Primary Care Provider
Eating disorders effect virtually every organ and organ system of the body. From the hair, skin and fingernails to the vital organs such as the heart, brain even the lungs. Most of the effects on the body result from the behaviors associated with the eating disorder. These behaviors include dietary and fluid restriction, binging and purging, over exercise and the taking of substances such and diet pills, laxatives and diuretics. The focus of this post will be on the effects of eating disorder behaviors on the reproductive system.
One of the most important and most common problems that occurs in the reproductive system of females with an eating disorder is amenorrhea. “Amenorrhea…is the absence of menstruation. Women who have missed at least three menstrual periods in a row have amenorrhea, as do girls who haven’t begun menstruation by age 15.” (Mayo Clinic Staff, 2014). Generally amenorrhea is classified as either primary or secondary. Primary amenorrhea is the absence of a period by the age 15 and secondary amenorrhea is defined as the “absence of menses for more than three months in girls or women who previously had regular menstrual cycles or six months in girls or women who had irregular menses.” (Welt & Barbieri, 2016).
Amenorrhea has multiple causes. In the general population the most common cause is pregnancy. This should always be ruled out first when considering a patient with either primary or secondary amenorrhea. There are other causes as well such as well such as breast feeding, menopause, certain medications, stress, excessive exercise, low body weight, hormone imbalances, and structural or anatomical problems such as scarring of the uterus, absence or abnormalities of reproductive organs. It is important for anyone experiencing amenorrhea to be evaluated by their medical provider to determine the cause and get appropriate treatment.
In the presence of an eating disorder, the most common cause of amenorrhea is suppression of the hypothalamus in the brain. When the body is under great stress, the hormones CRH and GnRH are suppressed. This leads to a cascading effect on the rest of the endocrine system or the body’s hormone system. Suppression of the hypothalamus leads to suppression of the pituitary gland hormones LH and FSH. The decrease of these two pituitary hormones leads to a drop in the production of estradiol from the ovaries. The result is something called hypogonadism or a hypoestrogenemic state. In summary, this means that there is a marked decrease in the production of estrogen secondary to suppression of the hypothalamus from a severe stressor such as malnutrition.
Why does this matter?
There are several other important health implications related to the how eating disorder symptoms impair the reproductive system.
- The first is infertility or the inability to conceive. Amenorrhea can decrease fertility. When the body is under enough stress from malnutrition, low body weight and cessation of the menstrual cycle, the body can cease to ovulate as well. This can lead to the inability to become pregnant and lead to infertility.
- Another concern that is less known is that despite the potential for infertility, women and adolescents with eating disorders can and do become pregnant. This is a concern because amenorrhea often leaves individuals not worrying about getting pregnant. Yet, there is a high rate of unplanned pregnancies within the eating disorder population. In fact, “Two large population-based studies have found that women with current anorexia nervosa have an earlier age of pregnancy compared with women in the general population without eating disorders. Further investigation in the Norwegian Mother and Child Cohort Study (MoBa; including 62,060 births in Norway) found that the risk of having an unplanned pregnancy was significantly increased in women with current anorexia nervosa in the 6 months before pregnancy, with 50% reporting that their pregnancy was unplanned compared with only 18.9% in the referent group. In addition, women with anorexia nervosa were significantly more likely to report a past induced abortion than the referent group (24.2 vs 14.6%). While the explanation for this finding requires additional study, the authors hypothesize that the absence or irregularity of menstruation in these women may lead them to the belief that conception is unlikely and that there is less need for adherence to guidelines for proper contraceptive use.” (Hoffman, Zerwas, Bulik, 2011).
- Another health-related issue is one that has the potential to greatly effect long term health. This issue is low bone density with associated increased risk of fracture. Fractures in bone with low bone mineralization can occur from injury but can also occur from normal activities such as jogging and walking. Spontaneous fractures that occur because of a disease process such as hypothalamic amenorrhea and hypogonadism secondary to anorexia nervosa are called pathologic fractures. As has been stated, hypothalamic amenorrhea occurs for multiple reasons but studies have shown that “the degree of low bone density in anorexia nervosa….is more severe than that seen in other women with hypothalamic amenorrhea matched for age and duration of amenorrhea suggesting other nutritional factors may be contributing.” (Grinspoon, S, Miller K, Coyle C et al, 1999). I have treated patients who have had pathologic fractures of the hip and lower back. These fractures are very painful and can be debilitating. They can lead to other problems with the bones such as loss of height of the vertebrae in the back and osteoarthritis later in life in the fractured bone. The impact that hypogonadism and decreased estradiol has on bone health effects females as well as males with severe malnutrition related to eating disorders. In both genders, without sufficient production of hormones there is a marked decrease in bone mineralization. The bones are living organs just like any other organs of the body. They are dynamic and bone remineralization is a process that is going on all the time. In order for bones to remain healthy it is important that we have adequate nutrition, adequate body fat content and hormone production to support bone health. Without these, bone mineral density decreases and results in an increased risk of pathologic fracture.
The good news is that amenorrhea can and will generally improve with adequate nutrition. Bone mineral density is slower to improve but in my experience it can improve marginally. There are medications that have shown some improvement in bone health and oral contraceptives can start women having periods but none of these have the effects that nutrition and cessation of eating disordered behaviors will have on overall physical and reproductive health. The key to improvement is recovery. Recovery has to be accompanied by nutrition, maintenance of a healthy weight, appropriate amounts of load bearing exercise (coupled with a healthy mindset related to exercise of course) and adequate body fat content over a long enough period of time for the hypothalamus, reproductive organs and bones to heal. This process can take months to even years but it IS possible and worth it! The health benefits of recovery when maintained are long lasting and life changing.
References
Grinspoon, S, Miller K, Coyle C et al. (1999). Severity of osteopenia in estrogen-deficient women with anorexia nervosa and hypothalamic amenorrhea. Journal of Clinical Endocrinology and Metabolism, 84, 2049-2055.
Hoffman, Elizabeth M., Stephanie C. Zerwas, and Cynthia M. Bulik. N.d. (2012). MS 7160, Expert Rev Obstet Gynecol. University of North Carolina at Chapel Hill. NCBI. US Library of Medicine National Institutes of Health, 1, Web 12 June 2017.
Mayo Clinic Staff. (2014). Causes and Conditions Amenorrhea. Mayo Clinic. N.p., 9. Web 12 June 2017.Welt, Corinne K., MD, and Robert L. Barbieri, MD. (2016) Evaluation and Management of Secondary Amenorrhea. UpToDate. N.p., 17. Web. 12 June 2017.