Implications of lack of menstruation in women with an eating disorder
In cases of eating disorders, the absence of menstruation (amenorrhea) is a common symptom. We can find ourselves with a complete cessation of menstruation, especially in cases of significant weight loss as occurs with anorexia nervosa or ARFID (emotional restriction/refusal of food intake), to alterations in the menstrual cycle in cases of bulimia or binge eating disorder.
Menstruation, as a general rule, stops when the person does not maintain a sufficient weight to allow the body to function properly. In eating disorders, this can occur through sustained dietary restriction, but also through compulsive exercise or high-frequency purging behaviors (vomiting, laxative abuse).
This is not the only reason why menstruation can stop, it can also be due to malnutrition, excessive exercise (for example, it can happen to high-level athletes), diseases with hormonal alterations (such as hypothyroidism), as a side effect of some medications and, sometimes, due to intense stress (which also occurs in an eating disorder). It is also common for menstruation to begin irregularly (menarche) until the cycle is established.
Knowing all the possible origins of the lack of menstruation, it is important to know the girls' eating and sports habits when health professionals approach a case. It should be borne in mind that some girls experience the absence of menstruation, which can often be painful, as one less thing to worry about and do not pay attention to it.
The lack of menstruation, however, is a major problem that has repercussions on the physical health of women. It affects reproductive capacity and, especially, bones, which lose density (osteoporosis) and become more fragile, something that also happens when women enter menopause.
Why do bones become fragile if we don't menstruate?
Bones need calcium to maintain their consistency, their internal framework. Menstrual hormones, specifically estrogen, which are what trigger bleeding, create the right environment for the calcium absorbed from food to be used by the bones, with the contribution of vitamin D, which sunlight activates. It is not enough to ingest calcium through the diet, no matter how rich or enriched in calcium certain products are made, sun and hormones are also needed.
This is why, if there is an absence of menstruation for a long time, the bones end up decalcifying and there is a risk of suffering bone fractures at a premature age.
It is debatable to what extent calcium supplements can replace this loss, or whether it is appropriate to prescribe hormones to artificially induce menstruation, but there is consensus that it is better to menstruate naturally.
Medium or long-term consequences of lack of menstruation:
- Slowing down growth
- It promotes the appearance of ovarian cysts, known as polycystic ovaries (which is not the same as polycystic ovary syndrome).
- Increased body hair in areas specific to boys.
- Risk of suffering bone fractures at premature ages.
- Loss of libido
- Fertility problems
- Risk of unwanted pregnancy, when menstruation does not occur but ovulation continues.
- Weakening of the immune system
- Mood swings
Everything in our body is interrelated . If the hormonal environment-balance is altered, it will have an impact on the rest of our body and our emotional state, worsening mood, obsession and behavior.
Recovering menstruation, one of the goals of treating ED
Getting menstruation to return (or appear if it had not) and to be maintained naturally is one of the goals of treating an eating disorder, as is normalizing the heartbeat, for example.
As we have already explained, having a sufficient weight that allows the body to function properly is a key factor in achieving a stable menstrual cycle. This weight depends on each person, but it must be within a normal range, which depends on sex, height, genetics and physical build.
Menstruation is linked to weight, but not in a directly proportional or immediate way: sometimes when food is cut back too much, menstruation is lost immediately; in others, underweight people still menstruate, and when this happens it is more difficult to become aware of the dietary problem.
Likewise, there are girls who regain some weight with the advice of professionals and their periods return immediately, long before their weight has returned to normal; this also makes it even more difficult to accept that it is necessary to maintain the intake guidelines so that the rest of the body can recover.
Once the weight is restored, menstruation usually reappears, but this is not always the case. The body can take months to restart the hormonal clock. And in some cases (when it has been years, if before the eating disorder it was already irregular, or when there are cysts), the ovaries remain "asleep" and do not wake up. In these cases, it is the gynecologist who assesses whether temporary hormonal treatment is necessary to stimulate them. However, giving hormones to restore menstruation prematurely is controversial, as it is not clear that they benefit the bones, and they make it difficult to become aware, giving a false impression of normality.
In some cases (more likely the longer you have been without menstruation), the ovaries fail to recover. This can cause permanent fertility problems . The longer you have been without menstruation, the more difficult it is for bone mass to be restored, and the skeleton may remain more fragile for life and fracture more easily. The bones most affected are those of the pelvis and legs, which support the upper body.
Lack of menstruation has other effects and reinforces the eating disorder
Both dietary restriction and compulsive overeating cause, in different ways, a predominance of male hormones (androgens) over female hormones (estrogens). This in turn favors impulsivity. And let's remember here how often restriction leads to binge eating .
When menstruation is absent, the hormonal balance of the ovaries is modified, favoring ovarian cysts. At the same time, the eating disorder disrupts the intestinal flora , which also responds to neuro-hormonal signals (serotonin, ghrelin and others), so that when it is modified, not only physical aspects (constipation, gas) but also emotional aspects (mood) are altered.
Furthermore, in situations of prolonged psychological stress, anxiety or depression, cortisol is excreted, which in turn stimulates insulin, which can lead to other metabolic disorders (insulin resistance and secondary diabetes, hypothyroidism, muscle involvement including the heart...). Insulin on the ovaries favors the production of male hormones, which we have already seen what they do. And thus a self-perpetuating circle is created and contributes to maintaining the eating disorder.
