Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Eating disorder prevalence has doubled in the last 10 years to about 7.8%
About 40% of eating disorders occur in adolescents aged 15 to 19 years
Among psychiatric disorders, eating disorders have one of the highest mortality rates at 5 to 6%, primarily from suicide and medical complications
DSM-5 removed the requirement for low BMI and amenorrhea from anorexia nervosa diagnosis criteria that existed in DSM-4
Atypical anorexia diagnosis applies to patients with all cognition and behavior of anorexia nervosa but at normal or above normal BMIs, with very similar medical complications
Female athlete triad terminology is being replaced with relative energy deficiency in sports for more inclusive language covering all genders and exercise contexts
Overweight adolescents have higher rates of body dissatisfaction and more weight concern compared to normal weight peers
In Rastogi study, 31% of eating disorder patients had a history of overweight, with prevalence of eating disorders in those with overweight/obesity history between 11 and 36%
Overweight patients with eating disorders are less likely to be hospitalized even with same degree of symptoms and similar medical presentation due to weight bias
Previously overweight patients resume menses at younger age and higher BMI than peers, suggesting individualized rather than absolute BMI threshold for menstrual return
Overweight patients return to menses 11 kg below maximum weight compared to 2 kg below for normal weight patients, representing higher BMI threshold
Family-based therapy has the strongest evidence for eating disorder recovery and is the first-line approach
CBT is generally more helpful in bulimia and binge eating disorder for working through compulsion to purge or compensate
Inpatient management criteria include BMI less than 75% median, dehydration, electrolyte abnormalities, EKG abnormalities, unstable vital signs, acute food refusal, uncontrollable binging/purging, failing outpatient treatment, acute medical complications, and significant comorbid conditions
Eating disorders primarily result in hypothalamic hypogonadotropic hypogonadism due to imbalance in energy intake/expenditure, stress, and loss of fat mass
Anorexia nervosa has 60-80% rate of amenorrhea compared to about 40% in bulimia
Self-induced vomiting alone has 3 times higher rate of irregular menses, and binge eating alone causes menstrual irregularity
Return of menstrual function is an important marker of physiologic recovery, serving as a natural test of endocrine system function
Endocrine Society guidelines recommend pregnancy test, prolactin, TSH for exclusionary causes, plus FSH, LH, estradiol, CBC, BMP, and AMH for functional hypothalamic amenorrhea evaluation
Functional hypothalamic amenorrhea shows low or normal FSH, low LH, and low estrogen
Patients with eating disorders are malnourished and not in good physiologic condition to carry pregnancy, making contraception discussion critical
Combined oral contraceptives should not be used for sole purpose of regulating menses
Women in recovery from eating disorders have significantly higher rates of unplanned pregnancy than general population
Mirena and Kyleena IUDs have no negative effect on bone mineral density
Nexplanon shows mixed results on bone mineral density with either no effect or slight decrease, but is still considered first-line therapy
For combined oral contraceptives, recommend at least 30 mcg ethinyl estradiol for better bone accretion compared to 20 mcg
Vaginal ring and patch don't negatively affect bone mineral density based on available studies
Depo-Provera is not best option for eating disorder patients because it is associated with decreased bone mineral density
Patients with anorexia who have amenorrhea for 20 months have 92% rate of osteopenia and 38% rate of osteoporosis
Rates of osteopenia are higher for those who have eating disorder in adolescence, a critical time for bone health development
Resumption of menses is critical for lumbar spine bone mineral density, while weight gain is more critical for hip bone mineral density
Combined oral contraceptives are ineffective for increasing bone mass in adolescents with anorexia nervosa, shown by multiple studies in 2000s
Hepatic metabolism of ethinyl estradiol down-regulates IGF-1, a factor anabolic to bone growth, explaining oral contraceptive ineffectiveness
Endocrine Society 2017 guidelines recommend short-term transdermal estradiol with cyclic progestin after 6-12 months of behavioral, nutritional, and psychological intervention
2011 study by MSR et al at Boston Children's showed transdermal patch increased bone mineral density at all skeletal sites (lumbar spine and hip)
Transdermal estrogen patch bone mineral density improvement was not related to changes in weight or fat mass
Estrogen patch itself doesn't cause weight or body composition changes, which can be used as discussion point to improve patient compliance
Boston Children's 18-month trial of DHEA plus combined oral contraceptives in 80 anorexia nervosa patients showed stabilization of bone mineral density compared to placebo, controlling for weight gain
DHEA plus combined oral contraceptive therapy showed improved bone geometry in addition to bone mineral density stabilization
Endocrine Society guideline 3.6 specifies transdermal E2 therapy with cyclic oral progestin, not oral contraceptives or oral ethinyl E2