs. Because donor eggs are taken from a younger woman, and pregnancy rates are dependent on the age of the eggs, you will have a greater chance of pregnancy no matter what age you are as long as your uterus is normal. That means the chances of pregnancy would be the same at 42 as at 45 years old. So that is a backup option that you will always have. If you wanted the best chances for pregnancy, then donor eggs would give you a 60-79% chance of pregnancy per attempt. In the U.S., we do allow donor egg cycles in single women.

So I hope that gives you some food for thought. I have written more extensively on this subject in my blog so you might want to use the search bar to look up more information.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Woman With Hypogonadotropic Hypogonadism Needs FSH, LH and Hormones To Get Pregnant With IUI

Question:

Dear Sir, I have hypogonadotropic hypogonadism. I am trying to get pregnant and did IUI twice, but did not succeed. I was injected with GMH 150. I had to take around 26 injection to develop my follicles and then had to be injected with HCG for ovulation. My E2 level was 2250 and 4 big follicle. After IUI my doctor gave me only progestrone support. My question is that " is there no need of any other hormone medication as my body don't produce any hormone"? After fertilization can egg produce enough hormone which need for proper implantation. Can taking so many injections for stimulating the ovary affect the ovary or uterus in future? M. from India

Answer:

Hello M. from India,

In order to get you pregnant, you need to take supplemental FSH and LH (such a Menopur) and then when the follicle is appropriate size (18-22 mms), HCG is given to trigger ovulation. Progesterone supplementation is then started 3-4 days after the HCG to support implantation. You also have to consider that since this is a "natural" treatment, and most normal women don't get pregnant immediately when they begin trying for pregnancy (it usually takes 8-12 months of trying), this treatment is just making you into a normal ovulatory woman and so it may take several tries as well.

Finally, you have to make sure that you are taking thyroid hormone and adrenal hormone (cortisol), as well so that all your hormones are normal. If you don't, that could affect your ability to become pregnant. It sounds like your doc is doing the proper thing so you should trust in him/her, and ask him/her the same question.

Follow-Up Question:

Hello Dr., Good news. After HMG therapy and IUI, now I'm pregnant. 3rd month is going on, right now I am taking progestrone support only. I want to know in future will breast milk produce naturally or I have to take any hormone replacement for that. Will my baby affect because of my diseases? Thank you!

Follow-Up Answer:

Hello Again,

The pregnancy takes over hormone production, so you should not have problems producing breast milk. Your disease should not affect your baby unless it is due to some sort of congenital/genetic disease that is passed to your child.

Congratulations!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

No Period, Low BMI Can Equal Hypoganodotropic Hypogonadism

Question:

I'm a 27 year old woman. I'm not pregnant. I went off the pill 7 months ago, and have not had a period since, though I had light spotting in response to a progesterone challenge. I'm about to be evaluated for PCOS, but I have a hard time believing this is what I have.

I have always been thin, and in the past I was told this was why I did not menstruate when I tried to go off the pill. I have made the effort to gain a little weight and my BMI is about 19 now. I work out regularly, though not more than 50 minutes a day. I have no family history of PCOS, diabetes or insulin resistance.

In the past 7 months I have developed benign PVC's of my heart, and have had a mild increase in facial hair and hair around my navel (this is why they think I might have PCOS).

My question is, are there any other conditions that might cause my symptoms that I should be aware of when I go to have the blood tests? Should I be tested for premature ovarian failure and hyperprolactinemia as well?

Thank you so much!

Answer:

Thank you for your question.

Your history does not quite fit PCOS. The most likely diagnosis is hypoganodotropic hypogonadism. It is a long name for saying that your brain is probably not stimulating the ovary. It is likely due to a lack of adequate body fat. Not premature ovarian failure. Since you had a little response to the Provera challenge, that shows that you are making a little estrogen, but the increase in hair growth is consistent with an elevation of the male hormone testosterone. If the ovary is not stimulated to ovulate, it does not produce estrogen and the available hormone precursors go to make testosterone.

Body fat is important because it is the chemical basis for the production of all hormones. If the body fat is too low, because of excessive exercise or anorexia or bulimia, the brain shuts down the production of FSH and LH. This leads to a lack of stimulation of the ovary, hence the above result.

This diagnosis can be made with blood testing. You should be tested for FSH, LH, Prolactin, TSH, Estradiol and Testosterone. This would test all the possible sources of your lack of menstruation. They will probably find that your FSH and LH are very low. Your thyroid may also be out of sync because of the same problem. TSH is the preliminary test for thyroid function.

It would be best if you could get your BMI up above 20, and increase your body fat content.

I hope this helps.

Sincerely,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/

Monterey, California, U.S.A.

No Menstruation

Question:

I am 26 and have two children. I am about 5'7.5" tall. My last spontaneous menses was April 6, 2005. After this, I became pregnant with my first child. After her birth, I dropped from 168 pounds (the same weight as prepregnancy, but since I stopped drinking alcohol and eating unhealthily and started walking daily, I maintained healthily) to 113 pounds in 10 months while breastfeeding and walking. I stopped breastfeeding and walking to try and gain weight to get pregnant with my second, but even after gaining 20 pounds, taking progestin and estrogen, there was no menses. After estrogen therapy plus clomid, I menstruated, took Clomid again, and got pregnant with #2. After her birth, my weight fell from 171 at her birth to 113 with breastfeeding and running. I never menstruated. She was born March 1, 2008.

Four months ago, I was prescribed the NuvaRing for amenorrhea after progestin again failed to produce a period. I have had four successful withdrawal bleeds. After this month, however, I have to stop; we cannot afford my taking it and pills make me sick.

I am currently training for a half marathon and run 50 miles per week. I am about 117 pounds now. I don't want to have more children but am concerned that after all of this time I won't be able to get my period back. I will cut back my running after my October 3 race, but what do I do to get my period back? CAN I get my period back? After gaining weight in late 2006/early 2007 there was no menses. There are no blockages or anything abnormal, though I may have mild subclinical hyperthyroidism as a byproduct of my running; my follicles are just dormant.

I want to be normal and healthy. I MISS my period, however odd that may sound to some. How can I get this back?

Answer:
Hello Bethany from the U.S.,

The problem that you have is more long-term than short term. The fact that you are not having periods is a sign that your ovaries are not functioning an therefore not ovulating. Because of that, you are NOT producing the essential female hormones, Estrogen and Progesterone. Without estrogen, you will be at long term risk for osteoporosis, heart disease, vaginal dryness and shrinkage. Once these occur, they are not reversible.

It is most likely that you have a disorder called "hypogonadotropic hypogonadism" which is a lack of hypothalamic stimulation to produce the hormones that the pituitary produces to stimulate the ovaries. The thyroid is one of those hormones that the pituitary stimulates as well. You need to see a Reproductive endocrinologist or Gynecologist to solve this problem. It is not so much that you need to have a period, that is just the monthly shedding of the uterine lining if you don't become pregnant, but the lack of hormone is worst. You need to be evaluated to make sure that you don't have some other underlying cause, other than your weight and decreased body mass.

In terms of replacing hormones, the birth control pill is the best because it has both estrogen and progesterone in it. If you can't tolerate the pill because of gastric side effects, then you can consider the patch. A progesterone only contraceptive of any type is NOT adequate. You need estrogen.

Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.blogger.com/www.montereybayivf.com

Monterey, California, U.S.A.