What are Menstural Disturbances in Eating Disorders?

What are Menstrual Disturbances in Eating Disorders?

Menstrual disturbance refers to menstruation that differs from the norm. For most women, a normal menstrual cycle ranges between 21 to 35 days. However, according to the literature, the prevalence of irregular menstruation occurs in 5% to 35.6% of women, depending on age, occupation, and country of residence (Kwak et al, 2019).

The most common menstrual irregularities include:

• Amenorrhoea or absent menstrual periods

• Oligomenorrhea or infrequent menstrual periods i.e., periods that occur more than 35 days apart

• Menorrhagia or heavy menstrual periods

• Prolonged menstrual bleeding or bleeding that exceeds 8 days in duration on a regular basis

• Dysmenorrhea or painful periods that may include severe menstrual cramps

• Polymenorrhea or frequent menstrual periods occurring less than 21 days apart

• Irregular menstrual periods with a cycle-to-cycle variation of more than 20 days

• Shortened menstrual bleeding of less than 2 days in duration

• Intermenstrual bleeding or episodes of bleeding that occur between periods, also known as spotting

(National Institute of Child Health, 2017)

Amenorrhoea

Amenorrhoea refers to the absence of a woman’s menstrual period when she is in her reproductive years. Amenorrhoea can be further defined as:

• Primary Amenorrhoea- Is the absence of menstruation with no development of any secondary sex characteristics by the age of 14, or the absence of menstruation with normal pubertal development by the age of 16.

• Secondary Amenorrhoea- Is the absence of menstruation following a history of menstrual cycles. This includes females who previously had regular cycles and have not menstruated for 3 months, or those who had irregular cycles and have not menstruated for 6 months.

(Deligeoroglou, 2010; Serret Montoya, 2012)

Causes of Menstrual Disturbance

Amenorrhoea occurs when the normal secretion of gonadotropin releasing hormone from the hypothalamus is interrupted. This is called hypothalamic amenorrhoea (HA).

Polycystic ovary syndrome (PCOS) is a condition where there is a complex hormonal imbalance, and it is a common cause of irregular or absent menstruation in women. PCOS can co-occur with an eating disorder or be a sole diagnosis. HA and PCOS are the most common causes of amenorrhoea in adolescents. One study found that 68% of those presenting with amenorrhoea were diagnosed with an eating disorder, and 55% of those presenting with oligomenorrhea were diagnosed with PCOS. It also found that 38% of those with oligomenorrhoea also had an eating disorder (Wiksten-Almströmer, 2007).

The most common causes of hypothalamic amenorrhoea are:

• Low weight

• Prolonged weight loss

• Erratic eating behaviours

• Poor nutrition

• Excessive exercise

• Medications

• Psychosocial stress

(Wiksten-Almströmer, 2007; Perkins, 2001)

Despite low weight being a common cause of HA seen in clinical practice, the other causes are also prominent, even in those who are seemingly not at a low weight. One study found that 1/3 of adolescents with an eating disorder had a menstrual disorder, and 2/3 of those presented with amenorrhoea (Vale et al, 2014). Menstrual disturbance is often thought of as a feature of only Anorexia Nervosa. In fact, in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-4), prior to its update in 2013 in DSM-5, this was a symptom featured only under the diagnosis of Anorexia Nervosa (American Psychiatric Association, 1994).

However, menstrual disturbance does not only occur in Anorexia Nervosa, but it can be an associated feature of all eating disorders. (Poyastro Pinheiro, 2007) In fact, another study found that there were menstrual disturbances found in a group of individuals with Bulimia Nervosa who were restricting their intake. They had menstrual irregularities even though this was not reflected by a low body weight or low energy intake. They concluded that fluctuations in body weight may have acted as a metabolic stress on the body, thereby causing menstrual disturbance. (Gendall et al, 2000)

Menstrual History and Assessment

To be able to evaluate whether an individual has menstrual disturbance, and what may be the cause, a menstrual history and assessment is essential. This should include:

• Age of menarche or pubertal status

• Date of last menstrual period, and their weight at this time (if known)

• Patterns of menstruation – regularity, period length, and flow

• Symptoms experienced and their severity e.g., pain/cramping, nausea

• Episodes of absent menstruation – frequency, length of time

• Use of hormonal contraception e.g., oral contraceptive pill, implant or IUD

• A medical history to help rule out other causes of amenorrhoea, including pregnancy

• Investigations - FSH, LH and oestradiol levels. A pelvic ultrasound can also be helpful to show if there are prepubertal-appearing ovaries and uterus, as this can help with diagnosis and monitoring

• Other investigations may be indicated where there are other features suggesting possible dual pathology e.g., PCOS

It is also helpful to link the individual's weight history, eating patterns, and use of eating disorder behaviours to their menstrual history in order to assess whether there is a correlation between the two.

Females who have not menstruated for 3 months should be evaluated to determine the cause. The persistence of amenorrhoea for longer than 6 months can be associated with lowered bone mineral density, and therefore needs to be addressed as a priority (NSW Health, 2018).

Menstruation usually returns upon the individual restoring their healthy weight and reducing eating disorder behaviours. Rates of recovery are more than 80% when precipitating factors are reversed (Perkins, 2001), although regular menstruation can be delayed for up to 12 months. Therefore, investigations such as measuring FSH, LH and oestradiol for objective evidence of recovery can be helpful.

Treatment Plan

The treatment goals should include:

• Facilitating weight restoration to the individual’s healthy weight

• Facilitating a regular eating pattern, including provision of a balanced diet which includes sufficient energy intake

• Supporting cessation of eating disorder behaviours

• Supporting a healthy relationship with exercise, which may involve reduction or cessation of exercise

• Supporting stress reduction e.g. meditation, relaxation, self-care

(NSW Health, 2018)

Monitoring for normalisation of biochemistry, menstrual function, growth, and pubertal development is important, and can also be used as a motivating factor for weight restoration for the individual. Liaising with the GP or paediatrician to support in the medical management and investigations of hormone levels and pelvic ultrasound can be helpful if indicated.

The Use of Hormonal Contraception

Keep in mind that a prescription of an oral contraceptive pill or other hormonal contraception to restart menstruation or to promote regularity of menstruation is not recommended. The use of hormonal contraception is not a treatment for menstrual disturbance, but rather mimics ‘normal’ menstruation without addressing the underlying cause. This can therefore provide the individual with a false sense of ‘health’, when in fact, the menstrual disturbance still exists.

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