Estrogen replacement therapy in the management of osteopenia related to eating disorders

Oral contraceptives partially protect from bone loss in young women with anorexia nervosa

OBJECTIVE

To evaluate the potentially protective effects of oral contraceptives (OC) on bone loss in a large population of young women with anorexia nervosa (AN).

DESIGN

Cross-sectional study.

SETTING

University hospital.

PATIENT(S)

Three hundred and five patients with AN (99 of them using OC) and 121 age-matched controls.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Areal bone mineral density (aBMD) evaluated by dual-energy X-ray absorptiometry and bone turnover markers, with leptin evaluated concomitantly.

RESULT(S)

Although the AN patients taking OC presented lower aBMD compared with the controls at all bone sites, the whole body excepted, their aBMD values were systematically higher than those of AN patients who were not taking OC for the whole body and the lumbar spine, femoral neck, hip, and radius. These differences persisted after multiple adjustments. Preservation of aBMD improved with longer durations of OC use and shorter delays between disease onset and the start of OC. Moreover, patients with the lowest body mass index showed the best bone tissue responses to OC. Bone formation markers were systematically lower in the two groups of patients with AN compared with the controls. The markers of bone resorption were normalized in AN patients using OC.

CONCLUSION(S)

Although OC use does not provide total protection of aBMD, our data suggest that OC might be prescribed for young women with AN to limit their bone loss.

Synaptic changes in the hippocampus of adolescent female rodents associated with resilience to anxiety and suppression of food restriction-evoked hyperactivity in an animal model for anorexia nervosa

Anorexia nervosa is a mental illness that emerges primarily during early adolescence, with mortality rate that is 200 times higher than that of suicide. The illness is characterized by intense fear of gaining weight, heightened anxiety, obstinate food restriction, often accompanied by excessive exercise, in spite of mounting hunger. The illness affects females nine times more often than males, suggesting an endocrine role in its etiology. Its relapse rate exceeds 25%, yet there are no accepted pharmacological treatments to prevent this. Here, we summarize studies from this laboratory that have used adolescent female rodents in activity-based anorexia (ABA), an animal model of anorexia nervosa, with the goal of identifying neurobiological underpinnings of this disease. We put forth a hypothesis that a GABAergic mechanism within the hippocampus is central to regulating an individual׳s anxiety which, in turn, strongly influences the individual׳s resilience/vulnerability to ABA. In particular, we propose that ionotropic GABAA receptors containing the subunits alpha4 and delta, are at play for exerting shunting inhibition upon hippocampal pyramidal neurons that become more excitable during ABA. Since these receptors confer insensitivity to benzodiazepines, this pharmacological profile of ABA fits with lack of report indicating efficacy of benzodiazepines in reducing the anxiety experienced by individuals with anorexia nervosa. The idea that the GABAergic system of the hippocampus regulates resilience/vulnerability to anorexia nervosa complements current opinions about the important roles of the prefrontal cortex, amygdala, striatum, gustatory pathways and feeding centers of the hypothalamus and of the neuromodulators, serotonin and dopamine, in the etiology of the disease. This article is part of a Special Issue entitled SI: Adolescent plasticity.

Eating disorders in the obstetric and gynecologic patient population

The eating disorders anorexia nervosa and bulimia nervosa and eating disorders not otherwise specified disproportionately affect women, have profound effects on the overall well-being of women and their children, and can have mortality rates as high as those found with major depression. These disorders may present to obstetrician-gynecologists (ob-gyns) clinically as menstrual dysfunction, low bone density, sexual dysfunction, miscarriage, preterm delivery, or low birth weight in offspring. Ninety percent of eating disorders develop before the age of 25 in otherwise healthy young women, a group that characteristically seeks the majority of their health care from ob-gyns. For all of these reasons, ob-gyns must have a greater awareness of these disorders and a lower index of suspicion for screening their patients than they currently do. Otherwise, they may miss life-threatening illness, treat characteristic amenorrhea inappropriately, or inadvertently intervene to help these women conceive, contributing to maternal and fetal risks. As providers of both primary and specialty care for women, ob-gyns have the opportunity to play a vital role in prevention and diagnosis of eating disorders and in the multidisciplinary management required to effectively manage these disorders.

Skeletal status and laboratory investigations in adolescent girls with anorexia nervosa

To our knowledge anorexia nervosa (AN) adversely influences bone density, but whether qualitative characteristics of bone are also affected is not known. For this reason we investigated prospectively the changes in skeletal status in a population of 18 adolescent girls with AN aged 11.5-18.1 years (mean 15.9+/-1.9 years) using both dual-photon X-ray absorptiometry (DXA) and quantitative ultrasound (QUS) measurements, bone turnover markers (osteocalcin, bone alkaline phosphatase - bALP, carboxy-terminal cross-linked telopeptide of type I collagen - ICTP), and laboratory investigations (serum total and ionised calcium, serum phosphate, urine calcium/creatinine ratio, luteinizing hormone - LH, follicle-stimulating hormone - FSH, estradiol). Measurements of bone mineral density at the spine (s-BMD) and total body (TB-BMD) and amplitude-dependent speed of sound (Ad-SOS) of the hand phalanges were performed at baseline, 7.8+/-2.4 and 19.4+/-5.6 months of follow-up. The mean values of TB-BMD, s-BMD and Ad-SOS measurements did not change during the period of observation. The mean Z-scores for TB-BMD and Ad-SOS were significantly lower after 19.4 months of observation vs. baseline (-1.06+/-1.00 vs. -0.67+/-0.98 vs. and -0.50+/-0.88 vs. 0.26+/-1.75, respectively). Z-scores for s-BMD decreased non-significantly (p=0.08). Among bone turnover markers, we observed a significant increase in bALP and a non-significant increase in osteocalcin serum concentrations which were below normal ranges for age, sex and Tanner stage at baseline. High baseline serum ICTP concentration decreased non-significantly, reaching normal ranges during the observation. We conclude that anorexia nervosa seriously affects skeletal status in adolescent girls. Bone turnover markers analysed together with densitometric parameters suggest that AN influences both bone formation and resorption processes. QUS measurements at hand phalanges may be an appropriate method in the evaluation of skeletal status in patients with AN.

Treatment of anorexia nervosa is associated with increases in bone mineral density, and recovery is a biphasic process involving both nutrition and return of menses

BACKGROUND

Recovery from osteoporosis in anorexia nervosa (AN) is uncertain.

OBJECTIVE

The purpose of this study was to understand the changes in bone mineral density (BMD) in women with AN and the mechanisms of recovery from osteopenia.

DESIGN

We studied BMD and markers of bone formation and resorption, osteocalcin and N-telopeptide (NTX), in patients with AN (n=28) who were following a behavioral weight-gain protocol.

RESULTS

Anorexic patients experienced significant percentage increases in BMD (4.38 +/- 7.48% for spine; 3.77 +/- 8.8% for hip; P<0.05 for both) from admission until recovery of 90% ideal body weight, achieved over 2.2 mo. NTX concentrations were higher in patients with AN at admission than in healthy control subjects (n=11; 69.0 +/- 31.09 and 48.3 +/- 14.38 nmol/mmol creatinine, respectively; P<0.05) and in reference control subjects (n=30; 69.0 +/- 31.09 and 37.0+/-6.00 nmol/mmol creatinine, respectively; P<0.001). In weight-recovered subjects with AN, osteocalcin increased (from 8.0 +/- 3.05 to 11.2 +/- 6.54 ng/mL; P<0.05), whereas NTX remained elevated (from 69.0 +/- 31.09 to 66.7 +/- 45.5 nmol/mmol creatinine; NS). A decrease in NTX (from 70.7 +/- 40.84 to 45.9 +/- 22.72 nmol/mmol creatinine; NS) occurred only in the subgroup of subjects who regained menses with weight recovery.

CONCLUSIONS

Nutritional rehabilitation induces a powerful anabolic effect on bone. However, a fall of NTX and a shift from the dominant resorptive state, which we postulate involves full recovery, may involve a hormonal mechanism and require a return of menses. Nutritional rehabilitation appears to be critical to bone recovery and may explain the ineffectiveness of estrogen treatment alone on BMD in the cachectic state.

Persistent osteopenia in ballet dancers with amenorrhea and delayed menarche despite hormone therapy: a longitudinal study

OBJECTIVE

To investigate the role of estrogen deprivation and replacement in amenorrheic and nonamenorrheic dancers on hormone therapy and calcium.

DESIGN

Clinical, placebo-controlled, randomized trial study.Healthy volunteers in an academic research environment.

PATIENT(S)

Fifty-five dancers (mean age: 22.0 +/- 4.6, age at menarche: 14.7 +/- 2.3 years), including 24 amenorrheics.

INTERVENTION(S)

Amenorrheics were randomized in a controlled trial to receive placebo or Premarin, 0.625 mg for 25 days monthly, with Provera, 10 mg, for 10 of these 25 days (hormone therapy) for 2 years. These women were compared to normally menstruating controls. The study participants also received 1250 mg of calcium per day.

MAIN OUTCOME MEASURE(S)

Bone mineral density (BMD) measured at the foot, wrist, and lumbar spine. Our overall results showed no difference in BMD between the treated or placebo groups, indicating that hormone therapy did not change or normalize BMD when compared to normals. Five patients (all on placebo) who resumed menses during the study showed an increase in BMD without normalization.

CONCLUSION(S)

These findings suggest that mechanisms other than hypoestrogenism may be involved with the osteopenia associated with exercise-induced amenorrhea.

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.

Hypothalamic amenorrhea. The effects of environmental stresses on the reproductive system: a central effect of the central nervous system

Although the treatment of anovulation has become significantly more specialized and complex in the centuries since Hippocrates, a complete understanding of the causes and mechanisms of hypothalamic amenorrhea has not been achieved. Even the best research on hypothalamic amenorrhea is plagued by the lack of longitudinal studies, the use of different exercise models, the difficulty of controlling for caloric intake, and the fact that genetics may have a role in the disorder. Continuing research on metabolic rate, leptin, and other factors will ultimately answer many of the outstanding questions and will help to create better tools for treating this disorder.