Female Hormones: The Missing Link to Eating Disorders?
Written by Kasia Kalinowska and Elizabeth Gordon
A recent article staked a heavy claim that Novo Nordisk’s drug, Wegovy, and others soon to be on the market, could improve the lives of millions by ending obesity.
Published during National Eating Disorder Awareness Week, the article highlighted a few celebrities, who would not be considered obese, flaunting the use of the drug to lose weight.
"Off-label” drug use for weight loss isn't new. However, the emergence of telehealth companies and online prescription services makes it easier for non-diabetic or obese people to access them.
Using before-and-after photos to “prove” substantial weight loss, advertisements run by these digital health startups can wind up in the hands of people without clinical indications for the drugs — leading to problems like body dysmorphia or eating disorders.
Given this growing market of diabetes-turned-weight loss drugs, we wanted to bring awareness back to the severity and prevalence of eating disorders among the female population and discuss new research into the causes of this condition.
The Eating Disorder Landscape: Prevalence and New Research Directions
Eating disorders are complex mental illnesses characterized by disturbances in behaviors to eating and thoughts or emotions about body weight or shape.
An estimated 9% of people worldwide suffer from anorexia nervosa, bulimia nervosa, binge-eating disorder, or other eating disorders—and the overwhelming majority of those people are women.
Eating disorders are the second most fatal of all mental illnesses. The mortality rate for people with eating disorders is up to six times higher than that for people without them.
Additionally, those suffering from anorexia nervosa are 18 times more likely to commit suicide.
A female’s mental and physical health can be impacted by an eating disorder throughout her life—starting as early as childhood.
According to the National Eating Disorder Association (NEDA), 35–57% of adolescent girls are estimated to engage in crash dieting, fasting, self-induced vomiting, or taking diet pills or laxatives.
Risk factors for developing an eating disorder involve a complex mix of biological, psychological, and sociocultural issues.
Scientists have begun to accept that, while genetic predispositions and comorbid mental health conditions are the tinder, societal pressure to achieve thinness is the match.
New research, however, suggests a new factor clinicians and patients need to take into account: reproductive hormones may also play a significant role in the activation of disordered eating behaviors.
The Impact of Eating Disorders on the Female Body
Having an eating disorder can affect nearly every organ system in the body and have long-lasting effects on a women’s physical, mental, and emotional well-being.
Hormones
Eating disorders affect female hormones by causing endocrine damage—especially when it comes to the malnourishment associated with anorexia nervosa.
Hormone issues associated with eating disorders can include:
Hypothalamic amenorrhea—or menstrual disruption
Nutritionally-acquired growth hormone resistance
Hypercortisolemia
Decreases in leptin, insulin, amylin, and incretins
Increases in ghrelin, PYY and adiponectin
Of note, approximately one-quarter of women diagnosed with type one diabetes will develop an eating disorder. The most common pattern is skipping insulin injections, known as diabulimia, which can be deadly.
Bone Health
Hormone changes and nutritional deficiencies harm bone health. The loss of bone density some eating disorder patients experience can lead to life-long health issues such as early-onset osteoporosis, which may not be reversible for some.
Females already have an elevated risk of developing osteoporosis during their lifetime. In fact, 1 in 4 women over age 65 are estimated to be affected by bone loss. Eating disorders make this risk worse, especially for younger women.
Mental Health
Eating disorders can perpetuate a vicious cycle of mental health challenges. Most eating disorder patients also have co-occurring mental health conditions—including anxiety, major depression, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and substance use disorder.
Having a pre-existing mental health condition may lead them to develop an eating disorder, which can worsen (or cause new) mental health conditions.
While it’s long been understood that eating disorders cause hormonal, bone, and mental health changes, recent studies suggest that female biology, and specifically, periods of hormonal flux such as puberty and menopause, may be responsible for the activation of an eating disorder.
Hormonal Effects on Eating Behaviors
Recent research on the effects of hormones on eating behaviors suggests that female reproductive hormones may contribute to changes in body weight, shape, and eating behaviors directly.
In particular, estradiol and progesterone (in the presence of estradiol) may play more of a role in eating disorder development than previously thought.
Here’s how researchers think this may work:
During the premenstrual period, progesterone levels are high, and post-puberty females tend to eat more food per meal. As a female’s estrogen levels rise through the follicular phase through to periovulation, food intake per meal is shown to decrease.
Estradiol seems to have a satiating effect, resulting in less food intake, whereas progesterone in the presence of estradiol is thought to increase appetite.
Women with anorexia have been reported to have decreased estrogen and progesterone levels overall—closer to the concentrations of post-menopausal women.
These reproductive hormones may also be in play when it comes to eating disorders’ psychological symptoms. Decreased estradiol and increased progesterone was found in women reporting body dissatisfaction and a drive for thinness.
But the picture gets more complicated when we look at other eating disorders—and the fluctuation of symptoms through the menstrual cycle.
In women with bulimia, binge eating appears to increase when there’s less estradiol—perhaps indicating less of that satiating effect.
It’s clear that there’s a fascinating—and potentially clinically significant—link between female sex hormones, eating behaviors, and eating disorders.
More research must be done to better uncover how this link can be used to help eating disorder patients.
Hormonal Fluctuations Influence on Eating Disorders
Given these findings about eating disorder symptoms and female reproductive hormones, it’s not far-fetched to imagine that periods of hormonal change may trigger eating disorder onset or relapse.
Menstruation
Puberty—and for girls, menarche—is seen as a high-risk time for eating disorder onset. But what many women may not realize is that eating disorder symptoms can fluctuate within the menstrual cycle.
This trend has particularly been noted with binge eating, body dissatisfaction, and the drive for thinness. For women with bulimia, these symptoms appear to increase in the luteal (premenstrual) phase.
Pregnancy and Postpartum
Pregnancy can be a complicated time for eating disorder recovery. Some females may experience an increase in symptoms (or even relapse from recovery), while others may experience pregnancy as a temporary period of eating disorder remission.
One study has shown that the trimester-by-trimester progression of pregnancy is associated with a decrease in bulimic symptoms—which then often returns postpartum.
Pregnancy also appears to be a period of risk for a new onset of binge-eating disorder.
The answer to how and why this happens is multifaceted. The most obvious initial answer is that bodily changes that occur with pregnancy can trigger complicated feelings about weight gain, body shape, and size—especially for women with a history of eating disorders. But female sex hormones also appear to play a role.
During pregnancy, both estradiol and progesterone levels continue to increase until childbirth, when they abruptly drop. It’d be safe to assume that the association between eating disorder symptoms and the levels of these hormones may impact eating disorder onset, remission, or relapse.
However, given how much variety there is between women—and between eating disorders—more research is needed to better understand this link for pregnant women.
Additionally, since many people with eating disorders also have other mental health conditions, the risk of developing postpartum depression may be higher in those with a history of disordered eating behaviors.
Menopause
As with pregnancy, bodily changes associated with menopause can trigger negative body image and eating disorder onset. This time of hormonal change may even mirror puberty in being a “window of vulnerability” for eating disorder development.
One study has suggested that menopause may be associated with the onset of orthorexia nervosa since women in this life stage are more likely to be anxious about their body image and health. However, more studies of eating disorders and disordered eating behaviors in women in menopause are needed to better assess how and why this may occur.
Eating Disorder Gaps in Care + Treatment
With the many fascinating (and troubling) connections researchers have found between eating disorders and women’s hormones thus far, it’s clear more research must be done to fully understand the link between female hormones and disordered eating.
Additionally, we encourage more research on how currently available hormone treatments could help prevent or treat eating disorders.
For example, studies to date on using estrogen, such as that found in birth control to treat eating disorders have focused on improving bone mass and density or improving the symptoms of bulimia. While hormone replacement itself is not a sufficient treatment for females with an eating disorder, when combined with additional treatments, it’s possible that it would improve outcomes.
Despite relatively high awareness of this condition in the US, due to clinical bias and expected norms of what an eating disorder may look like, many people are being overlooked for diagnosis.
This is a familiar issue for women’s health. For many health conditions—from polycystic ovary syndrome (PCOS) to heart attacks—women are often required to get to a critical level in disease progression before they’re diagnosed or given care.
With eating disorders, the disparity in diagnosis disproportionately impacts BIPOC, males, and people who do not “look” underweight. Anorexia in people with larger bodies is a critically undiagnosed and untreated issue.
Even for patients who do receive an eating disorder diagnosis and qualify for traditional treatment, there are still many gaps in care.
The current clinical gold standard for eating disorder treatment is largely based on individual psychotherapeutic or psychiatric care. It can range from outpatient care for patients who don’t require daily monitoring to residential or even inpatient care.
This care is expensive—with monthly costs in the 4- and 5-figures—and is often not covered by insurance. NEDA cites many reasons for treatment coverage rejection—including a patient’s weight not being low enough or a patient not progressing in treatment.
Eating disorders are notoriously difficult to treat. Further exploration into how and why female hormones cause a significantly higher risk of the onset of this condition could improve our ability to predict, diagnose, and treat people with disordered eating behaviors.
Innovation in Eating Disorder Treatment
Over the past few years, eating disorder advocates have gotten more health innovators involved in addressing the gaps in care for eating disorder patients.
Organizations like Project Heal raise funds to help those suffering from an eating disorder afford treatment and help rally more funding for research and innovation.
In the digital health space, apps like Recovery Record and telehealth platforms like Equip are working to decentralize and increase access to eating disorder care, bringing it directly to patients and families.
Arise is redefining what counts as treatment, including peer support and mentorship in a comprehensive virtual care platform.
Many of these startups place affordability front and center in their treatment offerings. Arise is currently working to expand its coverage network, and helps facilitate their members’ connection to coverage—with no self-pay option currently available.
However, insurance coverage still acts as a gateway to care with these companies, even with their more accessible and inclusive approaches.
Tackling the barriers to diagnosis, Arise is also focusing on opening up treatment to patients who haven’t been able to receive a formal diagnosis.
That’s why another important area to watch in eating disorder innovation is self-led prevention and recovery tools, such as Way, an app that helps users practice the principles of intuitive eating to combat and heal from disordered eating behaviors.
Overall, as innovation chips away at the care gaps that continue to exist for eating disorder patients, we’re eager to see more women access the care they need to heal and thrive.
Improving our understanding of the complex interaction between female biology, the significance of and sensitivity to fluctuating female hormones, and the implications of the lived female experience may be the key to improving diagnosis and treatment for eating disorders.
We, at FemHealth Insights, see the opportunity for more research into the multi-layered effects of eating disorders and the hormonal changes experienced by females as integral to understanding the causes and treatment of such a pervasive condition.
Innovations that will help identify, monitor, and support females at risk of or currently suffering from an eating disorder should incorporate wearables as well as cycle and hormone tracking.
This clinical knowledge in women’s hands can help those suffering from eating disorders or disordered eating understand how to work with their bodies to support a strong recovery.
Companies to Watch
Arise — This eating disorder virtual care platform, founded by two eating disorder patients, provides professional mentorship and peer support all in one digital place.
Bodiac - An educational app that coaches teens through bodily changes experienced through puberty to boost body acceptance level.
Equip — Founded by Project Heal’s Kristina Saffran, this startup’s telehealth platform provides family-based eating disorder care.
Recovery Record — An app that facilitates eating disorder treatment, geared towards providers such as dietitians.
Way — An app that helps users implement the practices of intuitive eating to combat and heal from disordered eating behaviors
About the Authors:
Kasia Kalinowska is an eating disorder survivor and Healthtech writer who helps medical innovators reach their audience online and bust health stigma along the way.
Elizabeth Gordon is a Femtech writer and content strategist, and Chief Marketing Officer of FemHealth Insights and the FemTech Focus podcast.
