Induction of ovulation with clomiphene citrate in combination with metoclopramide in patients with amenorrhea of hypothalamic origin

Literature data have demonstrated that the chronic use of metoclopramide (M CP), a dopamine antagonist, causes increased gonadotropin secretion in pati ents with hypothalamic amenorrhea but without triggering ovulation. It has also been observed that women with hypothalamic amenorrhea respond poorly t o ovulation induction with clomiphene citrate (CC). On this basis, the obje ctive of the present study was to determine the effect of MCP on the respon se to CC in patients with hypothalamic amenorrhea in order to evaluate the validity of the simultaneous use of these drugs as ovulation inducers in th is type of chronic anovulation. Twenty-two patients with amenorrhea of hypo thalamic origin were submitted to a randomized double blind study in which one tablet of 5 mg MCP or placebo was administered every 8 hours for 2 mont hs. After the 30th day of medication (MCP or placebo), CC, 100 mg orally, w as additionally administered to both groups for 5 days. Blood samples were collected on days 1, 15 and 30 during the first month of the study and on d ays 7, 14 and 21 after the last CC tablet during the second month, for late r measurement of follicle-stimulating hormone (FSH), luteinizing hormone (L H), prolactin, estradiol and progesterone by radioimmunoassay. The group th at received MCP showed a significant increase in LH and FSH during the firs t month of the study, as well as a slighter increase in estradiol. Prolacti n increased only during the second stage of treatment. No significant incre ases in gonadotropins, prolactin or estradiol occurred in the placebo group . In the group treated with MCP, 40% of the patients ovulated after CC, wit h menstruation occurring in 60% of them. In the placebo group, 33.3% of the women ovulated after CC and 44.4% menstruated at the end of the study. We conclude that MCP increases the circulating levels of LH, FSH, estradiol an d prolactin in patients with hypothalamic amenorrhea and low estrogen level s, supporting the hypothesis that an increase in hypothalamic dopaminergic tonus occurs in these patients. On the other hand, the combination of MCP a nd CC does not improve the rate of ovulation compared to placebo.