Current concepts in bone and reproductive health in adolescents with anorexia nervosa

Abstract

Anorexia nervosa (AN) initiates an adaptive response at the level of the hypothalamus, which results in a complex interplay involving most elements of the neuroendocrine axis. Consequences of onset of disease in adolescence include amenorrhoea, pubertal arrest with potential loss of target height, and osteoporosis with reduced capacity for future attainment of peak bone mass. With recovery, delay in restoration of menses is common. Hormonal therapies for restoration of bone mineral density (BMD) in adolescents have shown limited efficacy. This review will discuss the reproductive endocrine effects of AN in adolescence, and discuss new investigative tools for monitoring restoration of reproductive function and BMD in this population.Keywords Adolescence, amenorrhoea, anorexia nervosa, bone mineral density, eating disorders. IntroductionNinety percent of eating disorders present before the age of 25 years, and in the early stages they may present with menstrual dysfunction. 1 Therefore, it is important that gynaecologists have a good understanding of current concepts of hypothalamic regulation, as those physicians may be the first point of contact in subsyndromal eating disorders. Leptin, a hormone produced by adipocytes, appears to be the critical link between energy homeostasis and neuroendocrine regulation. 2 Since its discovery in 1994, 3 rapid gains in understanding of the hormonal and nutritional regulation of anorexia nervosa (AN) have occurred. 4 These findings are likely to have a significant impact on clinical management of the reproductive-endocrine aspects of AN. Bone loss consequent upon estrogen deficiency may be severe, of long duration with reduced capacity for recovery. Understanding bone loss mechanisms, correct interpretation of bone density measurements and consideration of treatment modalities to ameliorate the problems of eating disorders are an essential part of overall management strategies. EpidemiologyThe Society for Adolescent Medicine together with other medical bodies has recognised that strict Diagnostical and Statistical Manual of Mental Health Disorders-IV (DSM-IV) criteria 5 for AN (particularly requiring weight below 85% of normal and amenorrhoea for 3 months), may not apply to all women. 6,7 This is particularly so in adolescents because of their normal variability in development, and also because adverse health effects occur even in partial syndromes. In adolescence, prevalence of AN is 0.5%, bulimia nervosa is 1% and partial syndromes (eating disorders not otherwise specified) is 2.4-5.0%. 6,[8][9][10] Clinical sequelaeThe clinical sequelae of AN depend on timing of disease in relation to puberty. These may include pubertal delay and primary amenorrhoea, pubertal arrest with potential loss of target height, or secondary amenorrhoea. 11-13 Amenorrhoea has been reported to precede weight loss in 20% of women, which may lead to diagnostic confusion.Low bone mineral density (BMD) is an established risk in AN, with 50% of anorexics demonstrating osteopenia within 20 months of ameno...

Low Testosterone—An Important Predictor of Low Mineral Bone Density in Young Men—Our Own Experience and a Review of Literature

“…Both men and women achieve peak bone mineral density (BMD) in their early twenties [22]. The peak BMD depends on genetic background (family history), caloric and calcium intake, normal hormonal levels during childhood and adolescence [23].…”

Anoreksiya nervozada hormonal değişimler / Endocrinological changes in anorexia nervosa

“…Kronik enerji eksikliğinde, oreksijenik hormon olan ghrelin artar (31). Yapılan çalışmalarda, aşırı egzersiz yapmaya bağlı amenoresi olan genç kadın-ların ghrelin düzeyleri normalden %85 daha yüksek değerlerde saptanmıştır (32).…”

“…Eğer AN belirtileri ergenlik başladık-tan sonra ortaya çıkarsa, pubertal süreç uzar ve ikincil amenoreye neden olur (31).…”

Primary and Secondary Amenorrhea

“…Furthermore, this therapy should prevent the development of osteoporosis. Respect to oral estrogens, it has been demonstrated that transdermal hormone replacement therapy has better effects on bone density than oral hormone replacement therapy due to the absence of the first-pass hepatic metabolism (Jayasinghe et al, 2008). In addition, calcium and vitamin D supplementation is highly suggested (Master-Hunter & Heiman, 2006).…”