The reproductive endocrine consequences of anorexia nervosa

"It is more isolating to patients if you aren't familiar with the resources": a pilot test of a clinician sensitivity training on eating disorders in pregnancy

It is more isolating to patients if you aren't familiar with the resources: A pilot test of a clinician sensitivity training on eating disorders in pregnancy.(IRB Number: 1909705198).Background Pregnant women with a history of eating disorders (EDs) or active EDs have greater maternal and child health complications. They are also unlikely to disclose their history with an ED to their clinician, few of which are confident in their knowledge to provide appropriate care for patients who present with EDs. This study's goal was to evaluate changes to knowledge, behavior, and attitudes for health professionals who were part of a sensitivity training (to provide information of and awareness, address potential clinician biases, and offer strategies for more patient-centered care with de-stigmatizing language) about eating disorders and pregnancy compared with those who received a reference document.Methods Our pilot study compared responses of health professionals before and after this sensitivity training (N = 54) with a group who were provided a clinician reference document about the same topic (N = 61).Results Mann-Whitney Wilcoxon tests showed significant differences between the sensitivity training and reference document groups, with the sensitivity training resulting in increases to participants' perception of ED's relevance to overall treatment (p = 0.018), comfort in providing resources (p < 0.0001), frequency of ability to introduce strategies (p = 0.001), and interest in additional strategies/recommendations in treating patients with eating disorders (p = 0.009). Thematic analysis of the open-ended responses indicated four major themes: Resources and support, Treatment, Additional training, and Clinician Strategies. Discussion Results indicated that the sensitivity training improved training outcomes compared to the reference document group. Qualitative responses from both groups indicated four themes that can help inform ED-centered care. This study provides context for future directions for continuing education courses as well as clinical training recommendations for treating pregnant patients with EDs.

Body-fat sensor triggers ribosome maturation in the steroidogenic gland to initiate sexual maturation in Drosophila

Fat stores are critical for reproductive success and may govern maturation initiation. Here, we report that signaling and sensing fat sufficiency for sexual maturation commitment requires the lipid carrier apolipophorin in fat cells and Sema1a in the neuroendocrine prothoracic gland (PG). Larvae lacking apolpp or Sema1a fail to initiate maturation despite accruing sufficient fat stores, and they continue gaining weight until death. Mechanistically, sensing peripheral body-fat levels via the apolipophorin/Sema1a axis regulates endocytosis, endoplasmic reticulum remodeling, and ribosomal maturation for the acquisition of the PG cells' high biosynthetic and secretory capacity. Downstream of apolipophorin/Sema1a, leptin-like upd2 triggers the cessation of feeding and initiates sexual maturation. Human Leptin in the insect PG substitutes for upd2, preventing obesity and triggering maturation downstream of Sema1a. These data show how peripheral fat levels regulate the control of the maturation decision-making process via remodeling of endomembranes and ribosomal biogenesis in gland cells.

Menstrual Disorders Related to Eating Disorders

Eating disorders (ED) are associated with multiple physical complications that strongly affect the physical health of these young and fragile patients and can also cause significant mortality, the highest among psychiatric pathologies. Among the various organic complications, albeit still little known, the gynecological implications, up to infertility, are very widespread. Among adolescent and adult patients, gynecological symptoms can be very widespread and range from menstrual irregularities to amenorrhea, from vaginitis to ovarian polycystosis, up to complications during the gestational phase and postpartum, in addition to the possible consequences on the unborn child. Among the most frequent and significant gynecological disorders in women with ED, there are menstrual irregularities that may occur with oligomenorrhea or even amenorrhea. , Although no longer part of the DSM-5 diagnostic criteria for defining anorexia nervosa (AN), this symptom must be considered a very relevant event in the overall evaluation of young women and adolescents with eating disorders. Functional hypothalamic amenorrhea in ED patients is related to psychological distress, excessive exercise, disordered eating, or a combination of these factors, which results in suppression of the hypothalamic-pituitary-ovarian axis, and consequently, hypoestrogenism. This paper has the objective to summarize the causes and the mechanism underlying menstrual disorders and provide a better understanding of the correlation between the reproductive system and the mechanisms that regulate food intake and eating habits. In addition, early recognition of risk factors for eating disorders for gynecological implications can help put more accurate assessments of patients to prevent potentially fatal complications. The importance of the involvement of specialist gynecologists in the multidisciplinary team that has to follow patients with eating disorders is also discussed.

Lifestyle in urology: Benign diseases

Modifiable lifestyle-related risk factors are the object of increasing attention, with a view to primary and tertiary prevention, to limit the onset and development of diseases.Also in the urological field there is accumulating evidence of the relationship between urological diseases and lifestyle-related risk factors that can influence their incidence and prognosis. Risk factors such as nutrition, physical activity, sexual habits, tobacco smoking, or alcohol consumption can be modified to limit morbidity and reduce the social impact and the burdensome costs associated with diagnosis and treatment.This review synthesizes the current clinical evidence available on this topic, trying to satisfy the need for a summary on the relationships between the most important lifestyle factors and the main benign urological diseases, focusing on benign prostatic hyperplasia (BPH), infections urinary tract (UTI), urinary incontinence (UI), stones, erectile dysfunction, and male infertility.

Effects of blood pathological changes before TAI on pregnancy of dairy cows with anestrus and estrus

ABSTRACT The objective of this study was to investigate the influence of plasma pathological changes before timed artificial insemination (TAI) on pregnancy of cows. The contents of estrogen (E2), progesterone (P4), glucose (Glu), selenium (Se), brain-derived neurotrophic factor (BDNF), and histamine (HIS) in plasma of 48 Holstein cows were measured before TAI. According to the estrus detection, the cows were divided into estrus (E) and anestrus (A) groups. After pregnancy testing at 28 d after TAI, two groups of E and A were divided into positive pregnancy of E group (EP+), negative pregnancy of E group (EP-), positive pregnancy of A group (AP+), and negative pregnancy of A group (AP-). The contents of E2, P4, Glu, Se, BDNF and hIS significantly differed among the four groups (P<0.01). The ROC analysis was used to determine the risk of negative pregnancy test (-) after TAI was increased when plasma E2 was less than 46.45 pmol/L in cows before TAI. The changes in E2, P4,hIS, Glu, and BDNF in the blood of natural estrus and natural anestrus cows affected the pregnancy after TAI. the level of E2 in plasma may be used to assess the risk of negative pregnancy after TAI.

Kisspeptin-52 partially rescues the activity of the hypothalamus-pituitary-gonadal axis in underweight male rats dosed with an anti-obesity compound

Energy metabolism and reproduction are closely linked and reciprocally regulated. The detrimental effect of underweight on reproduction complicates the safety evaluation of anti-obesity drugs, making it challenging to distinguish pathological changes mediated through the intended drug-induced weight loss from direct drug effects on reproductive organs. Four-weeks dosing of normal weight Sprague Dawley rats with a glucagon-like peptide 1 (GLP-1)/glucagon receptor co-agonist induced a robust weight loss, accompanied by histological findings in prostate, seminal vesicles, mammary glands, uterus/cervix and vagina. Characterization of the hypothalamus-pituitary-gonadal (HPG) axis in male rats revealed reduced hypothalamic Kiss1 mRNA levels and decreased serum luteinizing hormone (LH) and testosterone concentrations following co-agonist dosing. These alterations resemble hypogonadotropic hypogonadism typically seen in adverse energy deprived conditions, like chronic food restriction. Concomitant daily administration of kisspeptin-52 from day 21 to the end of the four-week co-agonist dosing period evoked LH and testosterone responses without normalizing histological findings. This incomplete rescue by kisspeptin-52 may be due to the rather short kisspeptin-52 treatment period combined with a desensitization observed on testosterone responses. Concomitant leptin treatment from day 21 did not reverse co-agonist induced changes in HPG axis activity. Furthermore, a single co-agonist injection in male rats slightly elevated LH levels but left testosterone unperturbed, thereby excluding a direct acute inhibitory effect on the HPG axis. Our data suggest that the reproductive phenotype after repeated co-agonist administration was driven by the intended weight loss, however, we cannot exclude a direct organ related effect in chronically treated rats.

The effect of underweight on female and male reproduction

Chronic energy deficiency can impair the hypothalamic-pituitary-gonadal (HPG) axis and lead to hypothalamic anovulation in underweight women. This review presents the syndromes related to underweight status that are associated with infertility, summarizes the underlying mechanisms, and reviews the available treatment options. Eating disorders, such as anorexia nervosa (AN), constitute the most common cause of infertility in underweight women, who, in addition, experience miscarriages, and sexual dysfunction. The relative energy deficiency in sports (RED-S; former terminology: athlete's triad) involves menstrual dysfunction due to low energy availability, which results in anovulation. Moreover, lipodystrophies, malnutrition, starvation, systematic illnesses (malignancies, endocrinopathies, infectious diseases, advanced chronic diseases, neurologic illnesses), and the utilization of drugs can cause excessive weight loss. They may result in fertility problems due to the loss of adipose tissue and the subsequent hormonal disturbances. Each of these conditions requires multidisciplinary management. Nutritional counseling should target the restoration of energy balance by increasing intake and reducing output. Medical treatment, recommended only for patients who did not respond to standard treatment, may include antipsychotics, antidepressants, or leptin administration. Finally, psychiatric treatment is considered an integral part of the standard treatment.

Mental health dished up-the use of iPSC models in neuropsychiatric research

Genetic and molecular mechanisms that play a causal role in mental illnesses are challenging to elucidate, particularly as there is a lack of relevant in vitro and in vivo models. However, the advent of induced pluripotent stem cell (iPSC) technology has provided researchers with a novel toolbox. We conducted a systematic review using the PRISMA statement. A PubMed and Web of Science online search was performed (studies published between 2006–2020) using the following search strategy: hiPSC OR iPSC OR iPS OR stem cells AND schizophrenia disorder OR personality disorder OR antisocial personality disorder OR psychopathy OR bipolar disorder OR major depressive disorder OR obsessive compulsive disorder OR anxiety disorder OR substance use disorder OR alcohol use disorder OR nicotine use disorder OR opioid use disorder OR eating disorder OR anorexia nervosa OR attention-deficit/hyperactivity disorder OR gaming disorder. Using the above search criteria, a total of 3515 studies were found. After screening, a final total of 56 studies were deemed eligible for inclusion in our study. Using iPSC technology, psychiatric disease can be studied in the context of a patient’s own unique genetic background. This has allowed great strides to be made into uncovering the etiology of psychiatric disease, as well as providing a unique paradigm for drug testing. However, there is a lack of data for certain psychiatric disorders and several limitations to present iPSC-based studies, leading us to discuss how this field may progress in the next years to increase its utility in the battle to understand psychiatric disease.

Individuals who self-identify as having "orthorexia nervosa" score in the clinical range on the Eating Attitudes Test-26

PURPOSE

In recent years, there has been growing interest in pathologically healthful eating, often called orthorexia nervosa (ON). Much of the literature in this area has been about point prevalence of ON in particular populations, which range from less than 1% to nearly 90% depending on the study. Despite this interest, there has been no extensive examination of whether those with pathologically healthful eating are detected by screening instruments that identify disordered eating. This study examines whether individuals who self-report suffering from ON score in the clinical range on the 26-item Eating Attitudes Test (EAT-26).

METHOD

Individuals (n = 354) sampled from both clinical and non-clinical settings were administered the EAT-26 to determine whether those who self-identify as having ON scored in a range that suggests disordered eating.

RESULTS

Participants who self-report suffering from ON had a mean EAT-26 score of 30.89 (SD 12.60) scoring in a range that urges individuals to seek additional advice on whether there is an eating disorder present (scores of 20 and higher fall in a range suggesting a possible eating disorder). Furthermore, those in the ON group scored no differently than those reporting other eating disorders, but significantly higher than a non-clinical control group.

CONCLUSIONS

Our findings indicate that a screening instrument for a possible eating disorder is sensitive to pathologically healthful eating (but has no specificity).

LEVEL OF EVIDENCE

Level III, case control analytic study.

IS BODY FAT PERCENTAGE A GOOD PREDICTOR OF MENSTRUAL RECOVERY IN FEMALES WITH ANOREXIA NERVOSA AFTER WEIGHT RESTORATION? A SYSTEMATIC REVIEW AND EXPLORATORY AND SELECTIVE META-ANALYSIS

The resumption of menses (ROM) is an important outcome in anorexia nervosa treatment and is considered as a sign of recovery. Identification of relevant factors in its prediction is important in clinical practice. Therefore we aimed to conduct a systematic review and exploratory meta-analysis of the association between total body fat percentage (%BF) and ROM after weight restoration in adolescents and young adults with anorexia nervosa. The study was conducted by adhering to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Data were collated using meta-analysis and a narrative approach. Of the 604 articles retrieved, only seven studies comprising a total of 366 adolescent and young adult females with anorexia nervosa met the inclusion criteria and were reviewed, and preliminary results revealed three main findings. Firstly, patients who resumed their menstrual cycle had a significantly higher mean %BF when compared to those who did not, an overall effect confirmed by the meta-analysis (SMD: 3.74, 95% CI: 2.26-5.22). Secondly, %BF was found to be an independent predictor of the ROM in this population and an increase of only one unit of %BF can increase the odds of menstruation by ≈15-20%. Thirdly, despite the paucity of data, a cut-off point of %BF≈21was suggested as the minimum needed for ROM. In conclusion, a higher %BF seems to be associated with the ROM in weight-restored adolescent and young adult females with anorexia nervosa. Its assessment is important in a clinical setting, especially after complete weight restoration. The PROSPERO Registry - A systematic review and meta-analysis of the factors associated with the resumption of the menstrual cycle in females with anorexia nervosa after weight restoration (CRD42019111841).

The role of kisspeptin neurons in reproduction and metabolism

Kisspeptin is a neuropeptide with a critical role in the function of the hypothalamic-pituitary-gonadal (HPG) axis. Kisspeptin is produced by two major populations of neurons located in the hypothalamus, the rostral periventricular region of the third ventricle (RP3V) and arcuate nucleus (ARC). These neurons project to and activate gonadotrophin-releasing hormone (GnRH) neurons (acting via the kisspeptin receptor, Kiss1r) in the hypothalamus and stimulate the secretion of GnRH. Gonadal sex steroids stimulate kisspeptin neurons in the RP3V, but inhibit kisspeptin neurons in the ARC, which is the underlying mechanism for positive- and negative feedback respectively, and it is now commonly accepted that the ARC kisspeptin neurons act as the GnRH pulse generator. Due to kisspeptin's profound effect on the HPG axis, a focus of recent research has been on afferent inputs to kisspeptin neurons and one specific area of interest has been energy balance, which is thought to facilitate effects such as suppressing fertility in those with under- or severe over-nutrition. Alternatively, evidence is building for a direct role for kisspeptin in regulating energy balance and metabolism. Kiss1r-knockout (KO) mice exhibit increased adiposity and reduced energy expenditure. Although the mechanisms underlying these observations are currently unknown, Kiss1r is expressed in adipose tissue and potentially brown adipose tissue (BAT) and Kiss1rKO mice exhibit reduced energy expenditure. Recent studies are now looking at the effects of kisspeptin signalling on behaviour, with clinical evidence emerging of kisspeptin affecting sexual behaviour, further investigation of potential neuronal pathways are warranted.

Responses to warnings about the impact of eating disorders on fertility: a qualitative study

Eating disorders (EDs) have often been discussed as a risk to reproductive health. But existing research is quantitative in nature, paying no attention to issues of patient experience. In discussing data from 24 semi-structured interviews, this article draws on sociological approaches to medical 'risk' and feminist approaches to EDs to explore how women with experience of an ED responded to fertility warnings within treatment contexts. In doing so, it is suggested that responses to fertility warnings offer unique insight into the potentially damaging limitations of biomedical approaches to eating problems and their focus on EDs as individual 'pathologies' (rather than culturally embedded expressions of gendered embodiment). At best warnings are seen as making problematic assumptions about the aspirations of female patients, which may curtail feelings of agency and choice. At worst, they may push women further into destructive bodily and eating practices, and silence the distress that may be articulated by an ED.

Desire for a child and eating disorders in women seeking infertility treatment

OBJECTIVES

The purpose of this study was to evaluate the prevalence of EDs in women seeking treatment for infertility, and to better characterize their clinical profile.

STUDY DESIGN

Sixty participants completed self-report measures that assessed EDs, desire for a child, body preoccupations, quality of life, anxiety and depression.

RESULTS

Ten patients (17%) met criteria for a past or current ED. We showed a significant association between greater body dissatisfaction and a more ambivalent desire for a child. Furthermore, an ED was associated with (i) a lower quality of life, and (ii) more anxiety disorders.

CONCLUSION

Screening for a history of ED in infertile women is recommended to plan for adapted care regarding infertility but also regarding ED and psychiatric comorbidities. Therefore, the assessment has to take into account the desire for a child and the body satisfaction, that are essential parts of the ED process on the one hand and infertility process on the other. This could help with the infertility treatment and the prevention of negative maternal and fetal outcomes.

Insulin signalling and glucose transport in the ovary and ovarian function during the ovarian cycle

Data derived principally from peripheral tissues (fat, muscle and liver) show that insulin signals via diverse interconnecting intracellular pathways and that some of the major intersecting points (known as critical nodes) are the IRSs (insulin receptor substrates), PI3K (phosphoinositide kinase)/Akt and MAPK (mitogen-activated protein kinase). Most of these insulin pathways are probably also active in the ovary and their ability to interact with each other and also with follicle-stimulating hormone (FSH) and luteinizing hormone (LH) signalling pathways enables insulin to exert direct modulating influences on ovarian function. The present paper reviews the intracellular actions of insulin and the uptake of glucose by ovarian tissues (granulosa, theca and oocyte) during the oestrous/menstrual cycle of some rodent, primate and ruminant species. Insulin signals through diverse pathways and these are discussed with specific reference to follicular cell types (granulosa, theca and oocyte). The signalling pathways for FSH in granulosa cells and LH in granulosa and theca cells are summarized. The roles of glucose and of insulin-mediated uptake of glucose in folliculogenesis are discussed. It is suggested that glucose in addition to its well-established role of providing energy for cellular function may also have insulin-mediated signalling functions in ovarian cells, involving AMPK (AMP-dependent protein kinase) and/or hexosamine. Potential interactions of insulin signalling with FSH or LH signalling at critical nodes are identified and the available evidence for such interactions in ovarian cells is discussed. Finally the action of the insulin-sensitizing drugs metformin and the thiazolidinedione rosiglitazone on follicular cells is reviewed.

Modeling anorexia nervosa: transcriptional insights from human iPSC-derived neurons

Anorexia nervosa (AN) is a complex and multifactorial disorder occurring predominantly in women. Despite having the highest mortality among psychiatric conditions, it still lacks robust and effective treatment. Disorders such as AN are most likely syndromes with multiple genetic contributions, however, genome-wide studies have been underpowered to reveal associations with this uncommon illness. Here, we generated induced pluripotent stem cells (iPSCs) from adolescent females with AN and unaffected controls. These iPSCs were differentiated into neural cultures and subjected to extensive transcriptome analysis. Within a small cohort of patients who presented for treatment, we identified a novel gene that appears to contribute to AN pathophysiology, TACR1 (tachykinin 1 receptor). The participation of tachykinins in a variety of biological processes and their interactions with other neurotransmitters suggest novel mechanisms for how a disrupted tachykinin system might contribute to AN symptoms. Although TACR1 has been associated with psychiatric conditions, especially anxiety disorders, we believe this report is its first association with AN. Moreover, our human iPSC approach is a proof-of-concept that AN can be modeled in vitro with a full human genetic complement, and represents a new tool for understanding the elusive molecular and cellular mechanisms underlying the disease.

A model-driven approach to studying dissociations between body size mental representations in anorexia nervosa

This study compared dissociations between mental representations of current, ideal and normal body sizes (i.e., Current BS, Ideal BS and Normal BS) for women with anorexia nervosa (AN group, n=56) and healthy women (control group, n=56). Along the lines of the single channel model of Cornelissen et al. (2013), the discrepancy between Current BS and BMI for both groups was adequately described along a common linear continuum of Current BS (mis)perception. Body size mental representations were ranked similarly (Ideal BS<Current BS<Normal BS) in each group. Whilst the over-estimation of Current BS was much greater among the AN group than the control group, body dissatisfaction was better explained by Current BS for the AN group and by BMI for the control group. Dissociation between Current BS and participants' BMI appears to be a key element when seeking to understand AN.

Neonatal overfeeding induces early decline of the ovarian reserve: Implications for the role of leptin

Early life nutrition is crucial for reproduction. Overweight and obese girls are more likely to experience early menarche, increasing the risk of adult disease. We have previously demonstrated neonatal overfeeding in the rat leads to accelerated growth, early puberty and increased circulating levels of leptin, an adipocyte-derived hormone that regulates puberty. However, the long-term consequences of accelerated puberty and metabolic dysfunction on ovarian reserve are unknown. Here we show that neonatal overfeeding reduced the number of ovarian follicles in adult rats; specifically, the primordial follicle pool was reduced compared to controls. The reduction of ovarian reserve coincided with a diminished release of pituitary gonadotropins at ovulation and altered expression of ovarian markers important for follicular recruitment and survival. These changes were associated with increased levels of ovarian leptin and its receptor. Postnatal administration of leptin antagonist did not reverse the weight gain induced by early life overfeeding, but rescued the decline in the primordial follicle pool and abolished the differences in circulating leptin and gonadotropins. Our findings suggest that the acute effects of elevated circulating leptin may be responsible for the long-term reproductive outcomes after neonatal overfeeding, leading to premature ovarian ageing and changes in reproductive efficiency.

THE ENDOCRINOPATHIES OF MALE ANOREXIA NERVOSA: CASE SERIES

OBJECTIVE

Anorexia nervosa (AN) is a serious disorder with associated morbidity and mortality, most commonly diagnosed in females. Existing literature on male anorexia is sparse, and a review of the endocrine effects of AN in males has not previously been published. Our objective is to highlight the clinical characteristics of AN in males as a routinely overlooked cause of multiple endocrinopathies and systemic illness in hospitalized patients.

METHODS

We present 4 cases (2 cases at The Mount Sinai Hospital; 2 cases at Long Island Jewish Hospital) of young men with hormonal dysfunction due to underlying AN. Pertinent de-identified data were collected from a chart review of cases seen on the endocrinology consult service at both hospitals. Institutional Review Board approval was not required for an observational report of the cases presented.

RESULTS

Four young men with AN demonstrated evidence of multiple systemic complications from severe caloric and protein malnutrition. Varying degrees of endocrinopathies were present, including hypogonadotropic hypogonadism, hypercortisolemia, and nonthyroidal illness syndrome, resulting in bradycardia, gastroparesis, hypothermia, acute systolic heart failure, and erectile dysfunction. Ages at diagnosis were 20, 24, 23, and 20 years, with mean age 21.75 years. Most of the clinical effects from these endocrinopathies resolved with improved caloric intake and nutrition, although symptoms of hypogonadism persisted.

CONCLUSION

This small case series highlights the importance of AN as a potential cause of multiple endocrinopathies in males. The heterogeneous presentations and varying degrees of clinical manifestations in our cohort emphasize the challenge in diagnosis. Increased awareness of AN in males is vital, as its prevalence is likely underestimated and appropriate diagnosis and treatment can ameliorate the metabolic dysfunction in a majority of cases. Further studies on males with eating disorders are needed to help guide diagnostic and therapeutic decisions.

The effects of intrauterine malnutrition on birth and fertility outcomes: evidence from the 1974 Bangladesh famine

This article uses the Bangladesh famine of 1974 as a natural experiment to estimate the impact of intrauterine malnutrition on sex of the child and infant mortality. In addition, we estimate the impact of malnutrition on post-famine pregnancy outcomes. Using the 1996 Matlab Health and Socioeconomic Survey (MHSS), we find that women who were pregnant during the famine were less likely to have male children. Moreover, children who were in utero during the most severe period of the Bangladesh famine were 32 % more likely to die within one month of birth compared with their siblings who were not in utero during the famine. Finally, we estimate the impacts of the famine on subsequent pregnancy outcomes. Controlling for pre-famine fertility, we find that women who were pregnant during the famine experienced a higher number of stillbirths in the post-famine years. This increase appears to be driven by an excess number of male stillbirths.

Anorexia nervosa - medical complications

In contrast to other mental health disorders, eating disorders have a high prevalence of concomitant medical complications. Specifically, patients suffering from anorexia nervosa (AN) have a litany of medical complications which are commonly present as part of their eating disorders. Almost every body system can be adversely, affected by this state of progressive malnutrition. Moreover, some of the complications can have permanent adverse effects even after there is a successful program of nutritional rehabilitation and weight restoration. Within this article we will review all body systems affected by AN. There is also salient information about both, how to diagnose these medical complications and which are the likely ones to result in permanent sequelae if not diagnosed and addressed early in the course of AN. In a subsequent article, the definitive medical treatment for these complications will be presented in a clinically practical manner.

Treatments of medical complications of anorexia nervosa and bulimia nervosa

Inherent to anorexia nervosa and bulimia nervosa are a plethora of medical complications which correlate with the severity of weight loss or the frequency and mode of purging. Yet, the encouraging fact is that most of these medical complications are treatable and reversible with definitive care and cessation of the eating-disordered behaviours. Herein, these treatments are described for both the medical complications of anorexia nervosa and those which are a result of bulimia nervosa.

Minireview: Metabolism of female reproduction: regulatory mechanisms and clinical implications

Female fertility is highly dependent on successful regulation of energy metabolism. Central processes in the hypothalamus monitor the metabolic state of the organism and, together with metabolic hormones, drive the peripheral availability of energy for cellular functions. In the ovary, the oocyte and neighboring somatic cells of the follicle work in unison to achieve successful metabolism of carbohydrates, amino acids, and lipids. Metabolic disturbances such as anorexia nervosa, obesity, and diabetes mellitus have clinically important consequences on human reproduction. In this article, we review the metabolic determinants of female reproduction and their role in infertility.

Nutrition, bone, and aging: an integrative physiology approach

Osteoporosis, a condition associated with significant morbidity and mortality, is prevalent in the growing elderly population. Aging is associated with characteristic changes in the complex pathways of bone remodeling and in patterns of food intake. Whereas the traditional focus of nutritional supplementation for protection of bone health has centered around calcium and vitamin D, a multitude of nutrients have been identified with effects on bone, both individually and in combination. An integrative physiology approach can assist in formulating a deeper understanding of the complex interactions of nutrition and aging with bone, with the goal of identifying modifiable risk factors for the prevention of bone loss.

The effect of systemic and ovarian infusion of glucose, galactose and fructose on ovarian function in sheep

Glucose is a critical metabolic fuel in most mammals although many foodstuffs also contain high levels of the monosaccharides, galactose and fructose. The aims of this work were to determine the insulin response to challenges of these sugars (experiment 1) and to examine the effect of systemic (experiment 2) and direct ovarian (experiment 3) infusion of these monosaccharides on ovarian function in ewes with autotransplanted ovaries. In experiment 1, both fructose (fourfold increase peaking in 2 h) and galactose (twofold increase; 30 min) elicited markedly different (P<0.001) insulin responses than glucose (sevenfold increase; 20 min) although the total amount released following fructose and glucose challenge was similar. In experiment 2, low-dose systemic fructose infusion had no acute effect on insulin but did depress FSH (P<0.05), and following the end of fructose infusion, a transient increase in FSH and insulin was observed (P<0.05), which was associated with an increase (P<0.05) in ovarian oestradiol and androstenedione secretion. Systemic infusion of neither glucose nor galactose had a significant effect on ovarian steroidogenesis although glucose acutely suppressed insulin levels. In contrast, ovarian arterial infusion of fructose and glucose had no effect on ovarian function whereas galactose suppressed ovarian follicle number and steroid secretion (P<0.05). In conclusion, this work indicates that fructose and galactose can influence ovarian functionin vivoin sheep and that different mechanisms are involved. Thus, fructose exerts stimulatory effects through indirect modulation of peripheral insulin and/or gonadotrophin levels whereas galactose exerts primarily suppressive effects by direct actions on the ovary.

The effect of monosaccharide sugars and pyruvate on the differentiation and metabolism of sheep granulosa cells in vitro

The objective of this study was to investigate the effect of three monosaccharides or pyruvate on the ability of gonadotrophins to induce cellular proliferation and differentiation of cultured sheep granulosa cells. Lactate production and levels of mRNA expression for the glucose transporters SLC2A1, SLC2A4, SLC2A5 and SLC2A8 were also determined. No energy source in the culture media reduced cell number (50%) and oestradiol (E2) production. Dose and type of monosaccharide had a highly significant (P<0.001) effect on FSH-induced differentiation of the granulosa cells, and there was a highly significant interaction (P<0.001). Glucose supported higher levels of E2production than fructose, which was in turn higher than galactose (P<0.001). In contrast, pyruvate at low doses supported similar levels of E2production as glucose, but higher doses were markedly inhibitory to E2production (P<0.001). Cells responded positively to insulin (P<0.001) in the presence of all three monosaccharides. Glucose and the high doses of fructose resulted in the accumulation of lactate (P<0.001), but pyruvate, galactose and the low dose of fructose resulted in low lactate production. SLC2A5 expression was not detected and SLC2A8 expression was not affected, but SLC2A1 and SLC2A4 expression was depressed (P<0.05) by culture in the presence of fructose and glucose. These data show that glucose, metabolised under anoxic conditions to lactate, is the preferred energy substrate to support the gonadotrophin-induced differentiation of ovine granulosa cellsin vitro, and that fructose and pyruvate, but not galactose, are alternative energy substrates despite marked differences in the way these substrates are metabolised.

Psychosomatic approaches to obstetrics, gynaecology and andrology--a review

This review aims to clarify the scope and clinical importance of psychosomatic approaches to obstetrics, gynaecology and andrology. This gradually expanding sub-specialty covers a wide domain of complex disease conditions that can be managed more effectively if the various biological, psychological and social aspects are recognised at the start and concurrent treatment initiated. The current need to practise biopsychosocial management of disease conditions is highlighted along with a description of what this would involve. The nine-field psychosomatic approach, which can be applied to everyday clinical encounters, has been illustrated. Clinical applications of the psychosomatic approach are discussed for various conditions including chronic pelvic pain, eating disorders, tokophobia, post-traumatic stress disorder, depression, menstrual disorders, infertility, bereavement and testicular cancer. Cultural considerations and the need for further research are also briefly discussed.

The endocrinopathies of anorexia nervosa

OBJECTIVE

To describe the hormonal adaptations and alterations in anorexia nervosa.

METHODS

We performed a PubMed search of the English-language literature related to the pathophysiology of the endocrine disorders observed in anorexia nervosa, and we describe a case to illustrate these findings.

RESULTS

Anorexia nervosa is a devastating disease with a variety of endocrine manifestations. The effects of starvation are extensive and negatively affect the pituitary gland, thyroid gland, adrenal glands, gonads, and bones. Appetite is modulated by the neuroendocrine system, and characteristic patterns of leptin and ghrelin concentrations have been observed in anorexia nervosa. A thorough understanding of refeeding syndrome is imperative to nutrition rehabilitation in these patients to avoid devastating consequences. Although most endocrinopathies associated with anorexia nervosa reverse with recovery, short stature, osteoporosis, and infertility may be long-lasting complications. We describe a 20-year-old woman who presented with end-stage anorexia nervosa whose clinical course reflects the numerous complications caused by this disease.

CONCLUSIONS

The effects of severe malnutrition and subsequent refeeding are extensive in anorexia nervosa. Nutrition rehabilitation is the most appropriate treatment for these patients; however, it must be done cautiously.

[Anorexia nervosa during pregnancy: an unusual association]

We report the case of a pregnancy associated with severe restricting anorexia nervosa in a 33-year-old patient who weighed 41kg for 1.61m at conception. She continued to lose weight during pregnancy and she gave birth to an eutrophic child by cesarean section at 34 weeks of amenorrhea. Because of complications induced by the chronic food restriction, anorectic pregnant women should be viewed as being at high risk and also monitored closely both during and after pregnancy to optimize maternal and fetal outcomes.

Astressin B, a nonselective corticotropin-releasing hormone receptor antagonist, prevents the inhibitory effect of ghrelin on luteinizing hormone pulse frequency in the ovariectomized rhesus monkey

Administration of ghrelin, a key peptide in the regulation of energy homeostasis, has been shown to decrease LH pulse frequency while concomitantly elevating cortisol levels. Because increased endogenous CRH release in stress is associated with an inhibition of reproductive function, we have tested here whether the pulsatile LH decrease after ghrelin may reflect an activated hypothalamic-pituitary-adrenal axis and be prevented by a CRH antagonist. After a 3-h baseline LH pulse frequency monitoring, five adult ovariectomized rhesus monkeys received a 5-h saline (protocol 1) or ghrelin (100-microg bolus followed by 100 microg/h, protocol 2) infusion. In protocols 3 and 4, animals were given astressin B, a nonspecific CRH receptor antagonist (0.45 mg/kg im) 90 min before ghrelin or saline infusion. Blood samples were taken every 15 min for LH measurements, whereas cortisol and GH were measured every 45 min. Mean LH pulse frequency during the 5-h ghrelin infusion was significantly lower than in all other treatments (P < 0.05) and when compared with the baseline period (P < 0.05). Pretreatment with astressin B prevented the decrease. Ghrelin stimulated cortisol and GH secretion, whereas astressin B pretreatment prevented the cortisol, but not the GH, release. Our data indicate that CRH release mediates the inhibitory effect of ghrelin on LH pulse frequency and suggest that the inhibitory impact of an insufficient energy balance on reproductive function may in part be mediated by the hypothalamic-pituitary-adrenal axis.

Central dysregulations in the control of energy homeostasis and endocrine alterations in anorexia and bulimia nervosa

In the last decades we have come to understand that the hypothalamus is a key region in controlling energy homeostasis. A number of control models have been proposed to explain the regulation of feeding behavior in physiological and pathological conditions, but all those based on imbalances of single factors fail to explain the disrupted regulation of energy supply in eating disorders such as anorexia nervosa and bulimia nervosa, as well as other psychiatric disorders. A growing amount of evidence demonstrates that many signaling molecules originated within the brain or coming from the adipose tissue or the gastro-enteric tract are involved in the highly complex process controlling food intake and energy expenditure. The recent discovery of leptin, ghrelin, and other factors have made it possible to penetrate in the still undefined pathophysiology of eating disorders with the hope of finding effective treatments for such diseases.

Patterns of menstrual disturbance in eating disorders

OBJECTIVE

To describe menstrual disturbance in eating disorders (ED).

METHOD

We describe menstrual history in 1,705 women and compare eating, weight, and psychopathological traits across menstrual groups.

RESULTS

Menstrual dysfunction occurred across all eating disorder subtypes. Individuals with normal menstrual history and primary amenorrhea reported the highest and lowest lifetime body mass index (BMI), respectively. Normal menstruation and oligomenorrhea groups reported greater binge eating, vomiting, and appetite suppressant use. Amenorrhea was associated with lower caloric intake and higher exercise. Harm avoidance, novelty seeking, perfectionism, and obsessionality discriminated among menstrual status groups. No differences in comorbid Axis I and II disorders were observed.

CONCLUSION

Menstrual dysfunction is not limited to any eating disorder subtype. BMI, caloric intake, and exercise were strongly associated with menstrual function. Menstrual status is not associated with comorbidity. Menstrual irregularity is an associated feature of all ED rather than being restricted to AN only.

The psychobiology and diagnostic significance of amenorrhea in patients with anorexia nervosa

Amenorrhea is a diagnostic criterion for anorexia nervosa (AN), although menstrual cycles have been found to persist in some women with all the other features of AN. This study sought to determine factors that are associated with amenorrhea in 39 women with current primary spectrum AN. The use of exercise to control weight (odds ratio (OR) = 3.5; 95% confidence interval (CI) = 1.3-9.9; P = .02), low novelty seeking scores (OR = 0.7; 95% CI = 0.58-0.94; P = .02), and low systolic blood pressure (OR = 0.9; 95% CI = 0.84-0.99; P = .046) were predictors of amenorrhea independent of body mass index.

Serum leptin and lactational amenorrhea in well-nourished and undernourished lactating women

OBJECTIVE

To ascertain the possible role of leptin in the resumption of postpartum menstruation in lactating women with differing nutritional statuses.

DESIGN

Analysis of data and blood samples collected during a previous prospective study.

SETTING

Healthy volunteers in an academic research environment.

PATIENT(S)

Undernourished (body mass index [BMI]< or =19 kg/m(2)) and well-nourished (BMI> or =26 kg/m(2)) lactating women who resumed regular menstruation before 24 weeks and at or after 24 weeks postpartum.

INTERVENTION(S)

Venous blood samples at four-weekly intervals and other clinical data collected until resumption of regular menstruation.

MAIN OUTCOME MEASURE(S)

Serum leptin concentrations.

RESULT(S)

Leptin concentrations were significantly higher in the well-nourished than in the undernourished women, irrespective of the time of resumption of menstruation. Time of resumption of menstruation did not significantly affect leptin levels within well-nourished and undernourished groups. Leptin significantly correlated with BMI (r = 0.78). The BMI (r = -0.53), but not leptin, was significantly and negatively correlated with the duration of lactational amenorrhea.

CONCLUSION(S)

Leptin is unlikely to be a major determinant of early resumption of regular menstruation in well-nourished women.

Pregnancy and neonatal outcomes in women with eating disorders

OBJECTIVE

This study was initiated to examine pregnancy and neonatal outcomes in women with past or current eating disorders as compared with a control group.

METHODS

Forty-nine nulliparous nonsmoking women previously diagnosed with eating disorders (24 anorexia nervosa, 20 bulimia nervosa, 5 eating disorders not otherwise specified) and 68 controls were recruited in early pregnancy. Data on antenatal complications, mode of delivery, and neonatal outcome variables were collected. For comparisons between groups 1-way analysis of variance or chi(2) test was used.

RESULTS

Twenty-two percent of the patients had a verified relapse in eating disorders during pregnancy. Women with past or current eating disorders were at increased risk of hyperemesis (P < .01) and delivered infants with significantly lower birth weight (P < .01) and smaller head circumference (P < .001) as compared with controls. They were also at greater risk of delivering infants with microcephaly (P < .05) and small for gestational age infants (P < .05).

CONCLUSION

Pregnant women with past or active eating disorders seem to be at greater risk for delivering infants with lower birth weight, smaller head circumference, microcephaly, and small for gestational age.

LEVEL OF EVIDENCE

II-2.

Direct in vivo effects of leptin on ovarian steroidogenesis in sheep

Leptin, the metabolic fat hormone, has been shown to have effects on reproduction in mice and to modulate steroid production by cultured ovarian somatic cells in a number of species. However, a direct role of leptin on normal ovarian function in vivo has not been shown. In this paper the effect of passive immunisation against leptin (experiment 1; 20 ml antiserum or non-immune plasma i.v.; n = 6/treatment) and direct ovarian infusion of leptin (experiment 2; 0, 2 or 20 mug recombinant ovine leptin; n = 4/treatment) during the early follicular phase was investigated in sheep with ovarian autotransplants, which allow recovery of ovarian venous blood and regular non-invasive scanning of the ovary. Passive immunisation against leptin resulted in an acute increase (P < 0.05) in ovarian oestradiol secretion but had no effect on gonadotrophin concentrations, ovulation or subsequent luteal function. Conversely, direct ovarian arterial infusion of the low dose of leptin resulted in an acute decline (P < 0.05) in ovarian oestradiol secretion whereas the high dose, which resulted in supra-physiological leptin concentrations, had no effect on oestradiol production compared with the controls. Neither dose of leptin had any effect on gonadotrophin concentrations or ovulation but both doses resulted in an increase (P < 0.05) in progesterone concentrations over the subsequent luteal phase. In conclusion, together these data provide strong in vivo evidence that leptin can modulate ovarian steroidogenesis directly and acutely in ruminants and suggest that leptin is an alternate regulatory system whereby nutritional status can regulate reproductive activity.

Menstrual dysfunction in anorexia nervosa

Amenorrhea is a hallmark sign of anorexia nervosa. Its cause is multifactorial and its resolution necessitates treatment of the underlying eating disorder. The neuroendocrine changes associated with menstrual abnormalities in underweight and weight recovered anorexia nervosa, recent research on osteopenia, and treatment recommendations are addressed.

Osteoporosis and anorexia nervosa: relative role of endocrine alterations and malnutrition

BACKGROUND AND AIM

Anorexia nervosa (AN) is a psychiatric disorder characterised by self-induced starvation or a very reduced caloric intake, and frequently by severe life-threatening protein calory malnutrition. Its physiological consequences include amenorrhea, estrogen deficiency and osteoporosis. Osteoporosis may develop as a consequence of a lack of estrogens, low calcium or vitamin D intake, hypercortisolemia or the duration of the illness. The aim of this study was to identify the best endocrinological and nutritional indicators of bone density.

SUBJECTS AND METHODS

The study involved 49 young females with AN and malnutrition and 24 age-matched normal controls in whom AN had been excluded on the basis of a clinical evaluation using DSM IV criteria. We studied bone density in early osteopenia, a condition in which the potential risk of fractures is certainly high and traditionally related to a variety of endocrinological and nutritional factors.

RESULTS

Bone density was significantly lower in the AN than the control group in all of the examined bone districts: bone mineral density (BMD) spine 0.89 +/- 0.19 vs 1.27 +/- 0.2 (p<0.0001), BMD neck 0.75 +/- 0.14 vs 1.08 +/- 0.17 (p<0.001), BMD Ward 0.74 +/- 0.17 vs 1.12 +/- 0.11 (p<0.0001). Non-significant differences were found in the patients who had undergone previous estrogen medication. Body mass index (BMI) correlated with bone density, but caloric and calcium intake were not significant predictors. IGF-1, a known nutritionally dependent trophic bone factor, was significantly reduced in our patients but did not correlate with BMD. Like other authors, we found a close correlation between lean body mass and BMD in neck and spine. Physical exercise, urinary free cortisol osteocalcin and type I collagen-telopeptide (NTX) did not significantly correlate with the degree of osteopenia.

CONCLUSIONS

Our data suggest the importance of nutritional factors (particularly lean body mass and BMI) in determining bone mass, and the relatively limited importance of endocrinological factors with the exception of the duration of amenorrhea as an indirect indicator of endocrinological status.

Osteoporosis: prevention and treatment in anorexia nervosa

One of the most serious and potentially permanently disabling medical complications of anorexia nervosa is osteoporosis, which greatly increases the long-term risk of bone fractures. The decreased bone density in patients with anorexia nervosa (AN) is due to the many effects on bone metabolism of amenorrhea, reduced levels of insulin growth factor-1 (IGF-1), high cortisol levels and weight loss. Although estrogen replacement therapy is clearly efficacious in preventing postmenopausal osteoporosis, its efficacy in AN is uncertain. Clinicians caring for patients with AN need to be aware of this because, despite such therapy, there may be an inexorable decline in bone mineral density in what is a relatively young group of patients. AN frequently has its onset during adolescence, when peak bone mass is normally reached, and an anorectic episode in youth may permanently impair skeletal integrity and lead to debilitating fractures and pain. It is important to recognise this formidable risk, counsel AN patients about the longterm and possibly permanent sequelae of low body weight, use densitometry to screen for bone loss and treat it accordingly. The most effective treatment is still early weight restoration and the resumption of menses.

The forgotten female: Pediatric and adolescent gynecological concerns and their reproductive consequences

Future reproductive performance is not often addressed in pediatric and adolescent gynecological conditions. This overview reviews conditions that present in childhood and adolescence and discusses what is known about the future fertility in these women. The following topics are selected: STD exposure, dysfunctional uterine bleeding, eating disorders, adolescent athletics, polycystic ovarian syndrome, premature ovarian failure, childhood cancer survivors, Mullerian duct anomalies, congenital adrenal hyperplasia, cystic fibrosis, and epilepsy.

Anorexia nervosa: manifestations and management for the gastroenterologist

Anorexia nervosa is a complex psychiatric disorder with significant morbidity and mortality. It is important for gastroenterologists to be aware of the physiological effects and potential complications of anorexia nervosa, as they are frequently involved in treating patients with this disorder. We review the classic, GI, and neuroendocrinological features of anorexia nervosa. We also discuss gender differences and treatment options in anorexia nervosa. Further studies of GI physiology and pharmacology are needed to determine whether any disturbances may be amenable to therapeutic intervention. Future treatments directed at improving GI sensorimotor function and neurohormonal abnormalities in patients with anorexia nervosa may impact their nutritional rehabilitation and may have important health economic implications as patients avoid hospitalization and are restored to full activities in society. The current team approach, which incorporates psychiatrists, psychologists, nutritionists, pediatricians, internists, and gastroenterologists in the treatment of patients with anorexia nervosa, will continue to be essential.

Hazards of assisted conception in women with severe medical disease

The issues relating to assisted reproduction in women with severe medical disease can be divided into the likely effect of pregnancy upon the medical condition, and how the medical condition may adversely affect pregnancy outcome. In addition, consideration of the hazards relating to the process of assisted conception, in particular the risk of ovarian hyperstimulation syndrome and multiple pregnancy, must be remembered. In some women, successful assisted reproduction may result in a life-threatening pregnancy. Clinicians advising women about assisted conception should be aware of the medical conditions that are absolute contra-indications to pregnancy. Some women with severe medical disease may have a significantly reduced life expectancy, in which case ethical issues regarding the future welfare of the child must be considered. Examples include sickle cell disease, cystic fibrosis and HIV. One of the biggest advantages of assisted reproduction for women with severe medical disorders is that the pregnancy is planned. Thus, there is an opportunity for the patient to be informed fully about any risks, both to herself and her fetus. This article reviews the general management of women with severe medical disorders who seek assisted reproduction and gives specific guidelines for the more common conditions.

Lactational amenorrhea/anovulation and some of their determinants: a comparison of well-nourished and undernourished women

OBJECTIVE

To study the effect of maternal nutritional status and some other possible determinants on lactational amenorrhea/anovulation.

DESIGN

Prospective matched-pairs study.

SETTING

Postpartum wards and community and academic settings.

PATIENT(S)

Thirty matched pairs of otherwise healthy, well-nourished (body mass index > or = 26.00 kg/m2) and undernourished (body mass index < or = 19.00 kg/m2) postpartum women were selected.

INTERVENTION(S)

Infant feeding pattern was recorded weekly, and infant weights, maternal body mass index, and maternal PRL levels were estimated every 4 weeks until resumption of menstruation. Ovulatory activity was determined using urinary estrone and pregnanediol glucuronide concentrations.

MAIN OUTCOME MEASURE(S)

Time of resumption of menstruation, regular and ovulatory.

RESULT(S)

Well-nourished women resumed regular menstruation significantly earlier than undernourished women but resumed ovulatory menstruation at almost the same time. Undernourished women had fewer anovulatory cycles preceding first postpartum ovulation and a higher prevalence of formula feeding. Effect of body mass index on lactational amenorrhea became nonsignificant when nonintroduction of formula feeds, maternal age, and socioeconomic status were controlled for.

CONCLUSION(S)

Improved maternal nutritional status has no significant effect on fertility: ovulation is not advanced despite early resumption of regular menstruation.