I stumbled upon this article last week: Metabolic Assessment of Menstruating and Nonmenstruating Normal Weight Adolescents This is something that I have always been curious about — is amenorrhea associated with a low metabolic rate? I always assumed yes, at least a little bit. However, I didn’t really base this conclusion on any hard science. Let’s say that I used “Grey Science,” which goes something like this:
Your body requires a certain number of calories to function at full-capacity. When you chronically deprive your body of these calories, it has to adapt to the calorie deficit to survive. One of the ways that it does this is to cut out non-essential functions, like menstruation. However, in recovery, it’s possible to gain weight without really restoring your metabolism (believe me). If you’re still subsisting on a sub-optimal number of calories, then your body might still not feel like it can spare the extra calories that menstruation requires. You are only able to maintain that weight on those calories because there are still processes that are being cut out. This means that your metabolic rate is lower.
Again, this is my unscientific reason, that happens to make a lot of sense in my mind. Thankfully some researchers came along to actually research this…
From the article:
“The purpose of this study was to investigate a possible mechanism for amenorrhea in adolescents who were 90-130% expected body weight with a history of anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified. Using indirect calorimetry, we examined the metabolic differences between participants who were menstruating regularly compared with those who were amenorrheic. Our hypothesis was that participants with amenorrhea would have a lower REE than those with regular menses. We also proposed that both groups would have a lower REE than would be expected for age, weight, and height due to their dieting, calorie restriction, and eating disorder behaviors.”
And the conclusion:
“Using indirect calorimetry to assess REE, we showed that a hypometabolic state persists despite weight restoration. There were significant metabolic differences found in weight-restored participants was amenorrhea as compared to participants who had regular menses. Participants with amenorrhea consumed a lower fat diet, that a lower REE, and were at a lower mean body weight.”
So… overall, I was on the right track. However, the article leaves me with several questions:
- Why do recovered anorexics/bulimics have a lower REE than others their age without an ED history?
- What is necessary for resuming menses?
- I have been told by several doctors that often a stint on birth control is necessary to “jump-start” your period. How does that relate? And, how does that affect REE?
I think that the situation is a Catch-22. Weight-restored patients with amenorrhea have a lower REE, so their metabolic rate is reduced and therefore need fewer calories. However, they are still not getting their period, so do they need to be eating more? I understand that you need to eat more to raise your metabolic rate and get your period back (in theory), but as a weight-restored anorexic I will tell you that my ED is screaming, “See! You DON’T need that much food! Your metabolism is slower!” I think that it is a particularly difficult spot to be in since you can’t tell yourself “Well, you do need to gain…” I am waiting for a follow-up study that shows that increasing caloric intake fixes said metabolic and menstrual issues. Now THAT is a study I would be excited to read.
(Unrelated P.S. – This is the 100th Grey Thinking post!)
IMO, as a med/grad student, recover-ing anorexic/over-exercising… This is a really, ridiculously long comment. I should be writing a paper on how I feel about becoming a doctor. Physio is way more interesting.
1. Why do recovered anorexics/bulimics have a lower REE than others their age without an ED history?
-I think that you can get to your proper weight without giving your body all the food it needs… the body adjusts, you know, to not having enough intake, and it lowers its metabolic rate. So you may still level off at what is your normal weight, but your body still *feels* like it’s starving, because well, it is. You’re still shut down. Your grey thinking seems to be spot on.
Another IJED article from a while back says that there’s not a real difference in metabolisms– http://www3.interscience.wiley.com/journal/121583093/abstract?CRETRY=1&SRETRY=0.
I don’t know enough about calorimetry to understand which is the most effective way to measure fat oxidation, but I think it’s not unreasonable that the eating disorder shifts the way your breakdown calories, even if your BMR eventually levels.
2. What is necessary for resuming menses?
-Million dollar question!! Haha.
Personally, I really *do* believe that you hit a spot where your body feels like it’s nutritional intake is no longer threatened, and it kinda breathes a sigh of relief and starts acting normal again.
Weight restoration doesn’t seem to be key*, but it’s way easier to measure a cohort’s weight and assess whether it’s within normal limits than it is to assess their BMR. Plus none of these measures take into account an individual’s ‘normal’, not be able to assess whether they’re metabolism is reduced from their own unique needs, or whether their technically ‘healthy’ weight is actually under their body’s set point.
3. I have been told by several doctors that often a stint on birth control is necessary to “jump-start” your period. How does that relate? And, how does that affect REE?
I don’t believe that, and there haven’t really been studies that support that. Perhaps it “jump starts” your repro system, and therefore makes you use more calories, kinda pushing you over a bump so that even with cessation of OCPs you would continue having the elevated REE and menses? None of the endocrine docs I’ve worked with (and there are a lot of them) or sports med, orthos, internists etc have ever been able to pull up a single conclusive study re: the use of OCPs & bone mineral restoration, so I tend to think that OCPs aren’t really useful in restoring ‘real’ periods without changes in intake.
Somewhat related– they’ve done studies that demonstrate even with short term caloric restriction (ie: hours to 1-2 days) you get an increase in urinary markers of bone turnover. To me, that’s a pretty impressive indicator that your body adapts amazingly quickly to not being fed properly. Anne Loucks (out of ohio university, I think) has some pretty interesting papers on the topic.
This statement: “See! You DON’T need that much food! Your metabolism is slower
Is about as reasonable as me thinking that because my bone density was so low, my goal weight should be lower. Riiiiight. I don’t know if it’s possible for you to think of metabolism as a dynamic thing, but that’s helped me– really thinking about the fact that I don’t *want* my body to have to cut off non-critical functions. Because um, personally, bones are important to me! Honestly, I’m really surprised at this study, just anecdotally, it seemed to me that the anorexics I know who’ve recovered had a higher metabolism post-ED, even after the obvious hyper-metabolic refeeding point. I hope that’s not ridiculously patronizing. It is so so so so hopelessly easy to find ‘reasons’ to eat less, to justify not eating more, to excuse whatever ‘quirks’ your body experiences.
I hope you’ll find something science-y that helps you make sense of this.
*I don’t mean to say you can be underweight & be fine– just that weight isn’t the most reliable indicator of health. It’s a proxy for ‘meeting your nutritional needs’ which would be really, really hard to assess at a large level. Person to person, if you have a great nutritionist I think it’s more manageable.
interesting article and commentary. both you grey, and above. i certainly don’t have any answers, just wanted to add that i took ocp’s and recently went off of them to see if i ovulate on my own. well let’s just say so far it’s been one period in six months. so, in this study of one, that whole “jump start” theory is bullshit. i think it covers up the problem, which could cause more problems with fertility later.
congrats on post 100
I was in the body composition study at NYSPI as one of the few low-weight anorexics who has a period NO.MATTER.WHAT.
Although I never started menstruating as an adolescent, I found a brief period of remission shortly around the time I was married. And although I still wasn’t having periods, I became pregnant (and didn’t find out until four months in … seeing as I didn’t think I was actively fertile).
While not diagnostically anorexic during the pregnancy itself, I lost weight following delivery while still nursing. We had two more children, and though my weight was lower each time, I continued to have periods. My weight has been as low as 64 pounds at 5’5, and I was having my period on the EDU.
The docs at Columbia theorized that my body found itself in a state of malnutrition but simultaneous pregnancy and lactation and reasoned: “Well, we’re pregnant; we’re nursing … we must be OK to engage in this function” … and re-set my setpoint.
Additionally, I always fear non-rebounding hypometabilism, especially as a woman past the age of 40, but I have always been hypermetabolic and slow to gain weight. I feel blessed to have the periods, because my bone density has survived more than 27 years of anorexia.
Like the previous commenter, I also have met many women in the hospital who became and remained hypermetabolic. Additionally, I believe the nature of the intake I do manage helps support some metabolic function better than other more non-nutritive choices might … and a sort of constant “tiny grazing” keeps some semblance of a fire burning.
It seems, from a purely anecdotal view, that patients who purge or have inconsistent intake behavior (vs. even “stable” restricting) seem to experience amenorrhea and other menstrual changes more quickly and more enduringly. I wonder if the behavior somehow kindles the brain and its chemicals in a way that creates metabolic “confusion” or chaos.
Interestingly, or baffling, the theory that I might be a “fat” anorexic (emaciated b/w/ a higher/normal percentage of body fat) has been disproven. So, I guess I am an anomoly but one who is among a significant enough population that the revised DSM ponders the inclusion of amenorrhea as diagostic criteria.
@guinea–
really interesting point, re: ‘chaotic’ disordered eating vs. ‘stable’ disordered eating. I didn’t have my period at relatively normal weights when I was purging, on/off with the meal plan etc, but at significantly lower weights, I still got my period. Maybe if you’re at a certain level, your body does readjust?
I’ve been mostly stable for about 2 years now, and still insanely hypermetabolic (circa 4500-5000 calories a day to maintain). Everyone thought that would decrease once I gained the weight back, but it didn’t. Genetically, I think i’m ‘blessed’ with a high metabolism, but yeah… not THAT high.
The other theory was that my body kept such a high metabolism to repair the bone damage I had (a zillion stress fractures) and the last time I had a DEXA, I’d gained 6% in my L-spine & 8% in my hip.
Endocrine stuff is crazy interesting to me… but probably *not* a good field for me to wind up in.
I wonder if the ‘balance’ of the diet matters too? I didn’t catch that the first time I read it, that the non-menstruating ones consumed a lower fat diet? Because when I wasn’t having my period, I lived mostly on protein shakes, and when I did get it while being underweight, I was following a relatively balanced diet (and often used that as see?! I’m not afraid of fat=not sick, duh).
Interestingly enough, studies have frequently shown that athletes who eat a low fat diet have a greater percentage of body fat– your body holds onto what’s scarce. So maybe in perceiving that scarcity of fat, they turn off the baby making machinery? Whereas those eating a normal fat diet don’t have more fat in their body composition, but their body knows it’s not scarce & keeps things functioning?
[I'm chylo-- just wasn't logged into my blog when i posted the first one]
Not that I’m totally impressed, but this is more than I expected when I stumpled upon a link on Digg telling that the info is quite decent. Thanks.
I also have had an ED for several years, through which, and actually before which, I was either amenorrheic or very irregular. I also consequently felt completely unsexy and was not interested in sex or sexual behavioral, in general. However, when I first became interested in sex, and was still ED, I began having my period. Basically, I am saying that, while the body composition and metabolism are certainly critical in the bodies threshold for sexual function, other factors can play in.
Thanks for discussing this. It is of major relevance in my life right now since i am trying to get pregnant but i fear that i have forever killed my menstrual cycle. I have never been underweight…always had a BMI of 22 -27 my whole adult life however i did have bulimia for 10 years. For the last 3 years of the bulimia, i was amenhorreic.
I quit bulimia through cognitive behaviour therapy and a lot of self-help one year ago. My weight has steadily increased up to where i am now, BMI 26. My periods are still not back.
I am making this comment to see if anyone else has been in my shoes.
My caloric intake when i became amenhorreic was certainly adequate as i was not losing weight. The makeup of those calories may not have been good. I never ate added oils, eggs, cheese, dairy, or meat. Instead, i stuck to soy products, vegetables, carbohydrates and tofu. So i got enought calories but perhaps not enough essential vitamins and fats. Also, I feel like all the purging affected my brain chemistry, to an extent. After every purge session, I would feel like i had taken a sedative….spaced out and very sleepy. I feel like there was a release of something (opiods maybe?) via the act of binging and purging which actively suppressed GNrH production and release.
I hope that this suppression is not permanent. Anyone with any first hand experience with this??
I’m facing the struggle of trying to resume menses without birth control hormones (because of several studies that indicate this doesn’t help with the bone density issue), and based on this discussion an others it looks like raising my REE is maybe the solution. But how??? I am a normal (or very slightly under) weight woman, but I think I developed and perpetuated my last year and half of amenorrhea through one longer and several short episodes of relatively minor caloric restriction (so yes, even a day or two can set things off-kilter depending on the individual). Does it follow logically that if I just keep the calories coming without restrictive episodes that it’ll eventually right itself out? Has anyone had experience with this? Also, I eat very little meat and dairy, but eat nuts and seeds and oils often…is the fat/protein from meat and dairy different in a crucial way for this particular problem?
Finally, exercise and strength training according to some studies are said to be good for raising REE (and helping with bone density), but this seems counter-productive to the goal of adding a little weight in fat not muscle that my doctor has suggested would be beneficial. However, last spring immediately following my training for a half marathon I had a very brief light period…so maybe the increased training had finally pushed my REE over the mark, but since I cut back after the race it went back down.
Any thoughts would be much appreciated.
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Calorie restriction is very important if you want to live longer since too much calories can cause insulin resistance. `.”;’Have a great day!
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