Treatment Options for Chronic Anovulation

Diagnostic Evaluation

The American Academy of Family Physicians recommends measuring serum levels of hormones to identify the underlying cause of chronic anovulation, including LH, FSH, prolactin, progesterone, testosterone, and other hormones 3, 4
The American Academy of Family Physicians suggests checking for polycystic ovary syndrome (PCOS), which affects 4-6% of the general population and is a common cause of chronic anovulation 4
The European Society of Human Reproduction and Embryology recommends evaluating for functional hypothalamic amenorrhea (FHA), which is associated with stress, excessive exercise, and weight loss 5, 6
The American College of Obstetricians and Gynecologists advises screening for thyroid dysfunction, hyperprolactinemia, and other endocrine disorders that can cause anovulation 1
The American Institute of Ultrasound in Medicine recommends considering transvaginal ultrasound to assess for polycystic ovarian morphology 4

The American College of Obstetricians and Gynecologists recommends regular exercise and dietary changes as first-line interventions for PCOS-related anovulation 7
The Endocrine Society suggests that metformin can improve insulin sensitivity and ovulation rates in women with PCOS 7
The American College of Obstetricians and Gynecologists advises that combined oral contraceptives are effective for regulating cycles and reducing androgen levels in women with PCOS who are not seeking pregnancy 7
The American College of Obstetricians and Gynecologists recommends cyclic progestins, such as medroxyprogesterone acetate, to prevent endometrial hyperplasia in women with PCOS who are not seeking pregnancy 7

The European Society of Human Reproduction and Embryology recommends reducing excessive exercise, correcting energy deficits, and managing psychological stress to address underlying causes of FHA 6
The American College of Sports Medicine advises aiming for a BMI ≥18.5 kg/m² before ovulation induction in women with FHA 8
The European Society of Human Reproduction and Embryology suggests that pulsatile GnRH therapy is more effective than exogenous gonadotropins for ovulation induction in women with FHA 6, 8
The American College of Obstetricians and Gynecologists recommends hormone replacement therapy to prevent complications of hypoestrogenism in women with FHA who are not seeking pregnancy 8

The American Thyroid Association recommends appropriate thyroid hormone replacement or suppression for women with thyroid dysfunction-related anovulation 1
The American College of Obstetricians and Gynecologists advises that women with chronic anovulation are at increased risk for endometrial hyperplasia and cancer and require cyclic progestin therapy or combined hormonal contraception 2

The European Society of Human Reproduction and Embryology warns that failure to distinguish between PCOS and FHA can lead to inappropriate treatment choices 5, 6
The American College of Obstetricians and Gynecologists notes that metformin may cause gastrointestinal side effects but has fewer side effects than thiazolidinediones 7
The European Society of Human Reproduction and Embryology advises that in women with FHA who also have polycystic ovarian morphology (FHA-PCOM), diagnosis can be challenging and may require additional testing to differentiate from PCOS 5, 6