Skip to main content
SpringerLink
Log in

Amenorrhea in Eating Disorders

  • Chapter
  • First Online:
Amenorrhea

Part of the book series: ISGE Series ((ISGE))

  • 360 Accesses

Abstract

Eating disorders are serious diseases affecting mostly young women during their reproductive years. Anorexia nervosa (AN) is characterized by severe underweight, intense fear of becoming fat, disturbed body perception, and amenorrhea. The diagnosis of bulimia nervosa (BN) is based on recurrent episodes of binge eating in combination with inappropriate compensatory behavior like self-induced vomiting. Although body weight often remains normal, menstrual disturbances are also common in BN. Amenorrhea in AN is usually ascribed to inhibition of the hypothalamic-pituitary-gonadal axis, resulting in low levels of estradiol. Functional hypothalamic amenorrhea (FHA) can be normalized once body weight is restored. If there is a lack of response to psychotherapy and nutritional counseling, hormone substitution can be considered to prevent consequences of estrogen deficiency. The transdermal route is then recommended to overcome the suppressive effect of oral estrogen on bone trophic factors like insulin-like growth factor I. In BN, different mechanisms of amenorrhea have been proposed including FHA due to temporary starvation. In addition, BN seems to be linked to polycystic ovary syndrome (PCOS) since elevated prevalence of polycystic ovaries, acne, and hirsutism as well as high serum levels of androgens have been observed in bulimic women. It has been suggested that androgens may promote bulimic behavior and antiandrogenic oral contraceptives may therefore be beneficial in BN. Amenorrhea in women with eating disorders should be carefully evaluated in order to offer proper treatment depending on the underlying cause.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 16.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 99.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Treasure J, Duarte TA, Schmidt U. Eating disorders. Lancet. 2020;395:899–911.

    Article  PubMed  Google Scholar 

  2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Press; 2013.

    Book  Google Scholar 

  3. Mustelin L, Silén Y, Raevuori A, Hoek HW, Kaprio J, Keski-Rahkonen A. The DSM-5 diagnostic criteria for anorexia nervosa may change its population prevalence and prognostic value. J Psychiatry Res. 2016;77:85–91.

    Article  Google Scholar 

  4. Smink FRE, van Hoeken D, Hoek HW. Epidemiology, course, and outcome of eating disorders. Curr Opin Psychiatry. 2013;26(6):543–8.

    Article  PubMed  Google Scholar 

  5. Dobrescu SR, Dinkler L, Gillberg C, Råstam M, Gillberg C, Wentz E. Anorexia nervosa: 30-year outcome. Br J Psychiatry. 2019;22:1–8.

    Google Scholar 

  6. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry. 2011;68:724–31.

    Article  PubMed  Google Scholar 

  7. Marucci S, Ragione LD, DeIaco G, Mococci T, Vicini M, Guastamacchia E, Triggiani V. Anorexia nervosa and comorbid psychopathology. Endocr Metab Immune Disord Drug Targets. 2018;18(4):316–24.

    Article  CAS  PubMed  Google Scholar 

  8. Riva G. Neurobiology of anorexia nervosa: serotonin dysfunctions link self-starvation with body image disturbances through an impaired body memory. Front Hum Neurosci. 2016;10:600.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Allaway HCM, Southmayd EA, De Souza MJ. The physiology of functional hypothalamic amenorrhea associated with energy deficiency in exercising women and in women with anorexia nervosa. Horm Mol Biol Clin Investig. 2016;25(2):91–119.

    CAS  PubMed  Google Scholar 

  10. Hirschberg AL. Female hyperandrogenism and elite sport. Endocr Connect. 2020;9:R81–92.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Misra M, Klibanski A. Endocrine consequences of anorexia nervosa. Lancet Diabetes Endocrinol. 2014;2:581–92.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Müller TD, Föcker M, Holtkamp K, Herpertz-Dahlmann B, Hebebrand J. Leptin-mediated neuroendocrine alterations in anorexia nervosa: somatic and behavioral implications. Child Adolesc Psychiatr Clin N Am. 2009;18(1):117–29.

    Article  PubMed  Google Scholar 

  13. Muñoz-Calvo MT, Argente J. Nutritional and pubertal disorders. Endocr Dev. 2016;29:153–73.

    Article  PubMed  Google Scholar 

  14. Neale J, Pais SMA, Nicholls D, Chapman S, Hudson LD. What are the effects of restrictive eating disorders on growth and puberty and are effects permanent? A systematic review and meta-analysis. J Adolesc Health. 2020;66(2):144–56.

    Article  PubMed  Google Scholar 

  15. Kouba S, Lindholm C, Hällström T, Hirschberg AL. Pregnancy and neonatal outcomes in women with eating disorders—a prospective controlled study. Obstet Gynecol. 2005;105:255–60.

    Article  Google Scholar 

  16. Mantel Ä, Hirschberg AL, Stephansson O. Association of maternal eating disorders with pregnancy and neonatal outcomes. JAMA Psychiatry. 2020;77(3):285–93.

    Article  PubMed  Google Scholar 

  17. Shufelt CL, Torbati T, Dutra E. Hypothalamic amenorrhea and the long-term health consequences. Semin Reprod Med. 2017;35:256–62.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Misra M, Klibanski A. Bone metabolism in adolescents with anorexia nervosa. J Endocrinol Investig. 2011;34(4):324–32.

    Article  CAS  Google Scholar 

  19. Miller KK, Lee EE, Lawson EA, Misra M, Minihan J, Grinspoon SK, Gleysteen S, Mickley D, Herzog D, Klibanski A. Determinants of skeletal loss and recovery in anorexia nervosa. J Clin Endocrinol Metab. 2006;91:2931–7.

    Article  CAS  PubMed  Google Scholar 

  20. Lewiecki EM, Gordon CM, Baim S, Leonard MB, Bishop NJ, Bianchi M-L, Kalkwarf HJ, Langman CB, Plotkin H, Rauch F, Zemel BS, Binkley N, Bilezikian JP, Kendler DL, Hans DB, Silverman S. International Society for Clinical Densitometry 2007 adult and Pediatric Official Positions. Bone. 2008;43:1115–21.

    Article  PubMed  Google Scholar 

  21. Legroux-Gerot I, Vignau J, Collier F, Cortet B. Bone loss associated with anorexia nervosa. Joint Bone Spine. 2005;72:489–95.

    Article  PubMed  Google Scholar 

  22. Faje AT, Fazeli PK, Miller KK, Katzman DK, Ebrahimi S, Lee H, Mendes N, Snelgrove D, Meenaghan E, Misra M, Klibanski A. Fracture risk and areal bone mineral density in adolescent females with anorexia nervosa. Int J Eat Disord. 2014;47(5):458–66.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Almeida M, Laurent MR, Dubois V, Claessens F, O’Brien CA, Bouillon R, Vanderschueren D, Manolagas SC. Estrogens and androgens in skeletal physiology and pathophysiology. Physiol Rev. 2017;97:135–87.

    Article  PubMed  Google Scholar 

  24. Snow CM, Rosen CJ, Robinson TL. Serum IGF-I is higher in gymnasts than runners and predicts bone and lean mass. Med Sci Sports Exerc. 2000;32:1902–7.

    Article  CAS  PubMed  Google Scholar 

  25. Tauchmanovà L, Pivonello R, De Martino MC, Rusciano A, De Leo M, Ruosi C, Mainolfi C, Lombardi G, Salvatore M, Colao A. Effects of sex steroids on bone in women with subclinical or overt endogenous hypercortisolism. Eur J Endocrinol. 2007;157:359–66.

    Article  PubMed  Google Scholar 

  26. Rickenlund A, Thorén M, Carlström K, von Schoultz B, Hirschberg AL. Diurnal profiles of testosterone and pituitary hormones suggest different mechanisms for menstrual disturbances in endurance athletes. J Clin Endocrinol Metab. 2004;89:702–7.

    Article  CAS  PubMed  Google Scholar 

  27. Gordon CM, Ackerman KE, Berga SL, Kaplan JR, Mastorakos G, Misra M, Murad MH, Santoro NF, Warren MP. Functional hypothalamic amenorrhea: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102:1413–39.

    Article  PubMed  Google Scholar 

  28. Misra M, Prabhakaran R, Miller KK, Goldstein MA, Mickley D, Clauss L, Lockhart P, Cord J, Herzog DB, Katzman DK, Klibanski A. Weight gain and restoration of menses as predictors of bone mineral density change in adolescent girls with anorexia nervosa-1. J Clin Endocrinol Metab. 2008;93:1231–7.

    Article  CAS  PubMed  Google Scholar 

  29. Misra M, Katzman D, Miller KK, Mendes N, Snelgrove D, Russell M, Goldstein MA, Ebrahimi S, Clauss L, Weigel T, Mickley D, Schoenfeld DA, Herzog DB, Klibanski A. Physiologic estrogen replacement increases bone density in adolescent girls with anorexia nervosa. J Bone Miner Res. 2011;26:2430–8.

    Article  CAS  PubMed  Google Scholar 

  30. Weissberger AJ, Ho KK, Lazarus L. Contrasting effects of oral and transdermal routes of estrogen replacement therapy on 24-hour growth hormone (GH) secretion, insulin-like growth factor I, and GH-binding protein in postmenopausal women. J Clin Endocrinol Metab. 1991;72(2):374–81.

    Article  CAS  PubMed  Google Scholar 

  31. Hilbert A, Hoek HW, Schmidt R. Evidence-based clinical guidelines for eating disorders: international comparison. Curr Opin Psychiatry. 2017;30:423–37.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Fisher CA, Skocic S, Rutherford KA, Hetrick SE. Family therapy approaches for anorexia nervosa. Cochrane Database Syst Rev. 2019. Published online May 1. https://doi.org/10.1002/14651858.CD004780.pub4.

  33. van den Berg E, Houtzager L, de Vos J, Daemen I, Katsaragaki G, Karyotaki E, Cuijpers P, Dekker J. Meta-analysis on the efficacy of psychological treatments for anorexia nervosa. Eur Eat Disord Rev. 2019;27:331–51.

    Article  PubMed  Google Scholar 

  34. Zeeck A, Herpertz-Dahlmann B, Friederich HC, Brockmeyer T, Resmark G, Hagenah U, Ehrlich S, Cuntz U, Zipfel S, Hartmann A. Psychotherapeutic treatment for anorexia nervosa: a systematic review and network meta-analysis. Front Psychiatry. 2018;9:158.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Hay PJ, Touyz S, Claudino AM, Lujic S, Smith CA, Madden S. Inpatient versus outpatient care, partial hospitalisation and waiting list for people with eating disorders. Cochrane Database Syst Rev. 2019;1:CD010827.

    PubMed  Google Scholar 

  36. Keel PK, Brown TA. Update on course and outcome in eating disorders. Int J Eat Disord. 2010;43:195–204.

    PubMed  Google Scholar 

  37. Carter FA, McIntosh VV, Joyce PR, Frampton CM, Bulik CM. Bulimia nervosa, childbirth, and psychopathology. J Psychosom Res. 2003;55:357–61.

    Article  PubMed  Google Scholar 

  38. Steiger H, Bruce KR, Groleau P. Neural circuits, neurotransmitters, and behavior: serotonin and temperament in bulimic syndromes. Curr Top Behav Neurosci. 2011;6:125–38.

    Article  PubMed  Google Scholar 

  39. Kimmel MC, Ferguson EH, Zerwas S, Bulik CM, Meltzer-Brody S. Obstetric and gynecologic problems associated with eating disorders. Int J Eat Disord. 2016;49(3):260–75.

    Article  CAS  PubMed  Google Scholar 

  40. Münster K, Helm P, Schmidt L. Secondary amenorrhoea: prevalence and medical contact—a cross–sectional study from a Danish county. Br J Obstet Gynaecol. 1992;99:430–3.

    Article  PubMed  Google Scholar 

  41. Resch M, Szendei G, Haász P. Eating disorders from a gynecologic and endocrinologic view: hormonal changes. Fertil Steril. 2004;81(4):1151–3.

    Article  PubMed  Google Scholar 

  42. Gendall KA, Joyce PR, Carter FA, McIntosh VV, Bulik CM. Thyroid indices and treatment outcome in bulimia nervosa. Acta Psychiatr Scand. 2003;108(3):190–5.

    Article  CAS  PubMed  Google Scholar 

  43. Naessén S, Carlström C, Glant R, Jacobsson H, Hirschberg AL. Bone mineral density in bulimic women—influence of endocrine factors and previous anorexia. Eur J Endocrinol. 2006;155:245–51.

    Article  PubMed  Google Scholar 

  44. Hirschberg AL. Sex hormones, appetite and eating behaviour in women. Maturitas. 2012;71:248–56.

    Article  CAS  PubMed  Google Scholar 

  45. Azziz R, Carmina E, ZiJiang Chen Z, Dunaif A, Laven JSE, Legro RS, Lizneva D, Natterson-Horowtiz B, Teede HJ, Yildiz BO. Polycystic ovary syndrome. Nat Rev Dis Primers. 2016;2:16057.

    Article  PubMed  Google Scholar 

  46. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81:19–25.

    Article  Google Scholar 

  47. Hirschberg AL, Naessén S, Stridsberg M, Byström B, Holte J. Impaired cholecystokinin secretion and disturbed appetite regulation in women with polycystic ovary syndrome. Gynecol Endocrinol. 2004;19:79–87.

    Article  CAS  PubMed  Google Scholar 

  48. Thannickal A, Brutocao C, Alsawas M, Morrow A, Zaiem F, Murad MH, Chattha AJ. Eating, sleeping and sexual function disorders in women with polycystic ovary syndrome (PCOS): a systematic review and meta-analysis. Clin Endocrinol (Oxf). 2020;92(4):338–49.

    Article  PubMed  Google Scholar 

  49. McCluskey SE, Lacey JH, Pearce JM. Binge-eating and polycystic ovaries. Lancet. 1992;340:723.

    Article  CAS  PubMed  Google Scholar 

  50. Morgan JF, McCluskey SE, Brunton JN, Hubert Lacey J. Polycystic ovarian morphology and bulimia nervosa: a 9-year follow-up study. Fertil Steril. 2002;77(5):928–31.

    Article  PubMed  Google Scholar 

  51. Naessén S, Garoff L, Carlström K, Glant R, Hirschberg AL. Polycystic ovary syndrome in bulimic women—an evaluation based on the new diagnostic criteria. Gynecol Endocrinol. 2006;22:388–94.

    Article  PubMed  Google Scholar 

  52. Eriksson E. Behavioral effects of androgens in women. In: Steiner M, Yonkers KA, Eriksson E, editors. Mood disorders in women. London: Martin Dunitz; 2000. p. 233–46.

    Google Scholar 

  53. Cooney LG, Dokras A. Depression and anxiety in polycystic ovary syndrome: etiology and treatment. Curr Psychiatry Rep. 2017;19(11):83.

    Article  PubMed  Google Scholar 

  54. Abraham S. Sexuality and reproduction in bulimia nervosa patients over 10 years. J Psychosom Res. 1998;44(3–4):491–502.

    Article  CAS  PubMed  Google Scholar 

  55. Johansen N, Hirschberg AL, Moen MH. The role of testosterone in menopausal hormone treatment. What is the evidence? Acta Obstet Gynecol Scand. 2020;99(8):966–9.

    Article  CAS  PubMed  Google Scholar 

  56. Sundblad C, Landén M, Eriksson T, Bergman L, Eriksson E. Effects of the androgen antagonist flutamide and the serotonin reuptake inhibitor citalopram in bulimia nervosa: a placebo-controlled pilot study. J Clin Psychopharmacol. 2005;25(1):85–8.

    Article  CAS  PubMed  Google Scholar 

  57. Naessén S, Carlström K, Byström B, Pierre Y, Hirschberg AL. Effects of an antiandrogenic oral contraceptive on appetite and eating behavior in bulimic women. Psychoneuroendocrinology. 2007;32(5):548–54.

    Article  PubMed  Google Scholar 

  58. Robinson L, Aldridge V, Clark EM, Misra M, Micali N. A systematic review and meta-analysis of the association between eating disorders and bone density. Osteoporos Int. 2016;27(6):1953–66.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  59. Hagan KE, Walsh BT. State of the art: the therapeutic approaches to bulimia nervosa. Clin Ther. 2021;43(1):40–9.

    Article  CAS  PubMed  Google Scholar 

  60. Slade E, Keeney E, Mavranezouli I, Dias S, Fou L, Stockton S, Saxon L, Waller G, Turner H, Serpell L, Fairburn CG, Kendall T. Treatments for bulimia nervosa: a network meta-analysis. Psychol Med. 2018;48:2629–36.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Women’s and Children’s Health, Karolinska Institutet, Solna, Sweden

    Angelica Lindén Hirschberg

  2. Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden

    Angelica Lindén Hirschberg

Authors
  1. Angelica Lindén Hirschberg
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Angelica Lindén Hirschberg .

Editor information

Editors and Affiliations

  1. International Society of Gynecological Endocrinology, Pisa, Italy

    Andrea R. Genazzani

  2. Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden

    Angelica Lindén Hirschberg

  3. Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, MODENA, Modena, Italy

    Alessandro D. Genazzani

  4. Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, Pavia, Italy

    Rossella Nappi

  5. Faculty of Medicine Clinic of Endocrinology Diabetes and Diseases of Metabolism, University of Belgrade University Clinical Center of Serbia, Belgrade, Serbia

    Svetlana Vujovic

Rights and permissions

Reprints and permissions

Copyright information

© 2023 International Society of Gynecological Endocrinology

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Hirschberg, A.L. (2023). Amenorrhea in Eating Disorders. In: Genazzani, A.R., Hirschberg, A.L., Genazzani, A.D., Nappi, R., Vujovic, S. (eds) Amenorrhea. ISGE Series. Springer, Cham. https://doi.org/10.1007/978-3-031-22378-5_3

Download citation

  • DOI: https://doi.org/10.1007/978-3-031-22378-5_3

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-22377-8

  • Online ISBN: 978-3-031-22378-5

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation