Reply To: 19 yo female

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Carrie Decker, ND

Hello Debbie,

Thank you for contributing this case here. As a reminder, because labs can use different units, and because this is an international resource where different units are reported, it always is important to include the reference range when reporting test results. I’ll rely on your statement that these numbers reported were low, and proceed to offer feedback based on this. I’m also assuming her prolactin has also been tested and shown to be normal as this is a part of standard workup.

Stress is all relative, and I would actually suspect it is more of an issue for her than she reports. At a young age people often are not as cognizant of the things that are stressing their bodies. I used to have a sensitive menstrual cycle and longer periods of amenorrhoea, and upon traveling to South America for a prolonged period alone, I also ceased having my menses again. So, I would consider this trip to also be a factor in why she still is not having her period there. Some of the cultural differences there can be unsettling and be a challenge to women travelers, never mind the fact that in many places safety is also more of a concern as well as getting from A to B, language, etc.

Women with normal serum prolactin and thyroid, a low or normal serum FSH concentration, and no history of uterine instrumentation are likely to have a hypothalamic-pituitary disorder or PCOS. As her testosterone and LH measurements are also low and symptoms do not suggest PCOS, it is likely some aspect of hypothalamic-pituitary dysfunction. This constellation is one of the most common outcomes of laboratory testing in women with amenorrhoea.

Hypothalamic amenorrhea can also be seen with systemic illness such as coeliac disease and type 1 diabetes mellitus, and it is suggested that these possible aetiologies also be ruled out with standard screening (fasting blood sugar, HbA1c, and serological testing for coeliac). Magnetic resonance imaging (MRI) of the sella region is indicated in all women without a clear explanation for hypogonadotropic hypogonadism, such as weight loss, exercise, or stress, and in all women who have normal laboratory findings and symptoms such as visual field defects, headaches, or other signs of hypothalamic-pituitary dysfunction.

Although the standard approach is to initiate oestrogen therapy, there are additional options that can be tried from a natural perspective. I would be curious to hear what her acupuncturist feels is her primary issue as this can also be helpful to developing a holistic understanding. From my perspective, this is an excellent time to initiate glandular support and support with botanicals that support hormone adequacy in the body. Specific considerations are detailed in the suggestions below, but in short, they include phytoestrogenic botanicals (black cohosh, dong quai) as well as glandular support for hypothalamic and pituitary function. Glandular substances are excellent for supporting restoration of function in a state of deficiency.

With cycling women, I also find it useful to utilize seed cycling and essential fatty acid cycling to encourage healthy hormone metabolism. This also can be helpful in women who are lacking a menstrual cycle, following the moon cycle instead of menses. Flax or pumpkin seeds, 2 tablespoons freshly ground and/or fish oil 2000mg combined EPA/DHA should be taken from day 1 of the cycle to ovulation; and 2 tablespoons of sunflower or sesame seed and/or 2000mg of borage, black currant, or evening primrose oil (supplying approximately 400mg of gamma-linolenic acid) taken the second half of the cycle from ovulation through menstruation.

Prolonged loss of the menstrual cycle contributes to poor bone health and an increased risk of osteoporosis. Hormones play an important role in bone health, thus the absence of menstrual cycling and decreased estrogen and progesterone, as well as testosterone in the body leads to diminished bone strength. Both men and women experience a decrease in these hormones with age. Diminished bone integrity is commonly an issue with women athletes as they often experience amenorrhea – and is known as the female athlete triad (amenorrhea, osteoporosis, with nutritional deficiencies/eating disorders).

Although the nutrients most recognized by physicians as important for supporting bone health are vitamin D and calcium, there are many more minerals and vitamins which also play a role. Vitamin K plays a role in directing calcium deposition to the bone matrix, via activation of osteocalcin, and insufficiency may be associated with soft tissue calcification and lower bone mineral density.  Some forms of vitamin K are more active in the body than others. Menaquinone-7, or MK-7, is a highly bioactive form of vitamin K2. The form of vitamin D also is important, as vitamin D3 has been shown to be significantly more effective than vitamin D2 (calciferol) at raising the body’s serum 25(OH)D concentration.

Bügel S. Vitamin K and bone health in adult humans. Vitam Horm. 2008;78:393-416.

Inaba N, et al. Low-Dose Daily Intake of Vitamin K(2) (Menaquinone-7) Improves Osteocalcin γ-Carboxylation: A Double-Blind, Randomized Controlled Trials. J Nutr Sci Vitaminol (Tokyo). 2015;61(6):471-80.

Schurgers LJ, et al. Vitamin K-containing dietary supplements: comparison of synthetic vitamin K1 and natto-derived menaquinone-7. Blood. 2007 Apr 15;109(8):3279-83.


Magnesium, zinc, copper, boron, manganese and silica and other trace minerals also have importance for bone health, and although they are not the primary elements contained in the matrix of bone, deficiency is correlated either with reduced bone mass or slow healing of fractures. Many of these elements are essential cofactors for enzymes involved in the synthesis of bone. Silicon is involved in bone formation through the synthesis and/or stabilization of collagen.

Saltman PD, Strause LG. The role of trace minerals in osteoporosis. J Am Coll Nutr. 1993 Aug;12(4):384-9.

Jugdaohsingh R. Silicon and bone health. J Nutr Health Aging. 2007 Mar-Apr;11(2):99-110.



The following supplements are suggested for you to consider in light of your relevant expertise and understanding of the needs of your client. They may be used in isolation or as part of a multi supplement strategy, but at all times the consideration of their use should be tied into the specific needs of the individual you are responsible for.

Equi-Fem (BRC): 2 – 4 tablets with meal in AM. Broad-spectrum multi-vitamin formula that also supplies small amounts of glandular support as well as phytoestrogens.


Cytozyme-PT/HPT (BRC): 1 tablet daily with meal, possibly increasing to 2 after one month if well tolerated and changes are not yet seen.  Provides hypothalamus and pituitary glandulars with antioxidant enzymes.

ProOmega™ (NN): 2 softgels twice daily (2000 mg total combined EPA/DHA), new moon – full moon.

Alternating with:

GLA Borage Oil (ARG): 2 softgels with breakfast and dinner, full moon – new moon.

Osteo-Vi-Min Powder (ARG):  2 tsp in 8 oz of liquid daily.  Comprehensive bone support formula.  Possibly to include additional vitamin D if multivitamin does not contain at least 1000IU.

Please consider these suggestions in light of the other clinical information pertaining to your client.  If you have any more information about the specific problems this individual is experiencing, further refinement of these suggestions may be considered.  I hope this information is helpful, and if you have any further questions or information specific to the problems this individual is experiencing, please do provide feedback.

In health,

Dr. Decker