Amenorrhea

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Amenorrhea

Need to Know

Amenorrhea
A loss of periods is called amenorrhea, a condition that may result from low levels of certain hormones. According to research or other evidence, the following self-care steps may be helpful.
  • Get enough nutrients

    Eat more food or choose a high-calorie supplement if you are underweight, have low body fat, or are an athlete

  • Look after your bones

    Protect yourself from amenorrhea-related bone loss by taking 800 to 1,500 of calcium and 400 to 800 IU of vitamin D each day

  • Get a checkup

    Visit your doctor to find out if your amenorrhea is the result of a treatable medical problem

  • Regulate your workouts

    Balance hormone function by avoiding intense or excessive exercise

About

About This Condition

Amenorrhea is the absence of menstrual cycles.

Amenorrhea is called primary when a woman has not started to menstruate by the age of 16 years, while secondary amenorrhea refers to the abnormal cessation of menstruation in a woman who previously has had menstrual cycles.1 In amenorrheic women, the levels of female reproductive hormones are not sufficient to stimulate menstruation. This condition is sometimes associated with malnutrition, such as that which occurs in anorexia nervosa, or with extreme exercise, which puts excessive nutritional and other demands on the body.2 , 3 An association between stress and amenorrhea has also been demonstrated.4 Amenorrhea may also result from potentially serious disorders of the ovaries, the hypothalamus, or the pituitary gland; therefore, a physician should always evaluate chronic absence of menstrual cycles. Prolonged amenorrhea can result in early bone loss and increased risk of osteoporosis.5 Amenorrhea occurs naturally in women who are breast-feeding,6 but in these circumstances it does not put the bones at risk.7

Symptoms

Women with amenorrhea may have symptoms of absent periods, increased facial hair, decreased pubic and armpit hair, deeper voice, decreased breast size, and secretions from the breast.

Holistic Options

In a number of preliminary trials,8 , 9 , 10acupuncture has been shown to induce ovulation in women with disorders involving lack of ovulation. Preliminary studies show that levels of estrogen and progesterone, as well as levels of the related hormones LH (luteinizing hormone) and FSH (follicle-stimulating hormone), may all be affected by acupuncture.11 , 12 Few studies have looked at the use of acupuncture for treatment of amenorrhea, but one preliminary trial found it helpful for women who have widely separated menstrual cycles.13 In one controlled trial, amenorrheic women showed a trend toward normalizing hormone levels following acupuncture.14

Eating Right

The right diet is the key to managing many diseases and to improving general quality of life. For this condition, scientific research has found benefit in the following healthy eating tips.

Recommendation Why Get started
Add a little more to a low-fat diet In one study, women on diets low in fat who were experiencing amenorrhea returned to regular menstruation when they increased their fat intake and percentage of body fat.

Add a little more to a low-fat diet

When compared with women who menstruate regularly, women who menstruate infrequently or not at all often have lower dietary intakes of fat (especially saturated fat), protein, and total calories, as well as a greater proportion of carbohydrate and fiber in their diet.15 , 16 , 17 In preliminary studies of normal-weight women with no obvious eating disorders, women who experienced amenorrhea had diets described as “close to normal” but significantly low in fat. These women had lower percentages of body fat as well.18 , 19 In one of these studies, regular menstruation returned in women who increased their fat intake and percentage of body fat to normal over four months.20
Balance nutrition Ensuring adequate calories, protein, carbohydrates, fat, vitamins, and minerals may help women menstruate regularly.

Balance nutrition

It has long been known that extreme dietary restriction can cause amenorrhea.21 , 22 When such restriction is due to eating disorders, such as anorexia and bulimia,23 professional treatment is necessary. Athletic amenorrheic women may have low intakes of calories and other nutrients, and there are reports of some athletes resuming menstruation after adding to their diet a daily nutritional beverage containing additional calories, protein, carbohydrate, fat, vitamins, and minerals.24 , 25 However, these women also decreased their exercise intensity, which likely contributed to normalization of their menstrual function.
Look at your diet A strict raw foods diet has been associated with weight loss and amenorrhea.

Look at your diet

Specific diets may be associated with increased risk of amenorrhea. A strict raw foods diet was found in one preliminary study to be strongly associated with weight loss and amenorrhea.26Vegetarians have been studied for their susceptibility to amenorrhea, but the results so far have been inconsistent.27 Vegetarian diets tend to be rich in the antioxidant nutrients known as carotenes. Women with excessive carotene levels in their blood appear to be at higher risk of amenorrhea than women with normal levels,28 , 29 and, while research has not shown high carotene levels to directly cause amenorrhea, they may constitute a contributing factor.30 In one preliminary study, women with high levels of both carotenes and amenorrhea had predominantly vegetarian diets, and reducing dietary intake of carotenes led to lower carotene levels and improvement in their amenorrhea.31 Women vegetarians often rely heavily on soy foods as sources of protein, and a number of studies have found that increasing dietary intake of soy reduces levels of estrogen and progesterone in premenopausal women,32 , 33 , 34 , 35 , 36 , 37 although some studies have not found these changes.38 , 39 Changes in menstrual cycles were not consistent in these studies, and none found an increase in missed menses with high-soy diets. The only well-controlled comparison study found that the number of cases of amenorrhea among healthy, stable-weight vegetarian women was not different from that of healthy, stable-weight non vegetarian women.40 The authors of this study speculated that, after reviewing all of the evidence, a vegetarian diet is likely not to contribute to amenorrhea.
Watch what you eat Some vegetarian diets have been associated with weight loss and amenorrhea.

Watch what you eat

Specific diets may be associated with increased risk of amenorrhea. A strict raw foods diet was found in one preliminary study to be strongly associated with weight loss and amenorrhea.41Vegetarians have been studied for their susceptibility to amenorrhea, but the results so far have been inconsistent.42 Vegetarian diets tend to be rich in the antioxidant nutrients known as carotenes. Women with excessive carotene levels in their blood appear to be at higher risk of amenorrhea than women with normal levels,43 , 44 and, while research has not shown high carotene levels to directly cause amenorrhea, they may constitute a contributing factor.45 In one preliminary study, women with high levels of both carotenes and amenorrhea had predominantly vegetarian diets, and reducing dietary intake of carotenes led to lower carotene levels and improvement in their amenorrhea.46 Women vegetarians often rely heavily on soy foods as sources of protein, and a number of studies have found that increasing dietary intake of soy reduces levels of estrogen and progesterone in premenopausal women,47 , 48 , 49 , 50 , 51 , 52 although some studies have not found these changes.53 , 54 Changes in menstrual cycles were not consistent in these studies, and none found an increase in missed menses with high-soy diets. The only well-controlled comparison study found that the number of cases of amenorrhea among healthy, stable-weight vegetarian women was not different from that of healthy, stable-weight non vegetarian women.55 The authors of this study speculated that, after reviewing all of the evidence, a vegetarian diet is likely not to contribute to amenorrhea.

Supplements

What Are "Star" Ratings?

a7_3star   Reliable and relatively consistent scientific data showing a substantial health benefit.

a7_2star   Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.

a7_1star   For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support.

Our proprietary “Star-Rating” system was developed to help you easily understand the amount of scientific support behind each supplement in relation to a specific health condition. While there is no way to predict whether a vitamin, mineral, or herb will successfully treat or prevent associated health conditions, our unique ratings tell you how well these supplements are understood by the medical community, and whether studies have found them to be effective for other people.

For over a decade, our team has combed through thousands of research articles published in reputable journals. To help you make educated decisions, and to better understand controversial or confusing supplements, our medical experts have digested the science into these three easy-to-follow ratings. We hope this provides you with a helpful resource to make informed decisions towards your health and well-being.


Supplement Amount Why
Progesterone
 Consult a qualified healthcare practitioner 2 stars   The oral, micronized form has been shown to successfully induce normal menstrual bleeding in women with secondary amenorrhea. (Use of this natural hormone should always be supervised by a doctor.)

2 stars  Progesterone

Consult a qualified healthcare practitioner

Oral, micronized progesterone (200 to300 mg per day) has been shown in at least one double-blind trial to successfully induce normal menstrual bleeding in women with secondary amenorrhea.56 Use of this natural hormone should always be supervised by a doctor.

Supplement Amount Why
Acetyl-L-Carnitine
 Refer to label instructions 1 star   Acetyl-L-carnitine may help restore menstruation in some amenorrheic women.


1 star  Acetyl-L-Carnitine

Acetyl-L-carnitine is an amino acid that may have effects on brain chemicals and hormones that control female reproductive hormones. In a preliminary trial, 2 grams daily of acetyl-L-carnitine was given to amenorrheic women who had either low or normal blood levels of female hormones. Hormone levels improved in the women with low initial levels, and half of all the women resumed menstruating within three to six months after beginning supplementation.57 Controlled trials are needed to confirm these promising results.

Supplement Amount Why
Blue Cohosh
 Refer to label instructions 1 star   Traditional practitioners consider blue cohosh to be a uterine tonic and an agent that stimulates menstrual blood flow, and it is used as a remedy for lack of menstruation.


1 star  Blue Cohosh

Blue cohosh is a traditional remedy for lack of menstruation. It is considered an emmenagogue (agent that stimulates menstrual blood flow) and a uterine tonic. No clinical trials have validated this traditional use.

Supplement Amount Why
Calcium and Vitamin D
(Osteoporosis)
 Refer to label instructions 1 star   Despite the lack of evidence that calcium and vitamin D supplements alone are helpful to amenorrheic women, they are still generally recommended to prevent the added burden of calcium and vitamin D deficiency from further contributing to bone loss.

1 star  Calcium and Vitamin D

A preliminary trial showed that bone loss occurred over a one-year period in amenorrheic exercising women despite daily supplementation with 1,200 mg of calcium and 400 IU of vitamin D.58 In a controlled study of amenorrheic nursing women, who ordinarily experience brief bone loss that reverses when menstruation returns, bone loss was not prevented by a multivitamin supplement providing 400 IU of vitamin D along with 500 mg twice daily of calcium or placebo.59 Despite the lack of evidence that calcium and vitamin D supplements alone are helpful to amenorrheic women, they are still generally recommended to prevent the added burden of calcium and vitamin D deficiency from further contributing to bone loss.60 Amounts typically recommended are 1,200 to 1,500 mg calcium and 400 to 800 IU vitamin D daily.

Supplement Amount Why
Motherwort
 Refer to label instructions 1 star   Motherwort has traditionally been thought to stimulate absent or diminished menses, though it has not been studied clinically.


1 star  Motherwort

Herbal emmenagogues traditionally regarded as stimulating absent or diminished menses are motherwort, rue, partridge berry, and yarrow. None of these herbs has undergone modern clinical trials to determine their efficacy. All emmenagogues should be avoided in pregnancy, as they may possibly cause a spontaneous abortion.


Supplement Amount Why
Partridge Berry
 Refer to label instructions 1 star   Partridge berry has traditionally been thought to stimulate absent or diminished menses, though it has not been studied clinically.

1 star  Partridge Berry

Herbal emmenagogues traditionally regarded as stimulating absent or diminished menses are motherwort, rue, partridge berry, and yarrow. None of these herbs has undergone modern clinical trials to determine their efficacy. All emmenagogues should be avoided in pregnancy, as they may possibly cause a spontaneous abortion.


Supplement Amount Why
Rue
 Refer to label instructions 1 star   Rue has traditionally been thought to stimulate absent or diminished menses, though it has not been studied clinically.

1 star  Rue

Herbal emmenagogues traditionally regarded as stimulating absent or diminished menses are motherwort, rue, partridge berry, and yarrow. None of these herbs has undergone modern clinical trials to determine their efficacy. All emmenagogues should be avoided in pregnancy, as they may possibly cause a spontaneous abortion.


Supplement Amount Why
Vitamin B6
 Refer to label instructions 1 star   Preliminary evidence found that vitamin B6 restored menstruation and normalized hormone levels in three women with amenorrhea who had high prolactin levels.


1 star  Vitamin B6

Prolactin is a hormone that may be elevated in some cases of amenorrhea. A preliminary trial of 200 to 600 mg daily of vitamin B6 restored menstruation and normalized prolactin levels in three amenorrheic women with high initial prolactin levels; however, 600 mg daily of vitamin B6 had no effect on amenorrheic women who did not have high prolactin levels.61 A number of other small, preliminary trials have not demonstrated an effect of either oral or injected vitamin B6 on prolactin levels,62 , 63 , 64 , 65 , 66 and they also have reported inconsistent effects on restoring menstruation.67 , 68 , 69 Larger, controlled trials are needed to better determine the usefulness of vitamin B6 in amenorrhea.

Supplement Amount Why
Vitamin C and Clomiphene
 Refer to label instructions 1 star  

Vitamin C combined with the drug clomiphene, which affects female hormone levels, is more effective at stimulating ovulation in women with amenorrhea than either substance alone.



1 star  Vitamin C and Clomiphene

Vitamin C alone, at 400 mg daily, had no effect on amenorrhea in one preliminary trial, although it was associated with the return of ovulation in some women who were menstruating regularly but not ovulating. In a second phase of the trial, the same amount of vitamin C was combined with a drug that affects female hormone levels, and this combination was associated with return of ovulation in almost half of amenorrheic women who had not benefited from the drug alone.70 More studies of the effect of vitamin C on amenorrhea are needed.

Supplement Amount Why
Vitex
 Refer to label instructions 1 star   In herbal medicine, vitex, also known as chaste tree, is sometimes used to treat amenorrhea. Research suggests it may regulate hormones related to menstruation and fertility.

1 star  Vitex

In herbal medicine, vitex (Vitex agnus-castus; chaste tree) is sometimes used to treat female infertility and amenorrhea.71 Elevation of prolactin can be a cause of amenorrhea, and vitex has been shown in animals to reduce elevated prolactin levels.72 In a controlled trial, prolactin production was normalized in women with high prolactin levels after three months of treatment with vitex.73 Vitex has also been found to raise levels of luteinizing hormone and subsequent progesterone levels in women with luteal phase defect—a condition that can also lead to menstrual cycle abnormalities, including amenorrhea.74 To date, only one small preliminary trial has studied the effects of vitex on amenorrhea. This study found that ten of fifteen women with amenorrhea began having a normal period after taking 40 drops of a liquid vitex preparation once daily for six months.75 Further research is needed to determine what role vitex may play in the management of amenorrhea.


Supplement Amount Why
Yarrow
 Refer to label instructions 1 star   Yarrow has traditionally been thought to stimulate absent or diminished menses, though it has not been studied clinically.

1 star  Yarrow

Herbal emmenagogues traditionally regarded as stimulating absent or diminished menses are motherwort, rue, partridge berry, and yarrow. None of these herbs has undergone modern clinical trials to determine their efficacy. All emmenagogues should be avoided in pregnancy, as they may possibly cause a spontaneous abortion.

References

1. :Fagan KM. Pharmacologic management of athletic amenorrhea. Sports Pharmacology 1998;17:327–41 [review].

2. :Yen SS. Effects of lifestyle and body composition on the ovary. Endocrinol Metab Clin North Am 1998;27:915–26,ix [review].

3. :Sanborn CF, Horea M, Siemers BJ, Dieringer KI. Disordered eating and the female athlete triad. Clin Sports Med 2000;19:199–213 [review].

4. :Berga SL, Loucks-Daniels TL, Adler LJ, et al. Cerebrospinal fluid levels of corticotropin-releasing hormone in women with functional hypothalamic amenorrhea. Am J Obstet Gynecol 2000;182:776–81.

5. :Carmichael KA, Carmichael DH. Bone metabolism and osteopenia in eating disorders. Medicine (Baltimore) 1995;74:254–67 [review].

6. :McNeilly AS, Tay CC, Glasier A. Physiological mechanisms underlying lactational amenorrhea. Ann N Y Acad Sci 1994;709:145–55 [review].

7. :Kalkwarf HJ. Hormonal and dietary regulation of changes in bone density during lactation and after weaning in women. J Mammary Gland Biol Neoplasia 1999;4:319–29 [review].

8. Stener-Victorin E, Waldenstrom U, Tagnfors U, et al. Effects of electro-acupuncture on anovulation in women with polycystic ovary syndrome. Acta Obstet Gynecol Scand 2000;79:180–8.

9. Mo X, Li D, Pu Y, et al. Clinical studies on the mechanism for acupuncture stimulation of ovulation. J Tradit Chin Med 1993;13:115–9.

10. Yu J, Zheng HM, Ping SM. Changes in serum FSH, LH and ovarian follicular growth during electroacupuncture for induction of ovulation. Chung Hsi I Chieh Ho Tsa Chih 1989;9:199–202,195 [in Chinese].

11. Mo X, Li D, Pu Y, et al. Clinical studies on the mechanism for acupuncture stimulation of ovulation. J Tradit Chin Med 1993;13:115–9.

12. Yu J, Zheng HM, Ping SM. Changes in serum FSH, LH and ovarian follicular growth during electroacupuncture for induction of ovulation. Chung Hsi I Chieh Ho Tsa Chih 1989;9:199–202,195 [in Chinese].

13. Gerhard I, Postneek F. Possibilities of therapy by ear acupuncture in female sterility. Geburtshilfe Frauenheilkd 1988;48:165–71 [in German].

14. Kubista E, Boschitsch E, Spona J. Effect of ear-acupuncture on the LH-concentration in serum in patients with secondary amenorrhea. Wien Med Wochenschr 1981;131:123–6 [in German].

15. Miller KK, Parulekar MS, Schoenfeld E, et al. Decreased leptin levels in normal weight women with hypothalamic amenorrhea: the effects of body composition and nutritional intake. J Clin Endocrinol Metab 1998;83:2309–12.

16. Snow RC, Schneider JL, Barbieri RL. High dietary fiber and low saturated fat intake among oligomenorrheic undergraduates. Fertil Steril 1990;54:632–7.

17. Warren MP, Holderness CC, Lesobre V, et al. Hypothalamic amenorrhea and hidden nutritional insults. J Soc Gynecol Investig 1994;1:84–8.

18. Couzinet B, Young J, Brailly S, et al. Functional hypothalamic amenorrhoea: a partial and reversible gonadotrophin deficiency of nutritional origin. Clin Endocrinol (Oxf) 1999;50:229–35.

19. Laughlin GA, Dominguez CE, Yen SS. Nutritional and endocrine-metabolic aberrations in women with functional hypothalamic amenorrhea. J Clin Endocrinol Metab 1998;83:25–32.

20. Couzinet B, Young J, Brailly S, et al. Functional hypothalamic amenorrhoea: a partial and reversible gonadotrophin deficiency of nutritional origin. Clin Endocrinol (Oxf) 1999;50:229–35.

21. Bringer J, Lefebvre P, Renard E. Nutritional hypogonadism. Rev Prat 1999;49:1291–6 [review, in French].

22. Yen SS. Effects of lifestyle and body composition on the ovary. Endocrinol Metab Clin North Am 1998;27:915–26,ix [review].

23. Bringer J, Lefebvre P, Renard E. Nutritional hypogonadism. Rev Prat 1999;49:1291–6 [review, in French].

24. Dueck CA, Matt KS, Manore MM, Skinner JS. Treatment of athletic amenorrhea with a diet and training intervention program. Int J Sport Nutr 1996;6:24–40.

25. Kopp-Woodroffe SA, Manore MM, Dueck CA, et al. Energy and nutrient status of amenorrheic athletes participating in a diet and exercise training intervention program. Int J Sport Nutr 1999;9:70–88.

26. Koebnick C, Strassner C, Hoffmann I, Leitzmann C. Consequences of a long-term raw food diet on body weight and menstruation: results of a questionnaire survey. Ann Nutr Metab 1999;43:69–79.

27. Barr SI. Vegetarianism and menstrual cycle disturbances: is there an association? Am J Clin Nutr 1999;70:549S–54S [review].

28. Kemmann E, Pasquale SA, Skaf R. Amenorrhea associated with carotenemia. JAMA 1983;249:926–9.

29. Frumar AM, Meldrum DR, Judd HL. Hypercarotenemia in hypothalamic amenorrhea. Fertil Steril 1979;32:261–4.

30. Martin-Du Pan RC, Hermann W, Chardon F. Hypercarotenemia, amenorrhea and a vegetarian diet. J Gynecol Obstet Biol Reprod (Paris) 1990;19(3):290–4 [in French].

31. Kemmann E, Pasquale SA, Skaf R. Amenorrhea associated with carotenemia. JAMA 1983;249:926–9.

32. Cassidy A, Bingham S, Setchell K. Biological effects of isoflavones in young women: importance of the chemical composition of soyabean products. Br J Nutr 1995;74:587–601.

33. Cassidy A, Bingham S, Setchell KD. Biological effects of a diet of soy protein rich in isoflavones on the menstrual cycle of premenopausal women. Am J Clin Nutr 1994;60:333–40.

34. Lu LJ, Anderson KE, Grady JJ, et al. Decreased ovarian hormones during a soya diet: implications for breast cancer prevention. Cancer Res 2000;60:4112–21.

35. Wu AH, Stanczyk FZ, Hendrich S, et al. Effects of soy foods on ovarian function in premenopausal women. Br J Cancer 2000;82:1879–86.

36. Xu X, Duncan AM, Merz BE, Kurzer MS. Effects of soy isoflavones on estrogen and phytoestrogen metabolism in premenopausal women. Cancer Epidemiol Biomarkers Prev 1998;7:1101–8.

37. Lu LJ, Anderson KE, Grady JJ, Nagamani M. Effects of soya consumption for one month on steroid hormones in premenopausal women: implications for breast cancer risk reduction. Cancer Epidemiol Biomarkers Prev 1996;5:63–70.

38. Martini MC, Dancisak BB, Haggans CJ, et al. Effects of soy intake on sex hormone metabolism in premenopausal women. Nutr Cancer 1999;34:133–9.

39. Duncan AM, Merz BE, Xu X, et al. Soy isoflavones exert modest hormonal effects in premenopausal women. J Clin Endocrinol Metab 1999;84:192–7.

40. Barr SI. Vegetarianism and menstrual cycle disturbances: is there an association? Am J Clin Nutr 1999;70:549S–54S [review].

41. Koebnick C, Strassner C, Hoffmann I, Leitzmann C. Consequences of a long-term raw food diet on body weight and menstruation: results of a questionnaire survey. Ann Nutr Metab 1999;43:69–79.

42. Barr SI. Vegetarianism and menstrual cycle disturbances: is there an association? Am J Clin Nutr 1999;70:549S–54S [review].

43. Kemmann E, Pasquale SA, Skaf R. Amenorrhea associated with carotenemia. JAMA 1983;249:926–9.

44. Frumar AM, Meldrum DR, Judd HL. Hypercarotenemia in hypothalamic amenorrhea. Fertil Steril 1979;32:261–4.

45. Martin-Du Pan RC, Hermann W, Chardon F. Hypercarotenemia, amenorrhea and a vegetarian diet. J Gynecol Obstet Biol Reprod (Paris) 1990;19(3):290–4 [in French].

46. Kemmann E, Pasquale SA, Skaf R. Amenorrhea associated with carotenemia. JAMA 1983;249:926–9.

47. Cassidy A, Bingham S, Setchell K. Biological effects of isoflavones in young women: importance of the chemical composition of soyabean products. Br J Nutr 1995;74:587–601.

48. Cassidy A, Bingham S, Setchell KD. Biological effects of a diet of soy protein rich in isoflavones on the menstrual cycle of premenopausal women. Am J Clin Nutr 1994;60:333–40.

49. Lu LJ, Anderson KE, Grady JJ, et al. Decreased ovarian hormones during a soya diet: implications for breast cancer prevention. Cancer Res 2000;60:4112–21.

50. Wu AH, Stanczyk FZ, Hendrich S, et al. Effects of soy foods on ovarian function in premenopausal women. Br J Cancer 2000;82:1879–86.

51. Xu X, Duncan AM, Merz BE, Kurzer MS. Effects of soy isoflavones on estrogen and phytoestrogen metabolism in premenopausal women. Cancer Epidemiol Biomarkers Prev 1998;7:1101–8.

52. Lu LJ, Anderson KE, Grady JJ, Nagamani M. Effects of soya consumption for one month on steroid hormones in premenopausal women: implications for breast cancer risk reduction. Cancer Epidemiol Biomarkers Prev 1996;5:63–70.

53. Martini MC, Dancisak BB, Haggans CJ, et al. Effects of soy intake on sex hormone metabolism in premenopausal women. Nutr Cancer 1999;34:133–9.

54. Duncan AM, Merz BE, Xu X, et al. Soy isoflavones exert modest hormonal effects in premenopausal women. J Clin Endocrinol Metab 1999;84:192–7.

55. Barr SI. Vegetarianism and menstrual cycle disturbances: is there an association? Am J Clin Nutr 1999;70:549S–54S [review].

56. Shangold MM, Tomai TP, Cook JD, et al. Factors associated with withdrawal bleeding after administration of oral micronized progesterone in women with secondary amenorrhea. Fertil Steril 1991;56:1040–7.

57. Genazzani AD, Petraglia F, Algeri I, et al. Acetyl-l-carnitine as possible drug in the treatment of hypothalamic amenorrhea. Acta Obstet Gynecol Scand 1991;70:487–92.

58. Baer JT, Taper LJ, Gwazdauskas FG, et al. Diet, hormonal, and metabolic factors affecting bone mineral density in adolescent amenorrheic and eumenorrheic female runners. J Sports Med Phys Fitness 1992;32:51–8.

59. Kalkwarf HJ, Specker BL, Ho M. Effects of calcium supplementation on calcium homeostasis and bone turnover in lactating women. J Clin Endocrinol Metab 1999;84:464–70.

60. Fagan KM. Pharmacologic management of athletic amenorrhea. Clin Sports Med 1998;17:327–41 [review].

61. McIntosh EN. Treatment of women with the galactorrhea-amenorrhea syndrome with pyridoxine (vitamin B6). J Clin Endocrinol Metab 1976;42:1192–5.

62. Kidd GS, Dimond R, Kark JA, et al. The effects of pyridoxine on pituitary hormone secretion in amenorrhea-galactorrhea syndromes. J Clin Endocrinol Metab 1982;54:872–5.

63. Spiegel AM, Rosen SW, Weintraub BD, Marynick SP. Effect of intravenous pyridoxine on plasma prolactin in hyperprolactinemic subjects. J Clin Endocrinol Metab 1978;46:686–8.

64. Lehtovirta P, Ranta T, Seppala M. Pyridoxine treatment of galactorrhoea-amenorrhoea syndromes. Acta Endocrinol (Copenh) 1978;87:682–6.

65. Tolis G, Laliberte R, Guyda H, Naftolin F. Ineffectiveness of pyridoxine (B6) to alter secretion of growth hormone and prolactin and absence of therapeutic effects on galactorrhea-amenorrhea syndromes. J Clin Endocrinol Metab 1977;44:1197–9.

66. Goodenow TJ, Malarkey WB. Ineffectiveness of pyridoxine in evaluation and treatment of the hyperprolactinemic amenorrhea-galactorrhea syndrome. Am J Obstet Gynecol 1979;133:161–4.

67. Tolis G, Laliberte R, Guyda H, Naftolin F. Ineffectiveness of pyridoxine (B6) to alter secretion of growth hormone and prolactin and absence of therapeutic effects on galactorrhea-amenorrhea syndromes. J Clin Endocrinol Metab 1977;44:1197–9.

68. Lehtovirta P, Ranta T, Seppala M. Pyridoxine treatment of galactorrhoea-amenorrhoea syndromes. Acta Endocrinol (Copenh) 1978;87:682–6.

69. Kidd GS, Dimond R, Kark JA, et al. The effects of pyridoxine on pituitary hormone secretion in amenorrhea-galactorrhea syndromes. J Clin Endocrinol Metab 1982;54:872–5.

70. Igarashi M. Augmentative effect of ascorbic acid upon induction of human ovulation in clomiphene-ineffective anovulatory women. Int J Fertil 1977;22:168–73.

71. Veal L. Complementary therapy and infertility: an Icelandic perspective. Complement Ther Nurs Midwifery 1998;4:3–6 [review].

72. Sliutz G, Speiser P, Schultz AM, et al. Agnus castus extracts inhibit prolactin secretion of rat pituitary cells. Horm Metab Res 1993;25:253–5.

73. Milewicz A, Gejdel E, Sworen H, et al. Vitex agnus castus extract in the treatment of luteal phase defects due to latent hyperprolactinemia. Results of a randomized placebo-controlled double-blind study. Arzneimittelforschung 1993;43:752–6 [in German].

74. Brown DJ. Herbal Prescriptions for Health and Healing. Roseville, CA: Prima Health, 2000, 235–8.

75. Loch EG, Katzorke T. Diagnosis and treatment of dyshormonal menstrual periods in general practice. Gynäkol Praxis 1990;14:489–95.

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