Calls for girls with eating disorders to be offered HRT to prevent osteoporosis

By Liam On Jul 8, 2023

Doctors are calling for some teenage girls with eating disorders to be given high-dose hormone replacement therapy (HRT) to stave off debilitating bone disease.

Young people with anorexia are three times more likely to develop weak bones and eventually develop osteoporosis, where their bones are fragile and likely to break.

This is due both to the lack of bone-promoting vitamins in their diets – including calcium-rich dairy products – and to the depletion of the female sex hormone estrogen, which is crucial for bone tissue growth and repair.

Low body weight can cause the ovaries to stop producing the reproductive hormones estrogen, progesterone and testosterone, causing the menstrual cycle to stop, known as amenorrhea.

Young people with anorexia are three times more likely to develop weak bones and eventually develop osteoporosis, where their bones are fragile and likely to break

Now a group of GPs and hormone specialists have published a report showing that HRT – usually given to menopausal women to boost their naturally declining levels of estrogen and progesterone – can help protect bones in girls aged 15 and over.

But eating disorder campaigners have warned that the treatment could lead to unpleasant side effects and even hinder the girls’ long-term recovery.

“I was presented with this by my GP last year – and it is horrific,” says eating disorder campaigner and former patient Hope Virgo. ‘It’s a quick fix, but puts a Band-Aid on the eating disorder patients [feel they] don’t have to recover well because they use medication.’

At least 1.2 million people in the UK live with an eating disorder. Anorexia – the deadliest of all eating disorders – is characterized by low body weight and an unhealthy obsession with food and body image.

Anorexia patients prescribed HRT told The Mail on Sunday of intense fatigue, brain fog and heavy bleeding, which they believe was caused by the treatment. “I felt like I had been hit by a bus. Never again,” said a 28-year-old.

And eating disorder specialists have raised concerns that the treatment could harm young bones by stopping the natural growth process.

‘If you give too much estrogen during adolescence, the ends of bones can fuse together before they reach their full length,’ says Dr Darren Cutinha, child and adolescent psychiatrist at South London and Maudsley NHS Foundation Trust.

Bones continue to grow and develop during adolescence and early adulthood, while most anorexics develop the condition between the ages of 12 and 25. About 40 percent of them will develop osteoporosis.

Dr. Laura Flexer, a general practitioner specializing in menopause and co-author of the new report on the use of HRT in anorexic patients, published in the journal Post Reproductive Health, says: ‘We have found that a number of menopausal women develop severe osteoporosis much earlier than others. In some cases, these women have a history of eating disorders.

“Broken and broken bones are serious — one in five dies in the year following a hip fracture from complications.”

NHS watchdog the National Institute For Health and Care Excellence (NICE) offers vague instructions for GPs, recommending that they ‘consider’ giving anorexia patients an estrogen patch. But of the 57 patients in Dr. Flexer was not offered any HST.

I thought, I don’t have to change with HRT

Samantha Matthews was diagnosed with anorexia ten years ago at the age of 20.

Within four years, she had developed osteoporosis in her spine and hips – a result of a lack of vital nutrients and hormones in her bones.

A hormone expert prescribed a tablet of combined HRT – estrogen and progesterone – daily. Samantha, a London-based psychologist, says taking the pills for four years stopped her bones from deteriorating, but it didn’t help her recover from her eating disorder.

“I stayed underweight the whole time,” she says. “Part of me thought if I take this drug, it means I don’t have to change.”

Samantha stopped taking the pills two years ago. ‘My last scan showed that my bones have not deteriorated since I started taking HRT.’

But she adds: ‘I’ve also gained weight since then – and I’m healthy now – so it’s hard to know if it was the pills or the diet. Still, I’m glad I took HRT and I’d advise others to ask if they need it.’

‘The guidance is so thin that it ends up being a postcode lottery,’ says Dr Flexer, who presented her report at the British Menopause Society’s annual conference. “Some specialist centers offer HRT to adolescent girls, but most don’t.”

Some patients are advised to take the combined contraceptive pill. However, studies show that it is of little help, as the type of estrogen it contains is different from the kind produced naturally by the body.

But a number of small studies have shown that giving estrogen to underweight patients can restore bone density to normal levels. A Harvard Medical School trial involving 110 teens with eating disorders found that using a patch of 100 mcg estrogen twice a week, along with increasing doses of progesterone over 18 months, increased bone strength in the hips and spine in compared to those who did not receive the hormones.

Those taking HRT were found to have healthy bone density.

Dr. Flexer says the ideal dose for anorexics is a 100 mcg estrogen patch replaced twice a week — the maximum allowable dose — combined with progesterone taken daily for two weeks, followed by two weeks of rest.

But dr. Cutinha shares campaigners’ concerns about the potential risks of HRT for long-term recovery.

“It can undermine the message that food is the key to getting better,” he says. “Medications that mask the symptoms of an eating disorder can give patients a false sense of security.”

Dr. Cutinha adds that the evidence that HRT protects bones in anorexia is limited and it may be only “partially beneficial.” “We don’t have enough to prove that the benefits outweigh the risks,” he says. ‘In order to get optimal bone strength, young people should eat all the different food groups in combination with weight recovery. This combination gets the body’s natural hormones working and helps the bones to recover.’