Hypothalamic-pituitary-gonadal function in anorexia nervosa and bulimia

Alteration in the relationship between tanycytes and gonadotrophin-releasing hormone neurosecretory terminals following long-term metabolic manipulation in the sheep

The activity of the hypothalamic-pituitary gonadal axis is influenced by energy reserves, such that an increase or a decrease in adiposity may perturb the secretion and action of gonadotrophin-releasing hormone (GnRH). This is considered to be a result of the signalling of hormones such as leptin, which act upon neuronal systems controlling GnRH secretion. Other work shows plasticity in the relationship between tanycytes and GnRH neurosecretory terminals in the median eminence across the oestrous cycle and we hypothesised that a similar plasticity may occur with altered metabolic status. We studied Lean, Normal and Fat ovariectomised ewes, which displayed differences in gonadotrophin status, and investigated the relationship between tanycytes and GnRH neuroterminals. Under both Lean and Fat conditions, an altered anatomical arrangement between these two elements was observed in the vicinity of the blood vessels of the primary plexus of the hypophysial portal blood system. These data suggest that such plasticity is an important determinant of the rate of secretion of GnRH in animals of differing metabolic status and that this also contributes to the relative hypogonadotrophic condition prevailing with metabolic extremes.

The Deep Correlation between Energy Metabolism and Reproduction: A View on the Effects of Nutrition for Women Fertility

In female mammals, mechanisms have been developed, throughout evolution, to integrate environmental, nutritional and hormonal cues in order to guarantee reproduction in favorable energetic conditions and to inhibit it in case of food scarcity. This metabolic strategy could be an advantage in nutritionally poor environments, but nowadays is affecting women's health. The unlimited availability of nutrients, in association with reduced energy expenditure, leads to alterations in many metabolic pathways and to impairments in the finely tuned inter-relation between energy metabolism and reproduction, thereby affecting female fertility. Many energetic states could influence female reproductive health being under- and over-weight, obesity and strenuous physical activity are all conditions that alter the profiles of specific hormones, such as insulin and adipokines, thus impairing women fertility. Furthermore, specific classes of nutrients might affect female fertility by acting on particular signaling pathways. Dietary fatty acids, carbohydrates, proteins and food-associated components (such as endocrine disruptors) have per se physiological activities and their unbalanced intake, both in quantitative and qualitative terms, might impair metabolic homeostasis and fertility in premenopausal women. Even though we are far from identifying a "fertility diet", lifestyle and dietary interventions might represent a promising and invaluable strategy to manage infertility in premenopausal women.

Medical Complications of Anorexia Nervosa and Bulimia

Anorexia nervosa and bulimia nervosa are serious psychiatric illnesses related to disordered eating and distorted body images. They both have significant medical complications associated with the weight loss and malnutrition of anorexia nervosa, as well as from the purging behaviors that characterize bulimia nervosa. No body system is spared from the adverse sequelae of these illnesses, especially as anorexia nervosa and bulimia nervosa become more severe and chronic. We review the medical complications that are associated with anorexia nervosa and bulimia nervosa, as well as the treatment for the complications. We also discuss the epidemiology and psychiatric comorbidities of these eating disorders.

Irregular menses linked to vomiting in a nonclinical sample: findings from the National Eating Disorders Screening Program in high schools

PURPOSE

Using data from an eating disorders screening initiative conducted in high schools across the United States, we examined the relationship between vomiting frequency and irregular menses in a nonclinical sample of adolescent females.

METHODS

A self-report questionnaire was administered to students from U.S. high schools participating in the National Eating Disorders Screening Program in 2000. The questionnaire included items on frequency of vomiting for weight control in the past 3 months, other eating disorder symptoms, frequency of menses, height, and weight. Multivariable regression analyses were conducted using data from 2791 girls to estimate the risk of irregular menses (defined as menses less often than monthly) associated with vomiting frequency, adjusting for other eating disorder symptoms, weight status, age, race/ethnicity, and school clusters.

RESULTS

Girls who vomited to control their weight one to three times per month were one and a half times more likely (risk ratio [RR] = 1.6; 95% confidence interval [CI] = 1.2-2.2), and girls who vomited once per week or more often were more than three times more likely (RR = 3.2; 95% CI = 2.3-4.4), to experience irregular menses than were girls who did not report vomiting for weight control. Vomiting for weight control remained a strong predictor of irregular menses even when overweight and underweight participants were excluded.

CONCLUSIONS

Our study adds to the evidence that vomiting may have a direct effect on hormonal function in adolescent girls, and that vomiting for weight control may be a particularly deleterious component of eating disorders.

Disturbances in gonadal axis in women with anorexia nervosa

Anorexia nervosa negatively affects multiple body systems including the reproductive system.

AIM

To assess the disturbances in the hypothalamic-pituitary-gonadal axis (HPG) and the relationship between the gonadotropins and body weight, duration of the disease and amenorrhea we studied 40 female anorexic patients (aged 14-31 years) with a body mass index (BMI) 15.14+/-1.80 kg/m(2) and a degree of weight loss 28.67+/-8.74%. Fifteen healthy, age-matched women with normal weight served as controls.

METHODS

We investigated the disturbances in the gonadotropin levels before and after stimulation with gonadotropin-releasing hormone (GnRH) 100 microg i.v. One week later 100 mg of clomiphene citrate (CC) was administered orally for 5 days.

RESULTS

Basal levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were significantly lower in the patients. The responses of LH to GnRH were diminished, but those of FSH were exaggerated. However, after clomiphene citrate administration, LH increased 5.4 times whereas FSH increased 1.7 times. The basal levels of LH were significantly correlated with body weight (r=+0.373, p<0.05), BMI (r=+0.385, p<0.01) and percentage of the weight loss (r=-0.356, p<0.05). FSH levels were positively correlated with the duration of the disease (r=+0.481, p<0.01) and amenorrhea (r=+0.540, p<0.01).

CONCLUSIONS

Our study demonstrates dissociation in the secretion of gonadotropins after hypothalamic stimulation in anorexic patients. It also reveals the relationship between alterations in the hormones of the HPG axis, not only with the changes in body weight, but also with the duration of the disease.

Patterns of menstrual disturbance in eating disorders

OBJECTIVE

To describe menstrual disturbance in eating disorders (ED).

METHOD

We describe menstrual history in 1,705 women and compare eating, weight, and psychopathological traits across menstrual groups.

RESULTS

Menstrual dysfunction occurred across all eating disorder subtypes. Individuals with normal menstrual history and primary amenorrhea reported the highest and lowest lifetime body mass index (BMI), respectively. Normal menstruation and oligomenorrhea groups reported greater binge eating, vomiting, and appetite suppressant use. Amenorrhea was associated with lower caloric intake and higher exercise. Harm avoidance, novelty seeking, perfectionism, and obsessionality discriminated among menstrual status groups. No differences in comorbid Axis I and II disorders were observed.

CONCLUSION

Menstrual dysfunction is not limited to any eating disorder subtype. BMI, caloric intake, and exercise were strongly associated with menstrual function. Menstrual status is not associated with comorbidity. Menstrual irregularity is an associated feature of all ED rather than being restricted to AN only.

Detrimental Psychological Outcomes Associated with Early Pubertal Timing in Adolescent Girls

Though often discussed as though it were a discrete event, puberty comprises one segment of a larger developmental continuum and is notable for rapid transformation across a multitude of domains. Research suggests that an earlier rate of pubertal maturation in girls correlates with a number of detrimental outcomes compared with on-time or later maturation. The present review synthesizes the research on negative psychological sequelae of early pubertal timing in adolescent girls. Emphasis is on three theoretical perspectives by which precocious development is believed to affect the emergence of adverse outcomes: biological, psychosocial, and selection effects.

Reproductive Health in Women With Eating Disorders

Medical complications are often the precipitants that lead women with eating disorders to seek health care. Complications can be wide ranging but frequently include symptoms associated with reproductive health. Unfortunately, because of the denial, embarrassment, shame, and secrecy associated with these psychiatric illnesses, the underlying cause of these complications can often go unacknowledged, delaying assessment and intervention. This article provides an overview of anorexia nervosa and bulimia nervosa, identifies the reproductive health issues that may occur in women with these disorders, and discusses the associated clinical implications for nursing practice.

Bulimia nervosa, childbirth, and psychopathology

OBJECTIVE

To examine whether having a baby following treatment for bulimia nervosa places women at increased risk for continuing or relapsing eating disorders or major depression.

METHODS

Subjects were women who had participated in a large randomized controlled trial evaluating cognitive behavior therapy for bulimia nervosa, who were prospectively followed-up over 5 years. At follow-up assessments (at least yearly), life charts were completed with patients and childbirth was recorded. The presence of eating disorders and major depressive disorder was assessed using the Structured Interview for DSM-III-R.

RESULTS

Childbirth was not specifically associated with increased symptomatology. This was found for both eating disorders and major depression in the same year as childbirth and for the year following childbirth.

CONCLUSION

Childbirth is not specifically associated with symptomatology following treatment for bulimia nervosa.

Menstrual functioning and psychopathology in a county-wide population of high school girls

OBJECTIVE

To examine the association between menstrual functioning and depressive disorder symptoms (DDS), obsessive-compulsive disorder symptoms (OCDS), and eating disorder symptoms (EDS) in high school girls.

METHOD

Survey data from a county-wide high school population (completion rate 91%) were used. Associations between menstrual indices and scores above clinical cutoff on the Beck Depression Inventory, Leyton Obsessive-Compulsive Inventory-Child Version, and Eating Attitudes Test were examined by using logistic regression ( = 2,547 girls).

RESULTS

Controlling for chronological age and other risk factors, late menarche was associated with DDS (odds ratio [OR] = 2.26, 95% confidence interval [CI] = 1.16-4.18). Gynecological year 1 (GY1) was associated with DDS (OR = 3.13, CI = 1.23-7.33), EDS (OR = 3.11, CI = 1.00-8.09), and OCDS, both number (OR = 5.75, CI = 1.79-15.74) and interference (OR = 12.55, CI = 3.20-41.4). Secondary amenorrhea was associated with DDS (OR = 1.94, CI = 11.30-2.84) and EDS (OR = 2.32, CI = 1.51-3.49); polymenorrhea with EDS (OR = 1.92, CI = 1.27-2.86); and irregular cycles with EDS (OR = 1.70, CI = 1.11-2.54) and DDS (OR = 1.76, CI = 11.21-2.53).

CONCLUSIONS

In high school girls, late menarche, GY1, and menstrual cycle abnormalities are associated differentially with DDS, OCDS, and EDS.

Pharmacotherapy and medical complications of eating disorders in children and adolescents

In this article, the authors cover two areas of interest regarding eating disorders in childhood and adolescence: (1) the detection of eating disorders in medical practice and their medical complications and (2) the psychopharmacologic treatment of patients with eating disorders.

Anorexia nervosa: manifestations and management for the gastroenterologist

Anorexia nervosa is a complex psychiatric disorder with significant morbidity and mortality. It is important for gastroenterologists to be aware of the physiological effects and potential complications of anorexia nervosa, as they are frequently involved in treating patients with this disorder. We review the classic, GI, and neuroendocrinological features of anorexia nervosa. We also discuss gender differences and treatment options in anorexia nervosa. Further studies of GI physiology and pharmacology are needed to determine whether any disturbances may be amenable to therapeutic intervention. Future treatments directed at improving GI sensorimotor function and neurohormonal abnormalities in patients with anorexia nervosa may impact their nutritional rehabilitation and may have important health economic implications as patients avoid hospitalization and are restored to full activities in society. The current team approach, which incorporates psychiatrists, psychologists, nutritionists, pediatricians, internists, and gastroenterologists in the treatment of patients with anorexia nervosa, will continue to be essential.

Pituitary LH reserve suggests high risk of bulimia in amenorrheic women

The present study was aimed at investigating a) the risk of having bulimia in a heterogeneous population of secondary amenorrhea; b) the LH and FSH secretion under basal and stimulated conditions (GnRH challenge) according to the presence of bulimic risk in our study population; c) the clinical and endocrine factors predictive of the bulimic risk in amenorrheic women. Amenorrheic women (n=73; age: 23.1+/-4.8 yrs; BMI:20.2+/-2.2 kg/m2) filled in a self rating scale for bulimia (BITE) and were classified accordingly, as being at low risk (score <10), at medium risk (score between 10 and 24), and at high risk (score > or =25) of having bulimia. In each subject basal mean plasma LH levels were calculated over one hour, sampling every 10 minutes, while in a subgroup of 45 patients the area under the curve (AUC) of plasma LH and FSH levels following a challenge with two doses of GnRH (10+10 microg, every two hours), sampling every 15 minutes, was also evaluated. High risk of bulimia was present in 12.3% of the population whereas 45.2% showed a low risk and 42.5% were at medium risk of developing the disorder. Mann-Whitney U test revealed that basal LH values were differently distributed with significantly lower levels (P<0.046) in amenorrheic women at high risk of bulimia in comparison with amenorrheic women at low risk. The AUC of LH secretion following the first challenge of GnRH was significantly higher in amenorrheic women with a high risk of bulimia in respect with both groups of women at low (P<0.034) and medium (P<0.009) risk. A similar result was found with FSH AUC following the first GnRH challenge (P<0.04 high risk vs low risk and P<0.014 high risk vs medium risk). In a multiple regression analysis, the best model predicting the risk of bulimia (BITE total score) included both the LH response to GnRH challenge and BMI. In conclusion, when facing secondary amenorrhea at first consultation, long before a precise pathophysiologic diagnosis of the disease, low basal plasma LH levels and LH response to GnRH challenge may allow one to suspect the presence of abnormal eating pattern of bulimic type.

Prenatal exposure to ethinylestradiol elicits behavioral abnormalities in the rat

Pregnant rats were i.p. injected with a solution of 17alpha-ethinylestradiol (15 microg kg(-1)) every day between day 9 and day 14 of pregnancy and the behavior of the offspring was compared to that of rats born from dams injected with the vehicle only during the same gestational period. The percentage of neonatal death was dramatically high in the prenatally treated group. Growth of the surviving animals was even better than that of controls, but when adult, they exhibited a number of behavioral abnormalities: increased spontaneous motor activity, decreased exploratory behavior, impaired cognitive processing, qualitatively different exploratory drive, and/or persevering behavior, increased anxiety-like behavior and social neophobia. These behavioral alterations, which resemble a number of psychiatric syndromes, suggest that ethinylestradiol altered the ontogenesis of different parts of the central nervous system involved in cognitive and emotional processes. However, it cannot be excluded that the changes in behavior of ethinylestradiol exposed offspring were due to the abnormal maternal behavior of the estradiol treated dams.

Update on endocrine disturbances in anorexia nervosa

The marked endocrine changes that occur in anorexia nervosa have aroused a great deal of interest, and over the last decade much research has been conducted in this field. The endocrine disturbances are not specific to this disorder, as they also occur in starvation states secondary to other causes, and they return to normal upon weight restoration. However, emaciation may have profound effects on psychological processes, establishing an intricate circular interaction whereby somatic and psychological manifestations of starvation may continue to act. The purpose of this paper is to provide an overview of the large body of literature concerning endocrine aspects of anorexia nervosa with the main focus on the latest results, which provide leads for potential etiological theories.

Menstrual cycle irregularity in bulimia nervosa. Associated factors and changes with treatment

OBJECTIVES

This study determined the clinical and nutritional variables associated with menstrual disturbance in women with bulimia nervosa (BN).

METHODS

Eighty-two women with DSM-IV BN underwent psychiatric, nutritional and menstrual related assessments prior to an outpatient treatment programme and at 12 months follow-up.

RESULTS

Forty-five percent reported a current irregular menstrual cycle. A high frequency of vomiting, low thyroxine concentrations and low dietary fat intake were independently associated with irregular menses at pretreatment. At 12 months follow-up, 30.5% reported irregular menstrual cycles. A greater difference between past maximum and minimum body weight, smoking and depression were associated with menstrual irregularity at 12 months follow-up. Of those with irregular menstrual cycles at pretreatment, 56.8% became regular at 12 months follow-up.

CONCLUSION

Menstrual irregularity in BN is associated with indices of nutritional restriction that are not reflected by low body weight or energy intake. Depression, cigarette smoking and fluctuations in body weight may act as metabolic stresses that contribute to the perpetuation of menstrual disturbances.

Pheromones cause disease: the exocrinology of anorexia nervosa

The aetiology of anorexia nervosa is exocrinological. This notion is supported by physical evidence in animal models with directly comparable symptomatology. Anorexia nervosa (AN) syndrome would be a puberty delay caused by reception and autoreception of conspecific pheromone emissions: a pheromone-induced puberty delay (PIPD). As such, it would be amenable to medical treatment drawing from forty years of research in animals. This hypothesis is testable. For instance, since food ad libitum is a prerequisite for PIPD, occasional supervised fasting in healthy peripuberal subjects should prevent AN. Besides, tolerating an untestable thought disease (1,2) with symptoms of a curable well-understood animal condition would be anti-scientific and perpetuates medical disaster. Even their endocrinologies are identical. Pheromone feedback tunes animal appetites and immunity to available resources and prospects. In addition to timing puberty, pheromones regulate fertility. Pheromones will probably be implicated in the aetiology of the psychiatric and autoimmune diseases. This is the second in a series of twelve papers to explore this contention systematically.

Eating disorders and reproduction

Eating disorders are common and characteristically affect young women at what would otherwise be their peak of reproductive functioning. Anorexia nervosa and bulimia nervosa impinge on reproduction both behaviourally and physiologically, with effects on menstruation, ovarian function, fertility, sexuality and pregnancy. This review presents a summary of current knowledge and makes suggestions for future research, along with some clinical recommendations for the management of eating disorders in pregnancy.

Differential dynamic responses of luteinizing hormone to gonadotropin releasing hormone in patients affected by bulimia nervosa-purging versus non-purging type

OBJECTIVE

Aim of the study was to investigate the presence of underlying abnormalities affecting the hypothalamus-pituitary-gonadal axis in 13 normal weight eumenhorreic bulimics as expressed by a different gonadotropin response to gonadotropin releasing hormone (GnRH), comparing patients with (n = 6) and without (n = 7) purging behaviours to controls (n = 5).

METHOD

Subjects were administered an intravenous GnRH infusion for four hours, with an additional bolus at first and third hour.

RESULTS

Non-purging bulimics showed a significantly reduced luteinizing hormone (LH) response to GnRH compared to controls; purging bulimics, following the second bolus, demonstrated a statistically reduced peak, in comparison to both controls and non-purging bulimics.

DISCUSSION

even in the absence of overt menstrual disturbances, an altered LH secretion elicited by pulsatile stimulation of endogenous GnRH was found, with a more severe impairment in purging than in non-purging bulimics, possibly related to their greater psychopathological and physical burden.

Biological correlates of binge eating

Eating disorders are associated with numerous biological perturbations; however, sorting out cause from effect is difficult. Neuroendocrine and metabolic abnormalities are seen in both anorexia nervosa and bulimia nervosa, but they have not been described in binge eating disorder, in which neither starvation nor compensatory behaviors are present. Although these findings may reflect biologic differences among subgroups of binge eaters, an alternative explanation is that many of the biological correlates of binge eating are the result of metabolic derangement secondary to starvation and/or purging. The identification of binge eating disorder provides an opportunity to study the causes and concomitants of binge eating in the absence of compensatory behaviors.

Osteoporosis and normal weight bulimia nervosa--which patients are at risk?

This study assesses the degree of bone mineral loss in women with active DSM IIIR bulimia nervosa. The subjects in this study were 20 GP-referred female patients of normal weight who met criteria for bulimia nervosa and 16 healthy age, sex and weight matched controls. Dual energy X-ray densitometry of lumbar L1-L4 vertebrae was performed on all subjects. The patients with bulimia nervosa had a significantly lower mean lumbar bone mineral density (0.964 g/cm2) than the control group (1.043 g/cm2, p < 0.01). Within the patient group only subjects with a past history of anorexia nervosa had a significantly lower mean bone mineral density (BMD) than the controls. Small sample sizes limit the power of the study, however significant correlations were found between duration of amenorrhoea, low BMI and lumbar BMD. Bulimic patients do suffer from osteoporosis. Risk factors for this may be; a past history of anorexia nervosa, prolonged secondary amenorrhoea, and a persistently low body mass index.

Reproductive functions in eating disorders

This article reviews current knowledge about the effects of anorexia nervosa, bulimia nervosa and partial syndromes on ovulation, menstruation, sexuality, fertility, pregnancy and fetal-infant health. Eating disorders may result in failure to ovulate, oligomenorrhea, amenorrhea, reduced sex drive, infertility, hyperemesis gravidarum, low maternal weight gain in pregnancy, small babies for gestational date, low birth weight infants, increased neonatal morbidity and problems in infant feeding. The available information suggests that clinicians should inquire about nutritional intake, a history of eating disorders and weight reducing behaviours as part of the routine assessment of patients with the disorders of reproductive function listed above. If an eating disorder is discovered before conception, the woman should be encouraged to delay pregnancy until the eating disorder is treated and effectively under control. If the woman is pregnant, early diagnosis and treatment are essential to reduce maternal and fetal complications. The infants of eating-disordered women should be carefully followed to ensure adequate nutritional intake. Problems in reproductive function related to eating disorders offer rich opportunities for multispecialty collaboration in primary and secondary prevention programmes directed toward both mother and infant.

Adolescent smoking, weight changes, and binge-purge behavior: associations with secondary amenorrhea

BACKGROUND

The association of secondary amenorrhea with extreme forms of substance use, weight control, and exercise in nonrepresentative samples raises questions as to whether adolescents in the general population who engage in these behaviors are at increased risk for secondary amenorrhea. We examined the prevalence and behavioral correlates of secondary amenorrhea in a county-wide high school population of 2544 girls aged 13 to 18.

METHODS

A survey questionnaire, which elicited menstrual history as well as weight history, weight control practices, level of exercise, and use of cigarettes, wine, and beer, was administered during school hours; absentees were also surveyed. The completion rate was 91%.

RESULTS

The 1-year prevalence of secondary amenorrhea was 8.5%. Secondary amenorrhea was associated with smoking one or more packs of cigarettes per day (adjusted relative risk [RRa] = 1.96, 1.21-3.10), with multiple binge-eating behaviors in combination with laxative use or self-induced vomiting (RRa = 4.17, 2.54-6.32), and with weight fluctuation due to weight control (RRa = 2.59, 1.33-4.79). There was no association between amenorrhea and alcohol consumption or exercise level.

CONCLUSIONS

Estimates of attributable risk are provided and indicate that bulimic behaviors and cigarette smoking may result in a considerable excess of cases of secondary amenorrhea in an adolescent population.

Infertility and eating disorders

Sixty-six consecutive infertility clinic patients were prospectively screened with the 26-item Eating Attitudes Test and a study questionnaire. Women identified as being at high risk for an eating disorder were then interviewed to confirm or refute the diagnosis. A total of 7.6% of infertility clinic women were found to suffer from anorexia nervosa or bulimia nervosa. If eating disorders not otherwise specified were included, a total of 16.7% of infertility patients were found to suffer from an eating disorder. Among infertile women with amenorrhea or oligomenorrhea 58% had eating disorders. Because women often fail to disclose eating disorders to their gynecologists and may appear to be of normal weight, it is recommended that a nutritional and eating disorder history be taken in infertility patients, particularly those with menstrual abnormalities. It has previously been shown that disorder eating and nutrition can affect menstruation, fertility, maternal weight gain, and fetal well-being.