In athletes with primary amenorrhea, one may consider the use of hormone replacement therapy (HRT) for the treatment of hypothalamic amenorrhea, as seen with anorexia nervosa, exercise-induced amenorrhea, and premature ovarian insufficiency [40]. The primary goals of HRT are to induce age-appropriate secondary sexual characteristics and to maximize skeletal health, although there is still limited research on the appropriate dosing for optimizing these outcomes [41]. Composed of three main phases, HRT should be individualized for each patient based on her physical and psychological needs and readiness [40]. In Phase 1, lower-dose estrogen monotherapy is used, either in a transdermal or oral preparation, to mimic the early phases of puberty in which estrogen is unopposed. During this phase, breast development and growth are stimulated. In Phase 2 of treatment, the estrogen dosages are increased, as would correspond to the hormonal shifts in a typical pubertal progression. Additionally, progestin therapy is begun to induce and maintain regular menses. Once menses have been established, Phase 3, or maintenance phase, commences in which adult serum levels of estrogen are achieved and maintained. A variety of hormonal preparations may achieve this, including combined estrogen/progesterone products in oral, transdermal, or transvaginal delivery modalities.

The use of oral contraceptive pills to resume menses in athletes with secondary amenorrhea is often recommended by some providers, but has little evidence to support its prescription [30, 42–46]. While using oral contraceptive pills may restore regular bleeding episodes, it does not restore the energy and hormonal balance that is critical for maximum bone development. Additionally, since regular periods are an important marker of a healthy weight and body, masking menstrual resumption with pill-induced menses results in a loss of an important clinical tool.