Strengths and Limitations
Due to the retrospective design, data collection was restricted to available content on databases, which resulted in missing data for various indices, limiting statistical comparison between the two groups. Furthermore, we were unable to assess psychological comorbidities such as EDs, depression and anxiety using scoring scales, which is the preferred method of assessment in most other FHA studies. In the absence of a psychological diagnosis, more subtle traits and behaviours may have gone undetected in our study. We also recognise that concomitant PCOS cannot be excluded in some women with FHA; in our study clinicians suspected underlying PCOS in 14 women with FHA. Previous studies, have demonstrated that PCOS-like abnormalities, including elevated anti-Mullerian hormone and PCOM on ultrasound, may be an incidental finding in up to 40% of women with FHA and 10% may have co-existing PCOS.
11,12 Thus, some women with FHA and low a BMI may represent a subgroup of “suppressed PCOS”, which may be uncovered with weight gain and lifestyle changes, ensuing hypothalamic-pituitary-ovarian (HPO) axis recovery. 16In an attempt to clarify this clinical dilemma, various retrospective studies have demonstrated lower incidence of hyperandrogenism, lower mean LH levels and sex hormone binding globulins (indicating insulin resistance), in women with FHA and underlying PCOS.
17,18 There remains, however, a lack of adequately powered, prospective trials to investigate to what extent parameters such BMI, estradiol, LH and LH:FSH ratio, differ in this subgroup of women with FHA. A strength of this study is our large sample of women with FHA, compared to previous studies. Our study is one of few to compare women with FHA to those with PCOS, rather than eumenorrheic women.