Amenorrhea, anorexia and the pill

Even though my weight got very low, I never actually completely lost my period. My doctor says that the reason I continued to get my period right throughout my illness (although they were very light) was because I was on the contraceptive pill (also called birth control pills). I went on this pill prior to being diagnosed with anorexia because I had acne as well as irregular and very painful periods.

The following information found here explains why anorexic girls often loose there period whilst underderweight and how it can have long term effects on the anorexic patient. 

Amenorrhea is simply a medical term defined as the absence of menses in a post-pubescent woman of reproductive age. Amenorrhea may be defined as either primary or secondary: in primary amenorrhea menses does not occur by the age of 16 in the presence of normal growth and secondary sexual characteristics while in secondary amenorrhea menstruation ceases after menarche.

There is no consensus definition as to when secondary amenorrhea begins, but in practical terms if a period has not occurred in over 90 days, medical attention should be sought. Both primary and secondary amenorrhea may occur as a result of eating disorders but secondary amenorrhea is by far more commonly seen.

Secondary Amenorrhea Caused by Eating Disorders

The type of secondary amenorrhea caused by eating disorders is termed functional hypothalamic amenorrhea. Although restrictive eating disorders or excessive exercise that lead to low body weight may result in primary amenorrhea if they exist prior to puberty, they usually shut down normal hypothalamic function after the onset of puberty.

Up to 20% of Bulimics may experience amenorrhea while between 5% and 44% ofAnorexics experience amenorrhea. People diagnosed with an Eating Disorder Not Otherwise Specified (EDNOS), Compulsive Exercise, or the Female Athlete Triad, may also experience amenorrhea. Eating disorders associated with a high body weight such as Binge Eating Disorder are not associated with amenorrhea. The presence of amenorrhea is, however, one of the criteria necessary to achieve a diagnosis of Anorexia Nervosa according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM IV).

Amenorrhea from Eating Disorders - Hormonal Interruption

When a person engages in excessive exercise or disordered eating that results in low body fat and low body weight the normal secretion of Gonadotropin Releasing Hormone (GnRH) from the hypothalamus is interrupted. This leads to disordered secretion of both Follicular Stimulating Hormone (FSH) and Leutenizing Hormone (LH) which are essential to the normal menstrual cycle and ovulation. A critical level of body fat must be present for normal GnRH, LH, and FSH secretion and subsequent menstruation.

Though often reversible and not a medical danger in and of itself, the type of secondary functional hypothalamic amenorrhea associated with eating disorders may result in complications. Both infertility and osteoporosis may occur after prolonged functional hypothalamic amenorrhea.

Treatment for the type of secondary amenorrhea associated with eating disorders requires treatment of the primary cause. Restoring normal body weight is the first course of action. Hormonal therapy may be required in resistant cases.

So even though my hormone production would have most likely been disrupted whilst I was so underweight, my period never stopped because my pill delivered the hormones into my body that my body was no longer making naturally. I didnt really feel right forcing my period by unnatural means but my doctor assured me that since I only give myself a period once every three months, I wouldnt be harming my body by forcing my period. In fact I would be protecting it my lessening my chances of osteoperosis as well as infertility in the future.

This made me wonder why the contraceptive pill isn't given to more anorexics to regulate their reproductive hormones like estrogen, but I think that it is because doctors dont want anorexics to see the pill as some kind of quick fix. Obviously the best treatment for anorexia is weight restoration and for the sufferer to allow their body to repair. Taking the pill therefore could stop an anorexic from making a full physical recovery as they think they are healthy before they actually are. 

It should be noted that just because your period returns, does not necessarily meal you are physically recovered. Some girls dont even lose their period whilst suffering from anorexia and becoming underweight. The following article sourced here explains how the return of an anorexics period can be a good natural indicator that they are weight restored and how the contraceptive pill eliminates this indicator. 

The weight necessary to resume menses can be estimated with great accuracy and success by using the Frisch tables, which are surprisingly not well known to many physicians (Frisch et al., 1974; Frisch, 2004). There are two Frisch tables, one for girls with primary amenorrhea (never had a period) and one for girls with secondary amenorrhea (began then lost menses). The second table (secondary amenorrhea) is the one that should be used for ED patients, including those who have never had a period before (pre-menarchal). Usually I will use the 50th percentile weight for height in determining goal weight range for any given individual with AN, which indicates a 50-50 chance of menstrual function returning at this weight for height. If menses have not returned after maintaining this weight for 3-6 months, then I recommend increasing the goal weight range by 5 lbs, and again wait for 3-6 months for results. Conversely, if menses commence at a weight lower than goal weight, then the goal weight range can be adjusted downward.

As a psychiatrist specializing in the treatment of eating disorders for most of my career, I can say that this approach works in at least 9 out of 10 times. Very commonly, patients do not want to stop their Birth Control Pills and risk having to gain more weight. Instead they prefer the false sense of security that having monthly blood flow brings them, their families and their uninformed health care providers. In summary, 1) Do not allow birth control pills (BCPs) to be prescribed to young women or girls with AN until after full restoration of weight and menses occurs (at least 2-3 cycles on time); 2) BCPs obscure the most reliable indicator of healthy weight recovery for adolescent girls and pre-menopausal women, i.e., restoration of menstrual function; 3) BCPs do absolutely nothing to prevent osteoporosis or osteopenia, which is driven by many other factors related to starvation besides low estrogen levels, e.g., alterations in cortisol, insulin-like growth factor, and leptin (Mehler & MacKenzie, 2009)

I found it interesting to read that this doctor does not think the contraceptive pill has ptotected me from osteoperosis when my doctor said it had. Perhaps I still am at risk because many hormones are involved in the development of osteoperosis, not only estrogen. While my doctor had told me to stay on my pill, I cant help but think it would be better to allow my body to do things naturally. What does anyone else think? If you were in my position, would you stay on the pill?