I think they're missing the point

One of the major criteria for diagnosing anorexia is amenorrhea- the absence of menstruation in women post-puberty but before menopause. The value of this criteria aside, amenorrhea is certainly an indicator that something is not quite right with your body. And that something usually has to do with an inadequate amount of fat on your body. Fat signals an appropriate energy reserve. Since menstruation takes energy (which is why you eat more right before your period), your body isn't going to waste it on something non-essential in the short term. Besides, thinks your body, she'll never be able to maintain a pregnancy with these energy reserves. So no period. Period.

Many female athletes report menstrual abnormalities, to the point where absent periods are just sort of thought to come with the territory. While researchers have known for a long time that too much exercise + too little food = loss of periods, the precise workings haven't been pinned down. Until now.

The culprit? Abnormalities in ghrelin levels. In research presented at the annual meeting of the Endocrine Society, age-matched high school female athletes who were not menstruating had higher ghrelin levels than those who continued to menstruate.

A press release titled "Hormone disorder may contribute to lack of menstruation in teenage athletes" said that:

The researchers studied 21 teenage athletes with amenorrhea, 19 normally menstruating athletes and 18 nonathletic girls. The body mass index, a measure of body fat, was lower in the amenorrheic girls than in the other two groups, but overall these athletes were not underweight. All girls were more than 85 percent of the ideal body weight for their ages. The amenorrheic group reported similar levels of physical activity as the normally menstruating group, and both groups of athletes reported more physical activity than the non-athletic group...

"These findings suggest that hormonal disorders may explain why amenorrhea occurs in some but not all adolescent athletes," Misra said. "In addition, ghrelin may be an important link between an energy deficit state and the hormones that regulate menstrual function."

I know that research presented at meetings tends to be much more preliminary, but all I could think while reading this was: didn't they think to check body fat levels? BMI is not the be-all and end-all of weight status. My periods stopped well within the "normal" weight range, above the target weight initially set for me at my first TWO hospital stays.* So their measurements might have left them scratching their heads a bit.

Also, there was no mention of whether these girls were screened for eating disorders before participating in the study. Which strikes me as something kind of important to look for.

I don't want to criticize the existence of such research because I do think it's important. Yet the elevated ghrelin levels, to me, simply say that this girl isn't eating enough for her activity level. Or that her activity level is too high for her food intake. It's not a hormone disorder. It's the result of an energy deficit. What I think is going on? Ghrelin levels are elevated when you aren't eating enough. The girls without their periods just aren't eating enough.

It would be interesting to look at ghrelin levels in athletes both during the current episode of amenorrhea and after menstruation resumes. This might help identify girls particularly at risk. But even if we do identify high-risk girls, I'm not so sure of the usefulness of such information. Because ALL girls should be eating enough to menstruate properly, ghrelin "disorder" be damned.

*And yes, I told them the actual weight at which my periods stopped. They still lowballed it. I didn't mind it at the time, but looking back, all I can do is shake my head.

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Anonymous said...

I had a similar reaction to this article, Carrie (although not as well thought and worded as yours). Sometimes it's just the malnutrition, folks!

carrie said...

I think it's an important subject to look into, and I'm curious to see what they find. But I think they're barking up the wrong tree.

What research I really would like to see them do is on ghrelin/leptin levels in people with a family history of EDs and then follow them to see if they develop an eating disorder. It would, however, be a logistical nightmare to design such a study.

A:) said...

It's also interesting that some AN sufferers do not lose their periods until lower weights.

My first bout of AN, I lost my period well within my weight range -- kind of similar to you Carrie. My second relapse I did not lose my period until I was well below my range.

I can't put a lot of weight (no pun intended) into the ammenorhea criteria because it seems so random -- my body just doesn't react the same way every time so it's not really a reflection of my struggles.

Does this make any sense?


tokaiangel said...

I cannot BELIEVE they didn't connect this with lack of food/fuel - surely it's the obvious connection to make?

I do think that there are a number of factors that contribute to menstrual patterns which vary massively from person to person (that's why some people start to get a period when they're ten, and others don't until their mid-teens) but essentially if your period stops when it was working fine before then your body is in some sort of confusion about something. Team that with the high ghrelin levels and the answer seems obvious.

Out of interest, I did wonder whether girls who lost their period in the earlier stages of anorexia were also the ones who got their first ever period quite early on in life? It would indicate that their bodies may be generally more sensitive/receptive to hormonal changes. I got my first period late-ish (when I was 14) and I didn't lose it again until I was quite seriousy underweight - I always wondered if that was a pattern.

Anonymous said...

I've stopped menstruating three times, for over five months each time. And each of these times I was losing weight (once unintentionally, the other two ED-related) but the menstruation stopped long before I ever became underweight. I don't know what this means...

Katy said...

Jeez, some people are DENSE. I can see how there's a possibility people who lose their period earlier have some sort of different hormonal predisposition than those whose periods hang on even at similar weights & intakes...but a hormonal disorder? Folks, it's called malnutrition! How is that hard to understand?

carrie said...

I think it would be interesting to see how ghrelin levels (or other hormones) influences the weight at which you lose your period. Or the amount of energy imbalance you need to have.

FWIW, I only lost my period on my first major anorexic episode. Even though the second major crash and burn I was at a lower weight (about 10 pounds) for over a year than when I lost my period the first time. Some purely anecdotal evidence: younger girls are MUCH more likely to lose their periods because the cycles haven't been as established. Women who have had long-term eating disorders are less likely to lose their period because their bodies have adapted to the deprivation.

Also, strenuous exercise (whether or not accompanied by weight loss) puts a tremendous stress on the body, which could also lead to loss of menstruation.

But hormone disorder? Give me a break.

Anonymous said...

I think it could be some (sum) of all of these parts ... and more.

I have had anorexia since childhood and never started my period. Fast-forward to post-college, in the first year of my marriage, thinking I couldn't get pregnant/have children b/c of the previous condition/circumstances. I found out, almost four months into the pregnancy, that I *was* pregnant ... without ever having had a period.

I was in the body-composition study at NYSPI, and Dr. Walsh theorized that my body released a random egg that "got lucky" and my brain thought: "Well, we're pregnant; we're nursing; we must be OK," despite body weight during the ensuring years (maintained appropriate weight and healthy pregnancies X 3) that persisted at less than 60 percent IBW and worse during hospitalization crises.

All of these times I maintained regular cycles, including through complications that included functional paraplegia from the AN, pump-dependent gastroparesis, malabsorption, cardiomyopathy, and peripheral nerve damage.

They say my brain probably re-set its setpoint for this function at each critical weight when followed by re-feeding, i.e., that then became the new low threshold at which AN and menstruation could still co-exist.

We thought maybe I was an internally "fat" anorexic, but my body-fat testing didn't support that. I never took birth-control pills, even though they were recommended to help with endometriosis.

The upside to this is that I am now in my 40s, after nearly 30 years of illness (though doing better now than ever before, aside from pregnancies), and I don't have osteoporosis. I feel very lucky and very thankful.

So, who knows what might be up with my ghrelin, hypothalmus, etc., but it underscores the argument to drop amenorrhea as criteria.

Laura Collins said...

It seems to me that until we develop a model for EDs that makes OPTIMAL body composition the MINIMUM standard, we will continue to fail patients.

Instead of keeping people out of intensive care, we need to keep them in best health.

To this day, no clinician treating my daughter's eating disorder has ever asked for any medical information. No one in her medical treatment ever asked for information on mental health. It's crazy.

carrie said...


Ditto. I suppose there would be a slight difference given that I was pretty much an adult when I got sick (therefore my starting weight would be pretty much what I needed to be at). But still. Other than "what did you weigh before the eating disorder?" I never got asked anything else.

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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