Predictors of recovery of ovarian function during weight gain in anorexia nervosa

New insights into the role of LH in early ovarian follicular growth: a possible tool to optimize follicular recruitment

Evidence shows that LH participates in enhancing transition from the early stage to the antral stage of folliculogenesis. It has been demonstrated that functional LH receptors are expressed, albeit at a very low level and even in smaller follicles, during the phase that was traditionally considered to be gonadotrophin independent, suggesting a role for LH in accelerating the rate of progression of non-growing and primary follicles to the preantral/antral stage. Hypogonadotropic hypogonadism, together with other clinical conditions of pituitary suppression, has been associated with reduced functional ovarian reserve. The reduction in LH serum concentration is associated with a low concentration of anti-Müllerian hormone. This is the case in hypothalamic amenorrhoea, pregnancy, long-term GnRH-analogue therapy and hormonal contraception. The effect seems to be reversible, such that after pregnancy and after discontinuation of drugs, the functional ovarian reserve returns to the baseline level. Evidence suggests that women with similar primordial follicle reserves could present with different numbers of antral follicles, and that gonadotrophins may play a fundamental role in permitting a normal rate of progression of follicles through non-cyclic folliculogenesis. The precise role of gonadotrophins in early folliculogenesis, as well as their use to modify the functional ovarian reserve, must be investigated.

Mechanisms and predictors of menses resumption once normal weight is reached in anorexia nervosa

BACKGROUND

In cases of Anorexia Nervosa (AN), achieving weight gain recovery beyond the lower limits set by the World Health Organization and normalizing classical nutritional markers appears to be essential for most patients. However, this is not always adequate to restore menstrual cycles. This discrepancy can cause concern for both patients and healthcare providers, and can impact the medical management of these individuals. Thus, the purpose of this study was to assess the ability of anthropometric and hormonal factors to predict the resumption of menstrual cycles in individuals with anorexia nervosa upon reaching a normal body weight.

METHOD

Patients with AN who had achieved a normal Body Mass Index but had not yet resumed their menstrual cycles (referred to as ANRec) were evaluated on two occasions: first at visit 1 and then again 6 months later, provided their body weight remained stable over this period (visit 2). Among the 46 ANRec patients who reached visit 2, they were categorized into two groups: 20 with persistent amenorrhea (PA-ANRec) and 26 who had regained their menstrual cycles (RM-ANRec). Anthropometric measurements, several hormone levels, Luteinizing Hormone (LH) pulsatility over a 4-h period, and LH response to gonadotropin-releasing hormone injection (LH/GnRH) were then compared between the two groups at visit 1.

RESULTS

Patients in the RM-ANRec group exhibited higher levels of follicular stimulating hormone, estradiol, inhibin B, LH/GnRH, and lower levels of ghrelin compared to those in the PA-ANRec group. Analysis of Receiver Operating Characteristic curves indicated that having ≥ 2 LH pulses over a 4-h period, LH/GnRH levels ≥ 33 IU/l, and inhibin B levels > 63 pg/ml predicted the resumption of menstrual cycles with a high degree of specificity (87%, 100%, and 100%, respectively) and sensitivity (82%, 80%, and 79%, respectively).

CONCLUSIONS

These three hormonal tests, of which two are straightforward to perform, demonstrated a high predictive accuracy for the resumption of menstrual cycles. They could offer valuable support for the management of individuals with AN upon achieving normalized weight. Negative results from these tests could assist clinicians and patients in maintaining their efforts to attain individualized metabolic targets.

TRIAL REGISTRATION

IORG0004981.

Extended LH administration as a strategy to increase the pool of recruitable antral follicles in hypothalamic amenorrhea: evidence from a case series

New evidence is indicating a growing role of LH in promoting ovarian follicular growth and maturation, even at the early stages. LH seems to enhance the transition of follicles to the antral stage hence leading to an increase in the so-called functional ovarian reserve (recruitable antral follicles). Hypogonadotropic hypogonadism is characterized by low, and sometimes undetectable, serum LH and FSH levels, which may indeed explain the low anti-Müllerian hormone (AMH) levels and antral follicle count (AFC) found in patients affected by this condition. We report here the cases of two young women affected by hypothalamic amenorrhea (HA) that presented for fertility treatment with very low functional ovarian reserve. The two patients were treated with exogenous LH for 1 and 2 months (extended LH administration: ELHA) at the dose of 187.5 IU LH every day and 150 IU LH every other day, respectively. In both the cases there was an increase in serum AMH levels and in the AFC. In one patient, the AMH and AFC increased from a baseline 1.3 ng/ml and 8 to 2.3 ng/ml and 14 at end of treatment, respectively. In the second case, serum AMH and AFC increased from 0.4 ng/ml and 6 to 1.6 ng/ml and 13, respectively. One patient underwent ovarian stimulation before and after ELHA, showing an increase in the number of mature oocytes recruited (3 versus 8 metaphase II (MII) oocytes before and after, respectively). The second patient underwent an IVF cycle after ELHA resulting in the retrieval of six MII oocytes and an ongoing pregnancy following transfer of a single blastocyst. Women with HA are characterized by chronic, low levels of gonadotrophins, which may impact not only on the cyclic recruitment of follicles but also the progression of small growing follicles through the first stages of folliculogenesis. Some women with HA may in fact show very low serum AMH and AFC. Our case series shows that the administration of LH at a dose of at least 150–187.5 IU every day or every other day may contribute to a clinically evident increase in the functional ovarian reserve (AFC), and probably accounts for a positive effect of LH on the progression of follicles throughout the early stages of folliculogenesis.

Clinical and biochemical discriminants between functional hypothalamic amenorrhoea (FHA) and polycystic ovary syndrome (PCOS)

BACKGROUND

Secondary oligo/amenorrhoea occurs in 3%-5% of women of reproductive age. The two most common causes are polycystic ovary syndrome (PCOS) (2%-13%) and functional hypothalamic amenorrhoea (FHA) (1%-2%). Whilst both conditions have distinct pathophysiology and their diagnosis is supported by guidelines, in practice, differentiating these two common causes of menstrual disturbance is challenging. Moreover, both diagnoses are qualified by the need to first exclude other causes of menstrual disturbance.

AIM

To review clinical, biochemical and radiological parameters that could aid the clinician in distinguishing PCOS and FHA as a cause of menstrual disturbance.

RESULTS

FHA is uncommon in women with BMI > 24 kg/m2 , whereas both PCOS and FHA can occur in women with lower BMIs. AMH levels are markedly elevated in PCOS; however, milder increases may also be observed in FHA. Likewise, polycystic ovarian morphology (PCOM) is more frequently observed in FHA than in healthy women. Features that are differentially altered between PCOS and FHA include LH, androgen, insulin, AMH and SHBG levels, endometrial thickness and cortisol response to CRH. Other promising diagnostic tests with the potential to distinguish these two conditions pending further study include assessment of 5-alpha-reductase activity, leptin, INSL3, kisspeptin and inhibin B levels.

CONCLUSION

Further data directly comparing the discriminatory potential of these markers to differentiate PCOS and FHA in women with secondary amenorrhoea would be of value in defining an objective probability for PCOS or FHA diagnosis.

Is Ovarian Reserve Impacted in Anorexia Nervosa?

STUDY OBJECTIVES

Hypothalamic amenorrhea is common in adolescents and young adults (AYAs) with anorexia nervosa (AN), and ovarian reserve is not routinely assessed. AN increases rates of fertility problems, but how or when AN negatively influences future fertility is unclear. We sought to determine whether biomarkers of ovarian reserve were impacted in AYA with AN.

DESIGN

Cross-sectional study.

SETTING

Tertiary care center.

PARTICIPANTS

Females with AN and amenorrhea (n = 97) at the pre-intervention visit of a clinical trial, n = 19 females without an eating disorder or menstrual dysfunction.

MAIN OUTCOME MEASURES

Serum anti-Müllerian hormone (AMH) concentrations.

RESULTS

AMH levels were higher in AYA with AN than unaffected adolescents (4.7 vs. 3.2 ng/mL; P = .03). Neither FSH nor inhibin B differed between groups. In 19.6% of participants with AN, AMH levels were elevated above the normal range (>6.78 ng/mL). These subjects had a longer disease duration than those with normal AMH levels (9 vs. 3 mos; P = .03); age or degree of malnutrition did not differ between AN subjects with normal or elevated AMH.

CONCLUSIONS

AMH levels appear to be normal or elevated in AYA with AN. Low AMH in a patient with AN should raise clinical concern regarding ovarian reserve, and should not be attributed to degree of malnutrition alone. Currently, AMH is not regularly assessed during routine AN clinical care. However, our findings suggest some clinical utility in identifying those patients with reduced ovarian reserve. Potential links between the hypothalamic amenorrhea suffered by patients with AN and PCOS should be explored.

Prevalence of lifetime eating disorders in infertile women seeking pregnancy with pulsatile gonadotropin-releasing hormone therapy

OBJECTIVES

Relationships between weight and fertility are well known. The aim of this study is to assess the prevalence of lifetime eating disorder (ED) in a sample of infertile women seeking a specific infertility treatment, pulsatile gonadotropin-releasing hormone (pGnRH) treatment, and to compare it to the prevalence of lifetime ED in a sample of infertile women seeking other types of assisted reproductive technology (ART) treatments.

DESIGN

Non-randomized, observational study including infertile female patients. Two-group design including consecutive women treated with GnRH pump (pGnRH) or with other types of ART.

SETTING

Multi-centric infertility centers, France METHODS: Twenty one consecutive women treated with pGnRH treatment were compared to 21 consecutive women receiving other types of infertility treatment. Diagnosis of ED was based on DSM-IV and the Composite International Diagnostic Interview (CIDI).

RESULTS

Twenty patients (95.2%) from the sample of women treated with pulsatile GnRH treatment and 5 patients (23.8%) from the patients receiving other types of infertility treatment met the criteria of lifetime ED diagnosis (p < 0.000).

CONCLUSION

This study highlights the fact that the prevalence of ED is considerably higher in women receiving GnRH pulsatile treatment, when compared to women receiving other kinds of infertility treatment. In our study population ED were under-diagnosed, particularly in women receiving pulsatile GnRH treatment. Fertility clinicians should use reliable diagnostic tools to identify promptly ED in women presenting with hypothalamic amenorrhea and difficulties in conceiving. Level III: Evidence obtained from well-designed cohort or case-control analytic studies.

MTHFR Polymorphisms in Girls with Anorexia Nervosa: Implications on Body Weight

The development of atypical vs typical anorexia nervosa (AN) might be explained by the genetic background. We assessed the link between the subtypes of AN and the genetic polymorphisms of the thrombotic panel and the methyltetrahydrofolate reductase (MTHFR) gene. This cross-sectional pilot study recruited 48 girls with AN and 10 age-matched control girls with normal menstruation. We recorded anthropometric parameters and obtained blood samples for genotyping and hormonal assessment. Classification of AN was performed according to the DSM-V criteria. Girls with AN had 2.66 times higher odds of carrying at least one genetic polymorphism from the MTHFR panel (C677T and A1298C) compared with girls without AN (OR = 2.660, p-value = 0.041; CI 95% 1.057-6.720). The presence of atypical vs typical AN was associated independently with the presence of any of the assessed MTHFR polymorphisms (C677T, OR = 4.929, 95% CI 1.076-22.579, p-value = 0.040; A1298C, OR = 0.097, 95% CI 0.011-0.866, p-value = 0.037) in age and estrogen adjusted models. The atypical presentation of AN is mainly linked with higher prevalence of the MTHFR C677T and lower prevalence of the A1298C polymorphism.

Polycystic ovary syndrome, amenorrhea and the diagnostic role of anti-Müllerian hormone

The differential diagnosis of anovulatory disorders is actually based on serum gonadotrophin and estradiol levels. However, several other markers have been proposed. The purpose of this review was to underline the role of anti-Müllerian hormone (AMH) as a possible marker in differential diagnosis of the anovulatory diseases and its use as a predictive marker of prognosis. In this article we discuss clinical and experimental evidences actually existing in literature and we suggest new potential clinical application of AMH.

Predictors of Resumption of Menses in Anorexia Nervosa: A 4-Year Longitudinal Study

OBJECTIVE

Amenorrhea is a disabling medical consequence of anorexia nervosa (AN); therefore, resumption of menses (ROM) represents an important goal in the treatment for these patients. The aim of the present study was to evaluate possible clinical, psychopathological, and biological predictors of ROM, including age, body mass index (BMI), AN subtype, childhood abuse, duration of illness, general and eating disorder (ED)-specific psychopathology, and sex hormones.

METHODS

Fifty amenorrheic patients with AN were enrolled. Baseline clinical data and information on childhood abuse were collected. Questionnaires to evaluate general and ED-specific psychopathology were administered, and blood samples were drawn. All patients received treatment as usual and underwent regular follow-up visits for 4 years or until ROM. Time to ROM, BMI at last evaluation, and data regarding diagnostic crossover into bulimia nervosa were collected.

RESULTS

Twenty-nine (58.0%) patients recovered menses. Diagnostic crossover was associated with a higher probability of ROM (odds ratio = 10.3, p = .030). Time-to-event analysis showed that a shorter duration of illness (χ(1) = 11.00, p = .001), binge-eating/purging subtype (χ(1) = 7.01, p = .008), and history of childhood abuse (χ(1) = 4.03, p = .045) were associated with an earlier ROM. Furthermore, higher baseline ED-specific psychopathology was associated with a reduced likelihood for ROM, whereas higher general psychopathology and follicle-stimulating hormone levels predicted an earlier ROM (all, p < .050). Age, BMI, luteinizing hormone, and estrogen hematic levels had no predictive value with respect to ROM.

CONCLUSIONS

The present study provides data in support of an integrated model, emphasizing the importance of duration of illness, childhood abuse, and psychopathological characteristics of amenorrheic patients with AN in predicting ROM.

Feasibility and effect of a Pilates program on the clinical, physical and sleep parameters of adolescents with anorexia nervosa

BACKGROUND AND PURPOSE

Anorexia nervosa (AN) becomes chronic, with high physical, psychological and social morbidity and high mortality without early and effective treatment. The impact of physical exercise as a coadjutant to conventional treatment in this clinical population has been studied with favorable results. Although a Pilates program could be beneficial for patients with AN, no study has analyzed its feasibility and effects in adolescents with AN. Therefore, this study evaluated the safety of a Pilates program and investigated the feasibility and effect in adolescents with AN.

MATERIALS AND METHODS

In this prospective quasi-experimental study, body composition, blood analysis, sedentary time, physical activity and time of sleep, and physical fitness were measured objectively before and after a 10-week Pilates supervised program.

RESULTS

Twelve female adolescents with AN (14.6 ± 1.7 years old) completed the program, with a session attendance rate of 96%, a persistence rate of 100%. There were significant increases in height, plasma calcium and sleep efficiency. Significant decreases in plasma follitropin, sleep duration and, duration and number of night perturbations were observed.

CONCLUSION

A Pilates program is safe and feasible in adolescents with AN when they have a controlled and stable weight, and such a program could be a viable alternative among treatment programs to achieve better sleep quality.

Anti-Müllerian Hormone and Ovarian Morphology in Women With Hypothalamic Hypogonadism

CONTEXT

Different phenotypical features of women with hypothalamic hypogonadism (HH), also known as World Health Organization-1 anovulation, including ovarian morphology, have been scarcely described in large cohorts. Some studies have reported increased levels of anti-Müllerian hormone (AMH) in women with HH.

OBJECTIVE

To assess whether women with HH, compared with healthy controls, have increased serum levels of AMH and what proportion of these women erroneously meet the Rotterdam Criteria for Polycystic Ovarian Syndrome (PCOS).

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort study in a Dutch academic medical center including 83 women with neither anovulation nor menstrual cycle disorders (healthy controls), 159 women with HH and 3640 women with PCOS. Age matching was used between the HH and PCOS group (1:2 ratio) to create a second group consisting of 318 age-matched women with PCOS.

INTERVENTION

None.

MAIN OUTCOME MEASURES

AMH levels and ovarian morphology.

RESULTS

Median AMH serum levels for the HH group were 3.8 (<0.1-19.8), compared with 7.5 (<0.1-81.0) in the PCOS group and 1.9 (<0.1-21.5) in the control group (P < 0.001). In the HH group, 58 (36%) erroneously met the Rotterdam Criteria for PCOS (meeting 2 of 3 criteria).

CONCLUSIONS

AMH levels are increased in women with HH. We hypothesize that this increase, although there was no increase in follicle count, may be explained by the presence of a relatively large pool of antral follicles smaller than 2 mm in diameter, that are undetectable by transvaginal ultrasound. This study highlights the importance of measuring gonadotropins and estradiol before diagnosing a patient with PCOS.

Use of AMH in the Differential Diagnosis of Anovulatory Disorders Including PCOS

Since the historical use of gonadotrophin and estradiol levels to define the different anovulatory disorders has shown some limitations, the use of other markers such as anti-müllerian hormone (AMH) has been proposed. This review addresses the role of AMH in the differential diagnosis of anovulatory disorders, especially focusing on its value in the prognostic characterization of their severity. Current limitations and future clinical applications are discussed.

Food Versus Pharmacy: Assessment of Nutritional and Pharmacological Strategies to Improve Bone Health in Energy-Deficient Exercising Women

PURPOSE OF REVIEW

The review aims to summarize our current knowledge surrounding treatment strategies aimed at recovery of bone mass in energy-deficient women suffering from the Female Athlete Triad.

RECENT FINDINGS

The independent and interactive contributions of energy status versus estrogen status on bone density, geometry, and strength have recently been reported, highlighting the importance of addressing both energy and estrogen in treatment strategies for bone health. This is supported by reports that have identified energy-related features (low body weight and BMI) and estrogen-related features (late age of menarche, oligo/amenorrhea) to be significant risk factors for low bone mineral density and bone stress injury in female athletes and exercising women. Nutritional therapy is the recommended first line of treatment to recover bone mass in energy-deficient female athletes and exercising women. If nutritional therapy fails after 12 months or if fractures or significant worsening in BMD occurs, pharmacological therapy may be considered in the form of transdermal estradiol with cyclic oral progestin (not COC).

Macronutrient intake associated with weight gain in adolescent girls with anorexia nervosa

OBJECTIVE

Adolescents and women with anorexia nervosa (AN) are known to severely restrict total calorie and fat intake. However, data are limited regarding specific macronutrient intake associated with weight gain in AN.

OBJECTIVE

To prospectively investigate dietary macronutrient composition associated with weight gain in adolescent girls with AN.

METHOD

A prospective naturalistic study of 90 girls 12-18 years old; 45 with AN and 45 healthy normal-weight-controls over a 6-12-month period. Participants completed four-day food diaries and underwent body composition assessment using dual energy X-ray absorptiometry. Weight gain was defined as a ≥10% increase in body mass index (BMI) from baseline.

RESULTS

Baseline clinical characteristics did not differ between girls with AN who did not gain weight (AN-0) versus those who did (AN-1) over the following 6-12 month period except for percentage of calories from proteins (p = 0.046). At 6-12 month follow-up, AN-1 consumed a lower percentage of total calories from protein (p = .001), and a higher percentage of total calories from fat (p = .02) compared to AN-0. AN-1 had a significant increase in the percentage of total calories obtained from and poly-unsaturated-fatty acids (PUFA) (p = 0.006) compared to AN-0, between baseline and follow-up. Within the AN group, BMI at follow-up was associated positively with percentage of total calories obtained from fat, MUFA, and PUFA (p < .05) at 6/12 months, and inversely with the percentage of total calories obtained from carbohydrates and proteins (p = .03).

DISCUSSION

Consuming a greater proportion of total calories from fat is associated with weight gain in adolescent girls with AN.

Body composition and menstrual status in adults with a history of anorexia nervosa-at what fat percentage is the menstrual cycle restored?

OBJECTIVE

To study the association between body composition measures and menstrual status in a large sample of adult patients with a history of anorexia nervosa and to calculate the predicted probability of resumption of menstrual function. Furthermore, to establish whether fat percentage is superior to body mass index in predicting the resumption of menses.

METHOD

One hundred and thirteen adult women with a history of anorexia nervosa underwent a dual energy X-ray absorptiometry (DXA) scan and completed questionnaires regarding medication prescription and menstrual function.

RESULTS

Fifty percent of patients were expected to resume their menstrual function at a body mass index of 19 kg m^-2 or a fat percentage of 23%. Twenty-five percent of patients were expected to resume their menstrual function at body mass index 14 kg m^-2 or fat percentage 11%. Fat percentage and body mass index were equally capable of predicting the resumption of menses.

DISCUSSION

Fat percentage and body mass index were positive predictors of the resumption of menses, however, body composition measured by dual energy X-ray absorptiometry was not superior to body mass index in predicting menstrual recovery, which is of great clinical relevance as body mass index is easier and cheaper to obtain. Body composition measures only account for one of numerous factors involved in the resumption of menses. Regression models based on our data had a R² value of 0.14, indicating that only 14% of the variation in menstrual recovery could be explained by the variables included. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:370-377).

Obstetric and gynecologic problems associated with eating disorders

OBJECTIVE

This article summarizes the literature on obstetric and gynecologic complications associated with eating disorders.

METHOD

We performed a comprehensive search of the current literature on obstetric and gynecologic complications associated with eating disorders using PubMed. More recent randomized-controlled trials and larger data sets received priority. We also chose those that we felt would be the most relevant to providers.

RESULTS

Common obstetric and gynecologic complications for women with eating disorders include infertility, unplanned pregnancy, miscarriage, poor nutrition during pregnancy, having a baby with small head circumference, postpartum depression and anxiety, sexual dysfunction and complications in the treatment for gynecologic cancers. There are also unique associations by eating disorder diagnosis, such as earlier cessation of breastfeeding in anorexia nervosa; increased polycystic ovarian syndrome in bulimia nervosa; and complications of obesity as a result of binge eating disorder.

DISCUSSION

We focus on possible biological and psychosocial factors underpinning risk for poor obstetric and gynecological outcomes in eating disorders. Understanding these factors may improve both our understanding of the reproductive needs of women with eating disorders and their medical outcomes. We also highlight the importance of building multidisciplinary teams to provide comprehensive care to women with eating disorders during the reproductive years.

Fertility Issues for Patients with Hypogonadotropic Causes of Delayed Puberty

Delayed puberty presenting with low gonadotropins has multiple causes. Self-limited delay (constitutional delay) is generally considered benign, but adult height and bone mineral density may be compromised, and fertility has not been studied. Functional hypogonadotropic hypogonadism due to a stressor is thought to resolve with removal of the stressor, but reproductive endocrine dysfunction can sometimes persist. Most but not all patients with idiopathic hypogonadotropic hypogonadism, a typically long-lasting condition, can achieve fertility with exogenous hormone therapy. Future studies are needed to determine fertility outcomes in self-limited delayed puberty and to more clearly define prognostic factors for fertility in functional and idiopathic hypogonadotropic hypogonadism.

ESCAP Expert Paper: New developments in the diagnosis and treatment of adolescent anorexia nervosa--a European perspective

Anorexia nervosa is a potentially life-threatening disorder with a typical onset in adolescence and high rates of medical complications and psychiatric comorbidity. This article summarizes issues relating to classification in DSM-5 and presents a narrative review of key evidence-based medical and behavioral interventions for adolescent AN and subthreshold restricting eating disorders, mainly, but not exclusively published between 2012 and 2014. In addition, it systematically compares the clinical guidelines of four European countries (Germany, Spain, The Netherlands, and United Kingdom) and outlines common clinical practice, in relation to treatment settings, nutritional rehabilitation, family-oriented and individual psychotherapy, and psychopharmacological treatment. With the exception of family-based treatment, which is mainly evaluated and practiced in Anglo-American countries, the evidence base is weak, especially for medical interventions such as refeeding and pharmacological intervention. There is a need for common European research efforts, to improve the available evidence base and resulting clinical guidance.

Predictors of the resumption of menses in adolescent anorexia nervosa

BACKGROUND

The resumption of menses is an important indicator of recovery in anorexia nervosa (AN). Patients with early-onset AN are at particularly great risk of suffering from the long-term physical and psychological consequences of persistent gonadal dysfunction. However, the clinical variables that predict the recovery of menstrual function during weight gain in AN remain poorly understood. The aim of this study was to investigate the impact of several clinical parameters on the resumption of menses in first-onset adolescent AN in a large, well-characterized, homogenous sample that was followed-up for 12 months.

METHODS

A total of 172 female adolescent patients with first-onset AN according to DSM-IV criteria were recruited for inclusion in a randomized, multi-center, German clinical trial. Menstrual status and clinical variables (i.e., premorbid body mass index (BMI), age at onset, duration of illness, duration of hospital treatment, achievement of target weight at discharge, and BMI) were assessed at the time of admission to or discharge from hospital treatment and at a 12-month follow-up. Based on German reference data, we calculated the percentage of expected body weight (%EBW), BMI percentile, and BMI standard deviation score (BMI-SDS) for all time points to investigate the relationship between different weight measurements and resumption of menses.

RESULTS

Forty-seven percent of the patients spontaneously began menstruating during the follow-up period. %EBW at the 12-month follow-up was strongly correlated with the resumption of menses. The absence of menarche before admission, a higher premorbid BMI, discharge below target weight, and a longer duration of hospital treatment were the most relevant prognostic factors for continued amenorrhea.

CONCLUSIONS

The recovery of menstrual function in adolescent patients with AN should be a major treatment goal to prevent severe long-term physical and psychological sequelae. Patients with premenarchal onset of AN are at particular risk for protracted amenorrhea despite weight rehabilitation. Reaching and maintaining a target weight between the 15th and 20th BMI percentile is favorable for the resumption of menses within 12 months. Whether patients with a higher premorbid BMI may benefit from a higher target weight needs to be investigated in further studies.

Gene receptor polymorphism as a risk factor for BMD deterioration in adolescent girls with anorexia nervosa

Anorexia nervosa is a serious eating disorder that is associated with decreased bone mineral density and greater lifetime risk for fractures. This case-controlled study, analyzed single nucleotide polymorphisms of genes encoding vitamin D receptor, estrogen receptor alpha (ESR1), collagen type I and calcitonin receptor (CTR). Relationships between genotype and body mass index, cycling status and lumbar spine bone mineral density (LBMD) were determined in 40 adolescent girls with anorexia nervosa and 10 age-matched controls. The distribution of CTR-AluI genotypes differed between groups, but this polymorphism was not associated with LBMD Z-score. Distribution of ESR1-XbaI genotypes did not differ between groups, but the AA genotype was associated with decreased LBMD Z-score (≤-1) (OR = 24.79, 95% CI, 1.01-606.08). Carriers of the A allele were more likely to have decreased LBMD Z-scores compared with carriers of the G allele (OR = 4.12, 95% CI, 1.23-13.85, p = 0.022). In conclusion, our study shows that anorexic patients with wild-type genotype ESR-XbaI receptor are in greater risk for decreased BMD in relation to those with the mutated gene. Prompt recognition of these patients is crucial because early administration of the proper therapeutic treatment may contribute to the prevention of adverse sequelae on bone metabolism.

Inhibins and activins in blood: predictors of female reproductive health?

Inhibins A and B are gonadal factors which are important in fertility. Their use as predictors of female reproductive health has centred on their application to ovarian cancer, Anorexia Nervosa, Down Syndrome and preeclampsia. Inhibin B also provides an index of the endocrine feedback relationship between the ovary and pituitary particularly when the ovarian follicle reserve is low. These applications are relevant in monitoring the onset of the menopause transition, ovarian recovery following chemotherapy and disturbances in pubertal development. Currently, these applications have only found widespread use in Down Syndrome and ovarian cancer. Activins, on the other hand, appear to have a limited application.

Amenorrhea in eating disorders: poor stability of symptom after a one-year treatment

OBJECTIVE

To examine whether patients with Eating Disorders (ED) who restore menses differ from those who remain amenorrheic after treatment and to provide longitudinal data about this debated criterion of Anorexia Nervosa (AN).

METHODS

184 outpatients were recruited: 50 patients with AN Restrictive type, 75 amenorrheic Eating Disorder Not Otherwise Specified (EDNOS) patients, 24 patients who recovered from AN with persistent amenorrhea, and 35 amenorrheic patients without ED. All participants were clinically assessed by psychiatrists and gynaecologists at the beginning of treatment and at the one-year follow-up. They also completed several psychometric tests: Eating Disorder Inventory-2, Temperament and Character Inventory, and Beck Depression Inventory.

RESULTS

After treatment, a large portion of the sample resumed menses but very few recovered completely from the ED. No psychopathological variables could clearly predict the recovery of menses in the different groups. However, Body Mass Index and some biological variables were associated with restoration of menses in ED patients.

CONCLUSION

Resumption of menses was not associated with a less severe eating symptomatology at the beginning of treatment nor with unequivocal psychopathological changes after treatment. It is important that clinicians consider not only the presence or absence of regular menses but also that they improve both ED screening and assessment in amenorrheic patients. Amenorrhea does not seem to represent a specific predictor of severity of illness or to show prognostic value.

Normal inhibin B levels suggest partial preservation of gonadal function in adult male patients with anorexia nervosa

INTRODUCTION

The impact of undernutrition on endocrine and exocrine gonadatrope function is poorly known in male anorexia nervosa (AN) patients.

AIM

The aim of this study was to compare the pituitary-gonadal function of male AN subjects with that of healthy controls, Kallmann syndrome (KS) patients, and female AN subjects.

METHODS

Observational monocentric cross-sectional study performed in 31 male and 25 female subjects with restrictive-type AN, 22 male and 20 female controls, and nine male KS patients.

MAIN OUTCOME MEASURES

Hormonal parameters are as follows: follicule stimulating hormone (FSH), luteinizing hormone (LH), sex hormone binding globulin, estradiol, testosterone, inhibin B, thyroid hormones, growth hormone (GH), insulin-like growth factor 1 (IGF-1), cortisol, adrenocorticotropic hormone (ACTH), dehydroepiandrosterone sulfate, and leptin.

RESULTS

Similar abnormalities of free T3, GH, IGF-I, cortisol, and leptin were found in men as in AN women with equivalent undernutrition status when compared with corresponding controls. Low levels of LH, FSH were found in both male and female AN patients. In male AN, total testosterone was found lower than in controls but higher than in KS, while a lack of estradiol was noticed in AN women. Sex hormones variations were directly related to weight gain only in AN men. No relationship was found between sex hormones and leptin variation for both sexes. In AN men, inhibin B levels were similar to that of controls and did not correlate with testosterone levels.

CONCLUSIONS

Significant differences of undernutrition impact on gonadal status were noticed between male and female AN subjects, including partial preservation of testosterone release and probable preservation of exocrine function, according to the normal inhibin B levels.

Gender differences in outcome of eating disorders: a retrospective cohort study

Eating disorders (EDs) are uncommon in males. The majority of outcome studies on ED have not presented gender-specific results, mostly because of small study samples or exclusion of males. Furthermore, psychometric tools and outcome criteria used in ED have mainly been validated for females only. The objective of this study was to evaluate gender differences in weight restoration in different EDs. We studied the male representation and outcome in a large retrospective single centre cohort, the Funen Anorexia Nervosa Study (FANS). A total of 1015 patients were included in the study. A total of 356 (35%) patients were diagnosed with anorexia nervosa (AN), 298 (29%) with eating disorder not otherwise specified (EDNOS) and 361 (36%) with bulimia nervosa (BN). The male fractions in AN and EDNOS were similar, but significantly lower in BN. When remission was defined as body weight restoration to at least 85% of ideal body weight (IBW) and no self-reported binge or purgative behaviors in six months, the median time from onset to remission for patients with AN was significantly shorter for males: 7 years for females vs. 3 years for males. Among patients with a 5 years history of disease, remission rates in AN were 39% for females vs. 59% for males. The median time to remission for patients with EDNOS was similar to that of AN: 6 years for females vs. 3 years for males. In patients with EDNOS, 45% of the females remitted within 5 years vs. 77% of the males. With regard to body weight restoration and remission of purging behavior, this study suggests a better outcome for males than for females.

How do eating disorder specialist clinicians apply DSM-IV diagnostic criteria in routine clinical practice? Implications for enhancing clinical utility in DSM-5

The clinical utility of the DSM-IV eating disorder (ED) diagnostic criteria among practicing clinicians has not been formally evaluated, despite the considerable diagnostic challenges these disorders present. This study evaluated inter-rater reliability between research and clinical diagnoses, identified discrepantly rated diagnostic criteria, and evaluated ED subtype use in a naturalistic treatment setting. Seventy-six adolescent and young adult female patients consecutively admitted to a residential ED program were evaluated independently by clinicians (unstructured clinical interview) and research assessors (Structured Clinical Interview for DSM-IV). Clinicians and research assessors conferred concordant ED diagnoses in 80.3% of cases (kappa=0.70), thus highlighting the clinical utility of the extant DSM-IV diagnostic scheme in this specialty ED treatment setting. All but two discordant cases included a diagnosis of ED not otherwise specified (EDNOS). Clinicians applied ED subtypes in just 20.4% of eligible cases, and were significantly more likely to apply subtypes to major depressive disorder. Although clinical and research interviews yielded substantial reliability, EDNOS had the lowest reliability among the ED diagnoses. Moreover, infrequent subtype application on this specialty unit raises questions about the clinical utility of DSM-IV anorexia nervosa and bulimia nervosa subtypes, even in the context of clinically useful overarching categories.

Normal serum concentrations of anti-Müllerian hormone in women with regular menstrual cycles

Anti-Müllerian hormone (AMH) has become the 'molecule of the moment' in the field of reproductive endocrinology. Indeed, it is valuable as a means of increasing understanding of ovarian pathophysiology and for guiding clinical management across a broad range of conditions. However, no normative values have been established for circulating AMH in healthy women. In this cross-sectional study, 277 healthy females (aged 18-50 years) were included. AMH was measured by commercial enzyme-linked immunosorbent assay. Serum AMH concentrations show a progressive decline with female ageing. The age-related changes in AMH were best fitted by a polynomial function. Mean AMH concentrations were not modified by past use of oral contraceptive and were independent of parity of women. Age-specific normative values for circulating AMH concentration were established. AMH concentrations seem to be independent of the reproductive history of the patient.

Effective nursing care of adolescents diagnosed with anorexia nervosa: the patients' perspective

AIMS AND OBJECTIVES

The purpose of this study is to develop - from the patients' perspective - a tentative theoretical model explaining the effectiveness of inpatient nursing care of adolescents diagnosed with anorexia nervosa.

BACKGROUND

The continuous and direct involvement of nurses with patients is likely to play a significant role in the recovery process of patients with anorexia nervosa. However, only limited evidence is available on what patients with anorexia nervosa themselves consider important and effective in terms of nursing care.

DESIGN

The design of this study was qualitative.

METHODS

A grounded theory approach was applied where 13 adolescents with anorexia nervosa were interviewed to generate data for the model.

RESULTS

Participants stated that nurses contributed significantly to their recovery from anorexia nervosa. Three recurring themes emerged from the data: (1) normalisation, (2) structure and (3) responsibility. The focus of nursing care with respect to these themes shifted during the phases of recovery.

CONCLUSIONS

Based on patients' experiences a theoretical model is developed describing effective nursing care of adolescents diagnosed with anorexia nervosa. Patients identified the key components of this model as essential to their weight recovery.

RELEVANCE TO CLINICAL PRACTICE

The model may be used to improve the quality of nursing care of adolescents diagnosed with anorexia nervosa through analysis of current practice with respect to the key components of our model. Interventions that are based on these components closely follow the patients' needs.

Anti-Mullerian hormone (AMH): what do we still need to know?

In the ovary, Anti-Müllerian hormone (AMH) is produced by the granulosa cells of early developing follicles and inhibits the transition from the primordial to the primary follicular stage. AMH levels can be measured in serum and have been shown to be proportional to the number of small antral follicles. In women serum AMH levels decrease with age and are undetectable in the post-menopausal period. In patients with premature ovarian failure AMH is undetectable or greatly reduced depending of the number of antral follicles in the ovaries. In contrast, AMH levels have been shown to be increased in women with polycystic ovary syndrome (PCOS). AMH levels appear to represent the quantity of the ovarian follicle pool and may become a useful marker of ovarian reserve. AMH measurement could also be useful in the prediction of the extremes of ovarian response to gonadotrophin stimulation for in vitro fertilization, namely poor- and hyper-response. Although AMH has the potential to increase our understanding of ovarian pathophysiology, and to guide clinical management in a broad range of conditions, a number of important questions relating to both the basic physiology of AMH and its clinical implications need to be answered.

The endocrinopathies of anorexia nervosa

OBJECTIVE

To describe the hormonal adaptations and alterations in anorexia nervosa.

METHODS

We performed a PubMed search of the English-language literature related to the pathophysiology of the endocrine disorders observed in anorexia nervosa, and we describe a case to illustrate these findings.

RESULTS

Anorexia nervosa is a devastating disease with a variety of endocrine manifestations. The effects of starvation are extensive and negatively affect the pituitary gland, thyroid gland, adrenal glands, gonads, and bones. Appetite is modulated by the neuroendocrine system, and characteristic patterns of leptin and ghrelin concentrations have been observed in anorexia nervosa. A thorough understanding of refeeding syndrome is imperative to nutrition rehabilitation in these patients to avoid devastating consequences. Although most endocrinopathies associated with anorexia nervosa reverse with recovery, short stature, osteoporosis, and infertility may be long-lasting complications. We describe a 20-year-old woman who presented with end-stage anorexia nervosa whose clinical course reflects the numerous complications caused by this disease.

CONCLUSIONS

The effects of severe malnutrition and subsequent refeeding are extensive in anorexia nervosa. Nutrition rehabilitation is the most appropriate treatment for these patients; however, it must be done cautiously.

Leptin, ghrelin, and endocannabinoids: potential therapeutic targets in anorexia nervosa

Anorexia nervosa (AN) has the highest mortality rate between psychiatric disorders, and evidence for managing it is still very limited. So far, pharmacological treatment has focused on a narrow range of drugs and only a few controlled studies have been performed. Furthermore, the studies have been of short duration and included a limited number of subjects, often heterogenic with regard to stage and acute nutritive status. Thus, novel approaches are urgently needed. Body weight homeostasis is tightly regulated throughout life. With the discovery of orexigenic and anorectic signals, an array of new molecular targets to control eating behavior has emerged. This review focuses on recent advances in three important signal systems: leptin, ghrelin, and endocannabinoids toward the identification of potential therapeutical breakthroughs in AN. Our review of the current literature shows that leptin may have therapeutic potentials in promoting restoration of menstrual cycles in weight restored patients, reducing motor restlessness in severely hyperactive patients, and preventing osteoporosis in chronic patients. Ghrelin and endocannabinoids exert orexigenic effects which may facilitate nutritional restoration. Leptin and endocannabinoids may exert antidepressive and anxiolytic effects. Finally, monitoring serum concentration of leptin may be useful in order to prevent refeeding syndrome.

Anti-Mullerian hormone, inhibin B, and antral follicle count in young women with ovarian failure

CONTEXT

Ovarian dysfunction is classically categorized on the basis of cycle history, FSH, and estradiol levels. Novel ovarian markers may provide a more direct insight into follicular quantity in hypergonadotropic women.

OBJECTIVE

The objective of the study was to investigate the distribution of novel ovarian markers in young hypergonadotropic women as compared with normogonadotropic regularly menstruating women.

DESIGN

This was a nationwide prospective cohort study.

SETTING

The study was conducted at 10 hospitals in The Netherlands.

PATIENTS

Women below age 40 yr with regular menses and normal FSH (controls; n = 83), regular menstrual cycles and elevated FSH [incipient ovarian failure (IOF); n = 68]; oligomenorrhea and elevated FSH [referred to as transitional ovarian failure (TOF); n = 79]; or at least 4 months amenorrhea together with FSH levels exceeding 40 IU/liter [premature ovarian failure (POF); n = 112].

MAIN OUTCOME MEASURES

Serum levels of anti-Müllerian hormone (AMH), inhibin B, and antral follicle count (AFC) was measured.

RESULTS

All POF patients showed AMH levels below the fifth percentile (p(5)) of normoovulatory women. Normal AMH levels (>p(5)) could be identified in 75% of IOF, 33% of TOF patients, and 98% of controls. AFC and AMH levels changed with increasing age (P < 0.0001), whereas inhibin B did not (P = 0.26). AMH levels were significantly different between TOF and IOF over the entire age range, whereas AFC became similar for TOF and IOF at higher ages.

CONCLUSIONS

Compared with inhibin B and AFC, AMH was more consistently correlated with the clinical degree of follicle pool depletion in young women presenting with elevated FSH levels. AMH may provide a more accurate assessment of the follicle pool in young hypergonadotropic patients, especially in the clinically challenging subgroups of patients with elevated FSH and regular menses (i.e. IOF) and in hypergonadotropic women with cycle disturbances not fulfilling the POF diagnostic criteria (i.e. TOF).

Efficacy of inpatient treatment in severely malnourished anorexia nervosa patients

OBJECTIVE

Our aim is to present clinical results achieved with an intensive treatment programme for severe anorexia nervosa (AN) patients at risk of severe disability or death. Aims of the treatment are to remove life threatening conditions, physical and nutritional rehabilitation, and psychological and relational rehabilitation.

METHODS

We present an observational retrospective study of a cohort of 99 consecutive patients affected by severe AN [according to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)] and a body mass index (BMI) <or=13.5 kg/m2 treated by a multidisciplinary comprehensive medical, nutritional, psychological treatment. Intensive treatment (inpatient day and night and day hospital care) of variable length, with resort to enteral nutrition if needed, ends by achieving a BMI of at least 18 kg/m2. Outpatient care phase follows. Main goals were the recovery of BMI and the ability to maintain it.

RESULTS

Ninety-nine patients affected by severe Protein- Energy-Malnutritrion (PEM) due to AN were eligible in the study. Mean BMI was 12.5+/-0.9 kg/m2, mean age 21.9+/-8.6 yrs. Of 99 patients, 75 (75.5%) completed the planned treatment (completer subgroup). Eighteen patients prematurely interrupted their treatment before achieving complete weight restoration (dropout subgroup); on average they were older and ill for a longer time before admission. Six patients asked to be transferred to other eating disorder units closer to their towns. Seventy-five completer AN patients continued to undergo intensive inpatient treatment till the achievement of BMI 18.3+/-0.8 kg/m2 and then they have been in follow-up outpatient for a mean period of 17.4+/-1.6 months with an average extra increase of their BMI until to 19.1+/-1.6 kg/m2. In 32 patients with a more severe malnutrition we had to resort to nasogastric enteral feeding for 4.4+/-2.5 months, with a mean caloric supply of 1375+/-211 Kcal until the patients were no longer at life risk and they started to co-operate to treatment, increasing oral food amounts.

DISCUSSION

Our results seem to provide strong support for using a highly structured program for treating patients with severe AN, including inpatient care and multidisciplinary medical and psychological teams specialized in eating disorder treatment.

Anti-Müllerian hormone and ovarian dysfunction

Anti-Müllerian hormone (AMH) has important roles in postnatal ovarian function. Produced by ovarian granulosa cells, AMH is involved in initial follicle development. In fact, serum AMH level correlates with ovarian follicle number. In patients with polycystic ovary syndrome (PCOS), AMH levels are elevated, which indicates its potential relevance in PCOS diagnosis and management. AMH represents a useful clinical marker for the assessment of ovarian reserve in cases of subfertility caused by advanced age in women. A potential role for AMH in dominant follicle selection has also been suggested. Future challenges comprise the availability of a well-standardized assay and the development of AMH agonists and antagonists as possible tools to manipulate ovarian function for contraception or ovarian longevity.

Energy availability and infertility

PURPOSE OF REVIEW

To relate recent research on the dependence of reproductive function on energy availability in women to recent clinical experience in the treatment of anorexia nervosa.

RECENT FINDINGS

The dependence of luteinizing hormone pulsatility on energy availability declines during adolescence, but the responses of leptin and other peripheral signals of energy deficiency do not. This finding suggests that central sensitivity to these signals may decline during adolescence. Energy availability may be inadequate in anorexia nervosa patients whose menstrual cycles are not restored after weight recovery.

SUMMARY

Energy availability is a theoretically satisfying and operationally controllable concept for understanding, investigating, and managing the energy dependence of reproductive function. Nutritional intervention to restore menstrual cycles in anorexia nervosa patients might be more successful if it was guided by energy availability and ovarian volume rather than energy intake and body weight.