From the Guidelines
The dose of estrogen in oral contraceptive pills does not appear to be the most effective factor in treating amenorrhea related to anorexia nervosa in adolescents for osteoporosis prevention, and transdermal oestradiol therapy with cyclic oral progestin is recommended instead of combined oral contraception. According to the most recent study by Gordon et al. (1), bone health in functional hypothalamic amenorrhea (FHA) women may not be protected with estrogen replacement therapy if nutritional and/or energy deficiencies persist. The study suggests that short-term use of transdermal oestradiol therapy with cyclic oral progestin in adolescents and women who have not had a return of menses after an adequate trial of nutritional, psychological, and/or modified exercise intervention is recommended.
The use of combined oral contraceptives is not recommended for the prevention of osteoporosis in FHA women, as it inhibits IGF-1 production via first-pass hepatic metabolism, which can decrease osteoblastic activity (1). In contrast, transdermal oestradiol is exempt from first-pass hepatic metabolism and has no impact on IGF-1 secretion.
Key points to consider in the treatment of amenorrhea related to anorexia nervosa in adolescents include:
- Comprehensive care including nutritional rehabilitation, weight restoration, and psychological treatment remains essential (1)
- Regular monitoring of bone density through DEXA scans is recommended to assess treatment effectiveness (1)
- Transdermal oestradiol therapy with cyclic oral progestin is recommended instead of combined oral contraception for the prevention of osteoporosis (1)
- The benefits of transdermal oestradiol on bone homeostasis in women with FHA have been highlighted in recent reviews of the literature (1)
From the Research
Impact of Estrogen Dose in Oral Contraceptives on Amenorrhea and Osteoporosis
- The dose of estrogen in oral contraceptive pills may have an impact on the treatment of amenorrhea related to anorexia nervosa in adolescents and the prevention of osteoporosis 2, 3, 4, 5, 6.
- Studies have shown that physiologic estrogen replacement can increase bone density in adolescent girls with anorexia nervosa, while high estrogen doses given as an oral contraceptive may not improve bone mineral density (BMD) 4, 6.
- The use of estrogen or birth control pills in patients with anorexia nervosa may create a false picture of bone health, potentially reducing motivation to regain weight and adhere to treatment for the eating disorder 3.
- Other factors, such as weight loss, duration of amenorrhea, and low levels of insulin-like growth factor-I (IGF-I), may contribute to the loss of bone mass in women with anorexia nervosa 6.
Role of Estrogen Replacement Therapy
- Estrogen replacement therapy may have a role in the management of girls and young women with primary ovarian insufficiency, but its exact role in the treatment of amenorrhea associated with anorexia nervosa or exercise remains controversial 2, 5.
- Physiologic estradiol replacement has been shown to increase spine and hip BMD in girls with anorexia nervosa, suggesting a potential benefit of estrogen replacement therapy in this population 4.
- However, estrogen replacement alone may not be sufficient to prevent progressive osteopenia in young women with anorexia nervosa, highlighting the need for a comprehensive treatment approach that addresses multiple factors contributing to bone loss 6.
Prevention of Osteoporosis
- Osteoporosis prevention is an important role for healthcare providers of adolescent girls and young women, particularly those with anorexia nervosa or other conditions that increase the risk of bone loss 2, 5.
- Early recognition and treatment of amenorrhea, as well as aggressive evaluation and management of underlying conditions, are crucial for preventing osteoporosis and optimizing bone health in this population 2, 5.