How eating disorders can do real damage to gynecological health — at any age

by Jessica Baker, Ph.D.

Jessica Baker is Associate Research Director for the Center of Excellence for Eating Disorders in the Department of Psychiatry at the University of North Carolina in Chapel Hill.

Jessica Baker, Ph.D, UNC-Chapel Hill, Center of Excellence for Eating Disorders

When most people think of eating disorders, and how the health of those who suffer from them are impacted, their minds go to weight. But, there’s much more to health than a number on the scale.

For instance, eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED) can have a damaging effect on a woman’s gynecological health from her teen years through late adulthood.

The onset of an eating disorder is most common during adolescence and young adulthood and can have detrimental effects on gynecological health during this important developmental period. For example, if an eating disorder is present during childhood or early adolescence, this could delay pubertal onset and menstruation. If an eating disorder develops in later adolescence or young adulthood this can result in amenorrhea, or the cessation of menstruation.

These types of menstrual disruptions are most common in AN, with up to 84% of women with AN experiencing amenorrhea. AN is a condition in which an individual has an extremely low body weight relative to their stature, which is often the result of extreme food restriction and/or excessive exercise. Individuals with AN also experience an intense fear of gaining weight or becoming fat and body dissatisfaction, an undue influence of weight or body shape on self-esteem, or lack of insight into the medical seriousness of the low weight.

The low body weight that is observed in AN is typically the cause of the menstrual cycle disruptions. This is because the low body weight also reduces the bodies’ fat stores. Fat stores play a necessary and important role in the production of reproductive hormones, which in turn are needed for the proper functioning of a woman’s menstrual cycle. Thus, without sufficient fat stores, reproductive hormones are not produced at an appropriate level to regulate the menstrual cycle causing either a delay in or cessation of menstruation.

Although amenorrhea is most frequently observed in AN, up to 40% of women with BN also experience amenorrhea. BN is a condition in which individuals engage in binge eating behaviors, followed by compensatory behaviors intended to circumvent weight gain (e.g., self-induced vomiting). Compared with amenorrhea, more commonly seen in BN is menstruation becoming infrequent and irregular (e.g., 35+ days without menstruating) with up to 64% of women with BN experience infrequent and irregular periods. Although individuals with BN are generally of normal weight for their stature, this cycle of binge eating and compensatory behaviors may disrupt the menstrual cycle in some women.

Further, some research suggests that 75% of women with BN have polycystic ovarian syndrome (PCOS) and around 30% of women with PCOS have BN. However, the link between PCOS and BN is unclear and it is not generally thought that BN causes PCOS, but that the disorders have shared risk factors.

While on the surface a delay or cessation of menstruation may not seem problematic, a prolonged delay or cessation of menstruation can have serious consequences. One of the biggest consequences is in regard to bone growth and health, which is negatively impacted by low levels of reproductive hormones. In children and adolescents, this can stunt bone growth, which in turn may prevent the individual from reaching their full potential in regard to stature. The cessation of menstruation also puts women at increased risk for osteoporosis.

For some women, another important area of gynecological health is the ability to conceive and carry a healthy baby to term. Despite the detrimental impact eating disorders can have on the menstrual cycle, there does not appear to be permanent effects on fertility. Although some studies suggest that women who have received inpatient treatment for AN, and thus may be more medically compromised, have a lower prevalence of pregnancy compared with women without a history of AN most studies show no severe long-term effects. An important caveat is that, while those with a history of AN may not struggle with infertility, some women who currently have AN may. If a woman is experiencing amenorrhea, then she may not be ovulating. And if a woman is not ovulating, she would not be able to become pregnant. However, it is possible to ovulate in the absence of menstruation. In contrast, women with a history of both AN and BN are more likely to have conceived using fertility treatment and to take longer than 6-months to conceive. Women with BED, a disorder characterized by binge eating, are at increased risk for miscarriage, which may be an indirect result of the fact many individuals with BED are obese.

Once pregnant, women with an eating disorder may need more calories than the typical recommendation to ensure proper weight gain. They may also need additional guidance and monitoring of their food intake to ensure appropriate nutrient intake. An eating disorder may also have detrimental effects on birth outcomes. For example, some studies have shown that women with AN have an increased risk of low weight babies, preterm birth, and a c-section. Women with BED are at increased risk for maternal hypertension, large-for-gestational-age babies, and a longer duration of labor. Thus, is it important that women with a current eating disorder or a history of an eating disorder find a practitioner they are comfortable sharing this information with so that proper services and monitoring can take place. After birth, women with a history of an eating disorder are at increased risk for postpartum depression and anxiety, with up to 35% of women with an eating disorder history experiencing postpartum depression.

Although the onset of an eating disorder is most common during adolescence and young adulthood, they do effect women at midlife. In fact, some eating disorder treatment centers have observed a 400% increase in women over 40 seeking treatment over the past 2–3 decades. It appears that midlife eating disorders present in one of three ways: 1) an early-onset, chronic condition without prior recovery; 2) relapse of a previous disorder; and 3) a late-onset condition, with no prior history of an eating disorder.

At midlife women experience another gynecological event — namely the menopause transition and menopause. Menopause is the complete cessation of ovulation and menstruation whereas the menopause transition is the transition into menopause — typically beginning around 5 years prior to menopause.

Some research has suggested that the menopause transition is a risk period for an eating disorder such that eating disorder symptoms are more prevalent in midlife women during the menopause transition compared with pre-menopause. This may be related to the change in reproductive hormones that happens during the menopause transition coupled with the bodily changes that occur at this time. For example, midlife women have greater levels of abdominal fat and greater body fat mass and waist circumference than younger women.

Although research has not established that eating disorders during the menopause transition have specific gynecological consequences for this age group, there are special considerations for women experiencing an eating disorder at midlife. For example, midlife women (age 40+ years) with an eating disorder have worse medical profiles compared with young adults. One or more medical complications has been reported by 60% of midlife women with AN compared with 10% of young adults, 46% of midlife women with BN compared with 15% of young adults, and 83% of midlife women with BED compared with 40% of young adults. The most common physical comorbidity among women aged 50 or older with an eating disorder is osteoporosis. The medical complications that arise from an eating disorder may be intensified at midlife due to the body’s reduced ability to recover from physical and medical complications.

Eating disorders can occur throughout the lifespan and can negatively impact a woman’s gynecological health and well-being. If you suspect you have an eating disorder or a disordered eating pattern, an annual visit with your gynecologist can be a place where you can bring this up and ask for help. Full recovery from an eating disorder is possible. And fortunately, some gynecological complications that occur from an eating disorder can be resolved with treatment.

The UNC Center of Excellence for Eating Disorders is a world leader in treatment, research, and training. Learn more at https://www.med.unc.edu/psych/eatingdisorders

References:
Baker, J.H., et al. (2016). Eating disorders in midlife: A perimenopausal eating disorder? Maturitas, 85, 112–116.
Kimmel, M.C., et al. (2016). Obstetric and gynecologic problems associated with eating disorders. International Journal of Eating Disorders, 49, 260–275.
Pinheiro, A., et al. (2007). Patterns of menstrual disturbance in eating disorders. International Journal of Eating Disorders, 40, 424–434.