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

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

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

This is due to both the lack of bone-boosting vitamins in their diet – including calcium-rich dairy foods – and the depletion of the female sex hormone oestrogen, which is crucial for the growth and repair of bone tissue.

Low bodyweight can trigger the ovaries to stop producing the reproductive hormones oestrogen, progesterone and testosterone, and as a result the menstrual cycle stops, known as amenorrhea.

Youngsters with anorexia are three times more likely to develop weak bones, eventually developing into osteoporosis, where their bones are fragile and likely to break

Youngsters with anorexia are three times more likely to develop weak bones, eventually developing into osteoporosis, where their bones are fragile and likely to break

Now a group of GPs and hormone specialists have published a report that highlights evidence showing that HRT – usually given to menopausal women to boost their naturally flagging levels of oestrogen and progesterone – can help protect the bones in girls as young as 15.

But eating disorder campaigners have warned that the treatment can result in unpleasant side effects and may even hinder the girls’ long-term recovery.

‘I was offered this last year by my GP – and it’s appalling,’ says eating disorder campaigner and former patient Hope Virgo. ‘It is a quick fix but sticks a plaster on the eating disorder – patients [feel they] don’t have to recover properly because they’re on medication.’

At least 1.2 million people in the UK live with an eating disorder. Anorexia – the deadliest of all eating disorders – is characterised by low bodyweight as well as 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’d been hit by a bus. Never again,’ said one 28-year-old.

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

‘If you give too much oestrogen in adolescence, the ends of bones could fuse together before reaching full length,’ says Dr Darren Cutinha, consultant child and adolescent psychiatrist at South London and Maudsley NHS Foundation Trust.

Bones continue to grow and develop through adolescence and early adulthood, while most anorexia patients develop the condition between 12 and 25. About 40 per cent of them will go on to develop osteoporosis.

Dr Laura Flexer, a GP specialising in menopause and a co-author of the new report into the use of HRT for anorexia patients, which was published in the journal Post Reproductive Health, says: ‘We noticed that a number of menopausal women develop severe osteoporosis much earlier than others. In some cases, these women have a history of eating disorders.

At least 1.2 million people in the UK live with an eating disorder. Anorexia ¿ the deadliest of all eating disorders ¿ is characterised by low bodyweight as well as an unhealthy obsession with food and body image

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

‘Broken and fractured bones are serious – one in five will die in the year following a hip fracture due to complications.’

NHS watchdog the National Institute For Health and Care Excellence (NICE) offers vague instructions for GPs, recommending they ‘consider’ giving anorexia patients an oestrogen patch. But of the 57 patients in Dr Flexer’s report, none were offered HRT.

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

Samantha Matthews  was diagnosed with anorexia a decade ago, aged 20.

Within four years she’d developed osteoporosis in her spine and hips – a result of her bones being starved of vital nutrients and hormones.

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

‘I continued to be underweight throughout,’ she says. ‘A part of me thought that, if I take this medication, it means that I don’t have to change.’

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

But she adds: ‘I’ve also put on weight since then – and I’m now healthy – so it is difficult to know whether it was the pills or the nutrition. Even so, I’m glad I took HRT and recommend others ask for it if they need it.’

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

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

But a number of small studies have shown that giving oestrogen to underweight patients can restore bone density to normal levels. One trial at Harvard Medical School involving 110 teenagers with eating disorders found that using a 100 mcg patch of oestrogen twice a week, along with increasing doses of progesterone for 18 months, boosted bone strength in the hips and spine compared with those not given the hormones.

Those on HRT were found to have healthy bone density.

Dr Flexer says the ideal dose for anorexia patients is a 100 mcg oestrogen patch changed twice a week – the maximum licensed dose – combined with progesterone taken daily for a fortnight, followed by two weeks off.

But Dr Cutinha shares campaigners’ concerns about the potential risks from HRT to long-term recovery.

‘It can undermine the message that food is key for getting better,’ he says. ‘Medication that masks the symptoms of eating disorders can give patients a false sense of security.’

Dr Cutinha adds that the evidence that HRT protects bones in anorexia is limited, and that it may be only ‘partially beneficial’. ‘We don’t have enough to prove the benefits outweigh the risks,’ he says. ‘For bones to reach optimal strength, young people need to eat all the different food groups in combination with weight restoration. This combination allows the body’s natural hormones to start working and helps bones recover.’

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