Amenorrhea (Absence of Menstruation) in Eating Disorder Patients
What is Amenorrhea?
Amenorrhea is the absence of menstruation, often defined as missing one or more menstrual periods, in women of childbearing age. Amenorrhea is divided into two subtypes:
- Primary amenorrhea: the absence of menstruation in someone who has not had a period by age 15
- Secondary amenorrhea: the absence of three or more periods in a row by someone who has had periods in the past.
Amenorrhea was previously considered a diagnostic criterion for anorexia nervosa, but it was removed with the publication of the DSM-5. Despite being removed, it continues to be a ubiquitous feature of severe weight loss in women.
Amenorrhea and Anorexia
Many women with a history of anorexia nervosa experience amenorrhea. Typically, this is secondary amenorrhea, with an estimated 66-84% of women with anorexia nervosa experiencing amenorrhea and 77% of women with bulimia with a history of anorexia nervosa also experience it.
Hypothalamic Amenorrhea
Amenorrhea in patients with eating disorders is related to loss of body weight and hormonal changes that follow, rather than a problem with the ovaries or uterus. This type of amenorrhea is referred to as hypothalamic amenorrhea. It is related to a combination of factors including nutritional deficiency, over-exercise and stress. This leads to dysfunction of the hypothalamus, a structure in the brain that is important in hormone function. Typically, the hypothalamus releases a hormone called gonadotropin-releasing hormone (GnRH) which regulates menstrual cycle hormones including luteinizing hormone (LH) and estradiol. Decreases in these hormones lead to loss of menses.
Leptin (a hormone that is secreted by adipocytes and functions as a mediator in the adaptation to energy deprivation) may also play a role in hypothalamic amenorrhea, with low levels contributing to abnormal GnRH secretion and loss of menstrual cycle.
Amenorrhea and Low Estrogen
Low estrogen resulting from abnormal GnRH can lead to symptoms that mimic pre-menopause:
- Night sweats
- Loss of sleep
- Frequent wakening
- Irritable mood
Another serious potential consequence of amenorrhea and low estrogen levels is decreased bone mineral density, also known as osteopenia, with the more severe form being osteoporosis. Decreased bone mineral density can lead to chronic pain, loss of height and increased risk of fractures. Because bone accrual is an ongoing process that peaks during adolescence, reduced bone mineral density is more common in those who developed their eating disorder younger.
Treatment of Amenorrhea
There is no clear treatment or preventative measure for this amenorrhea, other than weight restoration and adequate nutrition. There is variability in the literature regarding the degree of weight restoration needed for resumption of menses, with some sources citing return to ninety percent of ideal body weight, and others seeing a stronger correlation with the weight at which cessation of menses was observed.
It is not advised to use hormonal contraceptives in this setting singularly for the purpose of inducing a withdrawal bleeding for patients with anorexia nervosa. The induction of withdrawal bleeding can give a false sense of wellness to patients, which could decrease motivation for nutritional rehabilitation and weight restoration.
Depending on the severity of the eating disorder, malnutrition or other medical complications, it may be necessary for the patient to be admitted to a specialized medical stabilization unit for severe eating disorders.
Amenorrhea and Pregnancy
Even when a woman is not experiencing a monthly period, it is still possible for women with anorexia nervosa to become pregnant. While hormonal contraceptives should not be used to induce withdrawal bleeding, contraception may still be necessary to prevent pregnancy in sexually active patients. Regular obstetrician-gynecologist (OBGYN) visits are also recommended to keep patient informed about possible pregnancy.
Get Help for a Severe Eating Disorder
If you or someone you care about is experiencing severe medical complications due to an eating disorder, ACUTE can help. Reach out to us today to learn more about medical intervention for severe and extreme eating disorders with our experts at ACUTE. With proper care provided by experienced experts, we can help you restore your weight and regain your health.
Resources
- Ackerman, K. E. & Misra, M. (2022). Functional hypothalamic amenorrhea: Pathophysiology and clinical manifestations, UptoDate. Retrieved July 5, 2022 from https://www.uptodate.com/contents/functional-hypothalamic-amenorrhea-pathophysiology-and-clinical-manifestations
- Bulik, C. M., Hoffman, E. R., von Holle, A., Torgersen, L., Stoltenberg, C., & Reichborn-Kjennerud, T. (2010). Unplanned Pregnancy in Women With Anorexia Nervosa. Obstetrics & Gynecology, 116(5), 1136–1140.
- Chou, S. H., Chamberland, J. P., Liu, X., Matarese, G., Gao, C., Stefanakis, R., Brinkoetter, M. T., Gong, H., Arampatzi, K., & Mantzoros, C. S. (2011). Leptin is an effective treatment for hypothalamic amenorrhea. Proceedings of the National Academy of Sciences, 108(16), 6585–6590.
- Hoffman, E. R., Zerwas, S. C., & Bulik, C. M. (2011). Reproductive issues in anorexia nervosa. Expert Review of Obstetrics & Gynecology, 6(4), 403–414.
- Kimmel, M., Ferguson, E., Zerwas, S., Bulik, C., & Meltzer-Brody, S. (2015). Obstetric and gynecologic problems associated with eating disorders. International Journal of Eating Disorders, 49(3), 260–275.
- Welt, C. K. (2022). Normal Menstrual Cycle, UpToDate. Retrieved July 5, 2022 from https://www.uptodate.com/contents/normal-menstrual-cycle
- Welt, C. K., Chan, J. L., Bullen, J., Murphy, R., Smith, P., DePaoli, A. M., Karalis, A., & Mantzoros, C. S. (2004). Recombinant Human Leptin in Women with Hypothalamic Amenorrhea. New England Journal of Medicine, 351(10), 987–997.
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