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The Role of Hormones in Bone Health
Contributed by: Melanie Schorr, MD, Endocrinologist at Harvard Medical School/Massachusetts General Hospital
Bone loss is an important health concern in anorexia nervosa because it is common and can be severe. The causes of bone loss in anorexia nervosa are complex. There are a number of hormones important for bone health that are under the control of the hypothalamus and pituitary, which are two small glands near the brain.
1. Estrogen
The most well-recognized hormone complication of anorexia nervosa is low estrogen levels that result in absence of menstrual periods, which occurs in many, but not all, girls and women with anorexia nervosa.The cause of the low estrogen levels is decreased signaling from the hypothalamus and pituitary to the ovaries. The decreased signaling is due to the physical and psychological stress of an eating disorder — low weight, low percent body fat, and low levels of hormones that signal appropriate energy availability may all contribute (Grinspoon et al., 1996).
The set-point for decreased signaling that results in low estrogen levels may be different for different women, so that some women with low weight do not have menstrual periods, whereas others of similar weight have menstrual periods (Miller et al., 2004). Low estrogen levels are associated with bone loss (Klibanski et al., 1995). Weight recovery that results in resumption of menstrual periods is important to prevent further bone loss, and regain some bone mass (Miller et al., 2006). There is no convincing data that estrogen in the form of oral contraceptive pills alone increases bone density in women with anorexia nervosa, but it may help in preventing further bone loss (Grinspoon et al., 2007). Lower replacement doses of transdermal estrogen (to mimic puberty) with cyclic progesterone may be more effective in increasing bone density in adolescent girls (Misra et al., 2011), but do not normalize bone density. Studies are further investigating the effects of estrogen replacement on bone health.
2. Testosterone:
Low testosterone in men with anorexia nervosa is also due to decreased signaling from the hypothalamus and pituitary. Low testosterone levels in men are known to be associated with low bone density just as low estrogen levels are in women (Misra et al., 2008). Weight recovery that results in normalization of testosterone levels is an important treatment goal in men as it is in women.
3. Growth hormone (GH)/ insulin-like growth factor 1 (IGF-1):
Growth hormone is secreted by the pituitary, and stimulates the liver to make IGF-1. Anorexia nervosa is a state of GH resistance, meaning that the liver cannot respond to GH and make adequate amounts of IGF-1 (Stoving et al., 2007). IGF-1 levels are therefore low in women and men with anorexia nervosa, and lower IGF-1 levels are associated with lower bone density (Lawson et al., 2010). Studies suggest that IGF-1 levels increase with weight recovery (Stoving et al., 2007). Studies are currently investigating the effect of IGF-1 replacement on bone health.
4. Cortisol:
Anorexia nervosa is associated with increased signaling from the hypothalamus and pituitary to the adrenal glands. Mean blood cortisol levels are elevated in women with anorexia nervosa (Lawson et al. 2009). Higher cortisol levels are associated with more bone loss in anorexia nervosa (Lawson et al., 2009). Some studies suggest that cortisol levels normalize with recovery from the eating disorder (Doerr 1980).
Further studies are needed to determine how to optimize bone mineral density in anorexia nervosa. Improving health, particularly bone health, in patients with anorexia nervosa is a key mission of the Neuroendocrine Unit at Massachusetts General Hospital. If you are interested in learning more about our bone health studies, please click on our attached banner. We look forward to hearing from you.
Community Discussion – Share your thoughts here!
In what ways, can we as an eating disorder community, come together to support further studies on optimizing bone health mineral density in anorexia nervosa? What steps have you made to increase awareness?
About the author: Dr. Melanie Schorr is an Endocrine Fellow in the Neuroendocrine Unit at Massachusetts General Hospital, which is affiliated with Harvard Medical School. After graduating from Dartmouth College in 2006, she attended Johns Hopkins University School of Medicine, and went on to complete her internal medicine residency at Brigham and Women’s Hospital in 2013. She sees patients in the Neuroendocrine Clinical Center at Massachusetts General Hospital, and her research interests include skeletal health in
women with eating disorders.
References:
[1]: Doerr, P., Fichter, M., Pirke, K., & Lund, R. Relationship between weight gain and hypothalamic pituitary adrenal function in patients with anorexia nervosa. (1980). Journal of Steroid Biochemistry. 13, 529-537.[2]: Grinspoon, S., Gulick, T., Askari, H., Landt, M., Lee, K., Anderson, E., Ma, Z., Vignati, L., Bowsher, R., Herzog, D., & Klibanski, A. (2000). Serum leptin levels in women with anorexia nervosa. Journal of Clinical Endocrinology and Metabolism, 81, 3861-3863.
[3]: Grinspoon, S., Miller, K. K., Herzog, D., Clemmons, D., & Klibanski, A. (2003). Effects of recombinant human insulin-like growth factor (IGF)-1 and estrogen administration on IGF-1, IGF binding protein (IGFBP)-2, and IGFBP-3 in anorexia nervosa: a randomized-controlled study. Journal of Clinical Endocrinology and Metabolism, 88, 1142-1149.
[4]: Klibanski, A., Biller, B. M., Schoenfeld, D. A., Herzog, D. B., & Saxe V. C. (1995). The effects of estrogen administration on trabecular bone loss in young women with anorexia nervosa. Journal of Clinical Endocrinology and Metabolism, 80, 898-904.
[5]: Lawson, E. A., Donoho, D., Miller, K. K., Misra, M., Meenaghan, E., Lydecker, J., Wexler, T., Herxog, D. B., & Klibanski, A. (2009). Hypercortisolemia is associated with severity of bone loss and depression in hypothalamic amenorrhea and anorexia nervosa. Journal of Clinical Endocrinology and Metabolism, 94, 4710-4716.
[6]: Lawson, E. A., Miller, K. K., Bredella, M. A., Phan, C., Misra, M., Meenaghan, E., Rosenblum, L., Donoho, D., Gupta, R., & Klibanski, A. (2010). Hormone predictors of abnormal bone microarchitecture in women with anorexia nervosa. Bone, 46, 458-463.
[7]: Miller, K. K., Grinspoon, S., Gleysteen, S., Grieco, K. A., Clampa, J., Breu, J., Herzog, D. B., & Klibanski, A. (2004). Preservation of neuroendocrine control of reproductive function despite severe undernutrition. Journal of Clinical Endocrinology and Metabolism, 89, 4434-4438.
[8]: Miller, K. K., Lee, E. E., Lawson, E. A., Misra, M., Minihan, J., Grinspoon, S. K., Gleysteen, S., Mickley, D. Herzog, D., & Klibanski, A. (2006). Determinants of skeletal loss and recovery in anorexia nervosa. Journal of Clinical Endocrinology and Metabolism, 91, 2931-2937.
[9]: Misra, M., Katzman, D. K., Cord, J., Manning, S. J., Mendes, N., Herzog, D. B., Miller, K. K., Klibanski, A. (2008). Bone metabolism in adolescent boys with anorexia nervosa. Journal of Clinical Endocrinology and Metabolism, 93, 3029–3036.
[10]: Misra, M., Katzman, D., Miller, K. K., Mendes, N., Snelgrove, D., Russell, M., Goldstein, M. A., Ebrahimi, S., Clauss, L., Weigel, T., Mickley, D., Schoenfeld, D. A., Herzog, D. B., & Klibanski, A. (2011) Physiologic estrogen replacement increases bone density in adolescent girls with anorexia nervosa. Journal of Bone and Mineral Research, 26, 2430-2438.
[11]: Stoving, R. K., Chen, J. W., Glintbord, D., Brixen, K., Flyvbjerg, A., Horder, K., & Frystyk, J. Bioactive insulin-like growth factor (IGF) I and IGF-binding protein-1 in anorexia nervosa. (2007). Journal of Clinical Endocrinology and Metabolism. 92(6), 2323-2329.
The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer discussion of various issues by different concerned individuals.
We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.
Last Updated & Reviewed By: Jacquelyn Ekern, MS, LPC on April 27, 2016
Published on EatingDisorderHope.com
