Functional or hypothalamic amenorrhea is a form of female hypogonadism (reduced ovarian function) in which no organic cause for the absence of menstruation is found. It is due to hormonal dysfunction as a result of severe stress, caloric deficit or extreme training. The main risks of functional amenorrhea are bone loss, infertility, and delayed puberty. The loss or absence of menstruation in women of childbearing age is called amenorrhea. The most common causes of amenorrhea are four: polycystic ovary syndrome, hypothalamic amenorrhea, hyperprolactinemia, or ovarian failure. Hypothalamic amenorrhea is commonly seen in young, thin women who exercise hard and eat poorly. The most prone to this condition are women who practice ballet, gymnastics, figure skating and other sports that require a slender figure. Functional amenorrhea can also occur in athletes of normal weight subjected to heavy daily, including twice, training. Stress is also a well-known factor that can trigger the condition. The menstrual cycle can stop, regardless of the strength of the experienced stress. Functional amenorrhea can be triggered by seemingly insignificant things, such as worries about an upcoming exam, a change of job or place of residence, as well as by severe psychological and physical traumas. The other group of women who have menstrual disorders of the functional type are those with eating disorders, such as anorexia and bulimia. In cases of severe anorexia with very low weight, the organism enters “emergency mode” and is limited to the performance of only the most important life-supporting functions. One of the first functions that fall under such a strong stress on the body is sex. Energy deficiency underlies hypothalamic amenorrhea, which occurs as a result of weight loss or physical activity. It has been established that if the energy intake falls below the threshold of 30 kcal/kg, changes in the hormonal balance already occur. A regular menstrual cycle is extremely precisely regulated by complex neuro-endocrine mechanisms. The highest is the hypothalamus, which secretes the hormone gonadotropin-stimulating hormone (GnRH). This hormone reaches the pituitary gland and stimulates the release of luteinizing and follicle-stimulating hormone (LH and FSH). These, in turn, lead to the release of estrogens from the ovary and stimulate egg maturation and ovulation. The lack of sufficient energy for the body leads to a slowdown in metabolism, in order to preserve energy for the most important functions in the body. In this way, growth and reproduction are limited. Accordingly, it reduces the production of GNRH by the hypothalamus and the entire cascade of hormones that follow it. The other factor that leads to hormonal imbalance is stress. Under conditions of stress, the hormone cortisol begins to be released. It suggests to the organism that it is threatened by some “danger”, and in conditions of life-threatening conditions,reproductive function has little benefit. High levels of cortisol suppress the release of GNRH from the hypothalamus and lead to functional amenorrhea. The term “functional amenorrhea” means that the condition is reversible with a change in behavior. However, other organic causes leading to the absence of menstruation should be excluded. The differential diagnosis is broad and requires a number of investigations. The first and most important step is to rule out pregnancy. Next is the endocrine evaluation, which includes testing of thyroid hormones, prolactin, LH, FSH, estradiol and anti-Müllerian hormone. It is necessary to carry out a progestogen test, i.e. taking progesterone on a schedule, after which menstrual bleeding should occur. A lack of periods is a sign of low estrogen levels. Decreased levels of LH, FSH, and estradiol, and a negative progestogen test, suggest disturbances in hypothalamic-pituitary function. It is important to perform an imaging study of the hypothalamic-pituitary region (MRI) to rule out a tumor leading to hypogonadism. It is necessary to conduct an ultrasound examination of the small pelvis to rule out abnormalities in the development of the ovaries and uterus. Women who have been amenorrhoeic for more than 6 months should have their bone density assessed. Treatment of functional amenorrhea is difficult because it requires behavioral changes to restore the energy deficit. Teamwork with a psychologist is often necessary to change the stress response and improve low self-esteem. References: Gordon CM, Ackerman KE, Berga SL, Kaplan JR, Mastorakos G, Misra M, Murad MH, Santoro NF, Warren MP. Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017 May 1;102(5):1413-1439. doi: 10.1210/jc.2017-00131. PMID: 28368518. Meczekalski B, Podfigurna-Stopa A, Warenik-Szymankiewicz A, Genazzani AR. Functional hypothalamic amenorrhea: current view on neuroendocrine aberrations. Gynecol Endocrinol. 2008 Jan;24(1):4-11. doi: 10.1080/09513590701807381. PMID: 18224538.It is important to perform an imaging study of the hypothalamic-pituitary region (MRI) to rule out a tumor leading to hypogonadism. It is necessary to conduct an ultrasound examination of the small pelvis to rule out abnormalities in the development of the ovaries and uterus. Women who have been amenorrhoeic for more than 6 months should have their bone density assessed. Treatment of functional amenorrhea is difficult because it requires behavioral changes to restore the energy deficit. Teamwork with a psychologist is often necessary to change the stress response and improve low self-esteem. References: Gordon CM, Ackerman KE, Berga SL, Kaplan JR, Mastorakos G, Misra M, Murad MH, Santoro NF, Warren MP. Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017 May 1;102(5):1413-1439. doi: 10.1210/jc.2017-00131. PMID: 28368518. Meczekalski B, Podfigurna-Stopa A, Warenik-Szymankiewicz A, Genazzani AR. Functional hypothalamic amenorrhea: current view on neuroendocrine aberrations. Gynecol Endocrinol. 2008 Jan;24(1):4-11. doi: 10.1080/09513590701807381. PMID: 18224538.It is important to perform an imaging study of the hypothalamic-pituitary region (MRI) to rule out a tumor leading to hypogonadism. It is necessary to conduct an ultrasound examination of the small pelvis to rule out abnormalities in the development of the ovaries and uterus. Women who have been amenorrhoeic for more than 6 months should have their bone density assessed. Treatment of functional amenorrhea is difficult because it requires behavioral changes to restore the energy deficit. Teamwork with a psychologist is often necessary to change the stress response and improve low self-esteem. References: Gordon CM, Ackerman KE, Berga SL, Kaplan JR, Mastorakos G, Misra M, Murad MH, Santoro NF, Warren MP. Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017 May 1;102(5):1413-1439. doi: 10.1210/jc.2017-00131. PMID: 28368518. Meczekalski B, Podfigurna-Stopa A, Warenik-Szymankiewicz A, Genazzani AR. Functional hypothalamic amenorrhea: current view on neuroendocrine aberrations. Gynecol Endocrinol. 2008 Jan;24(1):4-11. doi: 10.1080/09513590701807381. PMID: 18224538.