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Low bone density

Bone loss is best treated by correction of the underlying cause. Patients should undergo evaluation of bone marrow density using a DEXA scan and started on Vitamin D and calcium supplementation. If menstruation does not resume after 6 months with reasonable trial of non-pharmaceutical management, loss of bone mass becomes the main concern. Short-term use of transdermal estradiol E2 with cyclic oral progestin may be used for estrogen replacement. Care must be taken to exclude risks for thromboembolic disease prior to implementation of hormonal therapy given the associated increase in risk for venous thromboembolism. The Endocrine Society Clinical Practice Guidelines on Functional Hypothalamic Amenorrhea (FHA) recommend against oral contraceptives, bisphosphonates, denosumab, testosterone, and leptin for the improvement of bone mass density in FHA. The limited numbers of studies evaluating the effect of bisphosphonates on BMD did not provide significant evidence of improvement, and the scope of studies are inadequate to ensure safety and efficacy in FHA patients. While denosumab has been used to improve fracture risk in postmenopausal women with osteoporosis, it has not been adequately studied in premenopausal women and may pose a risk of inadvertent fetal exposure.