Eating disorders and menopause

• Eating disorders disproportionately affect women
• Some women experience a worsening or resurfacing of eating disorders during menopause, while some may develop an eating disorder for the first time
• Information on the perimenopause and menopause if you currently have, or previously had an eating disorder

Content advisory: this article includes themes of mental health and suicide

Prevalence of eating disorders is increasing worldwide, with an estimated 1.25 million people affected in the UK alone [1]. However, the true number is likely to be higher still as many people do not seek help from healthcare services.

Eating disorders disproportionately affect women, with 90% of those affected being female[2]. Because adolescents and young adults are at highest risk of developing an eating disorder, you could be forgiven for thinking they don’t affect women during the perimenopause and menopause, yet the two are often linked [2]. In fact, eating disorders among women in their 40s and 50s are more common than you may expect, with one study reporting a prevalence of 3.6% [3]. 

What are eating disorders?

Eating disorders are defined as the disruption in eating behaviours with excessive concern about body weight that impairs physical health or psychosocial functioning [4]. The underlying causes of eating disorders vary, but can include physical, psychological, developmental, social and cultural factors.

There are eight main categories of eating disorder but the most common include:

• Anorexia nervosa
• Bulimia nervosa
• Binge eating disorder.

What is the perimenopause and menopause?

The menopause is when the ovaries stop producing eggs and levels of the hormones oestrogen, progesterone and testosterone fall.

The definition of menopause is when a woman hasn’t had a period for 12 months. The perimenopause is the time leading up to this and varies from months to years, when you still have periods, but the fluctuating hormone levels can herald a range of symptoms.

This cycle of high and low hormone levels will occur repeatedly, and this hormonal instability is often why the perimenopause can be a harder time to navigate for many women than the menopause itself.

How are eating disorders and the menopause linked?

Some women experience a worsening or resurfacing of eating disorder symptoms and behaviours during the menopause, while some may develop an eating disorder for the first time.

Symptom overlap

When an eating disorder leads to underconsumption of calories, extreme exercise, or a very limited intake of certain foods, the body is placed under extreme stress as a result of a huge energy deficit. This can affect the signaling pathway from your brain to your ovaries, and shut down the production of sex hormones. Ovulation may no longer occur, and periods frequently stop.

When a woman no longer has a period because of an eating disorder this is called functional hypothalamic amenorrhoea (FHA). Women with FHA typically have low oestrogen levels. Therefore, they may have very similar symptoms to those that occur in the perimenopause and menopause such as:

• Feeling very tired
• Dizziness
• Problems with digestion
• Low mood
• Anxiety
• Irritability
• A change in temperature control – you may feel very cold but may also experience night sweats.

Risk of future diseases

Women with FHA will be at higher risk of developing certain diseases such as osteoporosis. Women who go through an early menopause – before the age of 45 years – will also be at a greater risk of osteoporosis. Both FHA and early menopause share the same thing in common, low oestrogen.

Eating disorders such as binge eating disorder and bulimia can increase the risk of type 2 diabetes and heart disease. Low hormones during and after menopause can also increase the risk of developing type 2 diabetes and heart disease.

Weight and disordered eating

A common symptom of menopause is weight gain and a redistribution of body weight around your middle. On average, women may gain half a kilo per year during the perimenopause, in the absence of HRT[5]. Weight gain can leave some women dissatisfied with their body appearance, and body dissatisfaction is associated with disordered eating [6].

Another common symptom of the menopause is low self-esteem, and the combination of weight gain and low self-esteem may make perimenopausal women susceptible to the development of eating disorders through desperate efforts to lose weight or regain their pre-menopausal shape.

Due to the increased risk of diseases such as type 2 diabetes and heart disease in the menopause, compounded by weight gain, some women may begin to make healthier food choices. Undoubtedly, this is a positive behaviour change, but for some women eating healthy food can become a risky, obsessive, psychologically limiting, and sometimes physically damaging behaviour, as they repeatedly fight against the sentiments of being unclean because of the food they have eaten. This damaging pattern of eating healthy foods is known as orthorexia nervosa. One cross-sectional study including over 1,000 women, found that postmenopausal women are more prone to orthorexia nervosa than premenopausal women [6].

In addition, menopausal women are susceptible to experiencing psychological symptoms such as depression, stress, anxiety, and body image concerns. This can be exacerbated by disturbed sleep, a common menopausal symptom. A combination of poor mental health and poor sleep leads to psychological distress, which has been associated with higher rates of disordered eating habits such as emotional eating and over-eating [5].

Eating disorders, menopause and suicide

Individuals suffering with an eating disorder will experience dysregulation of the chemical dopamine in the brain. Low oestrogen is associated with dopamine dysregulation, or more specifically, a lack of dopamine [7]. As a result of changes in dopamine, perimenopausal/menopausal women and women with eating disorders may be more susceptible to developing depression and suicidal behaviours.

Studies have shown that eating disorders are associated with a significantly increased risk of suicide attempt [8]. Equally, women aged 50-54 years have the highest rate of suicide in the UK, which falls in the typical age range for perimenopause and menopause [9]. One in ten women report experiencing suicidal thoughts owing to the menopause [10]. Studies have shown that suicide attempts may be more frequent when oestrogen and progesterone levels are low, which can be the case both during the menopause and in women with eating disorders [11].

Treatment options for eating disorder and menopause

The treatment approach for both eating disorders and the menopause is holistic.

The treatment of an eating disorder will require input from a range of different healthcare professionals and often will encompass psychological treatments and, where appropriate, specific medications. Eating disorders inflict huge stress on the body which can affect many hormonal systems including your sex hormones like oestrogen and testosterone, thyroid hormones, and vitamin D, which is also a hormone. As a result, hormone replacement may also have a role to play in the multi-faceted approach of treating eating disorders.

Hormone replacement therapy (HRT) is the first-line treatment for menopause related symptoms and may be used in women going through the perimenopause and menopause alongside an eating disorder or in those with FHA.

HRT contains oestrogen, a progestogen (or progesterone) to protect the lining of your womb if you have one, and in some cases, testosterone.

In addition to easing menopause symptoms, HRT also protects your future health. Replacing hormones with HRT helps protect your bones against osteoporosis, a condition which weakens your bones and is a common complication of eating disorders and early menopause. HRT is, in fact, licensed as a treatment for osteoporosis in the UK.

It’s important to take a holistic approach to managing your menopause, which could include options including HRT, non-hormonal treatments, prescribed medications, complimentary therapies, supplements such as vitamin D, magnesium and important lifestyle changes such as prioritising sleep, limiting alcohol and stopping smoking.

Where can I get help with my eating disorder or more information?

If you are struggling with an eating disorder or know someone who is, please reach out for help.

Your GP can refer you to local services for your area. In addition, the charity BEAT has a helpline and many online resources, while the National Centre for Eating Disorders is another good source of information.

Contact the Samaritans for 24-hour, confidential support by calling 116 123 or email jo@samaritans.org.

References

1. Beat, ‘How many people have an eating disorder in the UK?’
2. National Institute for Health and Care Excellence (2019) Eating disorders: prevalence
3. Micali, N., Martini, M.G., Thomas, J.J. et al. (2017), ‘Lifetime and 12-month prevalence of eating disorders amongst women in mid-life: a population-based study of diagnoses and risk factors’, BMC Med, 15(12). doi.org/10.1186/s12916-016-0766-4
4. Balasundaram P., Santhanam P. (2023), Eating disorders. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.
5. Chopra S et al. (2019), ‘Weight management module for perimenopausal women: a practical guide for gynecologists’, J Midlife Health,10(4):165-172. doi: 10.4103/jmh.JMH_155_19. PMID: 31942151; PMCID: PMC6947726.
6. Khalil J et al. (2022), ‘Eating disorders and their relationship with menopausal phases among a sample of middle-aged Lebanese women’ BMC Womens Health, 10;22(1):153. doi: 10.1186/s12905-022-01738-6. PMID: 35538474; PMCID: PMC9092875).
7. Yale School of Medicine (2001), ‘Oestrogen deprivation associated with loss of dopamine cells’
8. Patel R.S., Machado T., Tankersley W.E. (2021), ‘Eating disorders and suicidal behaviors in adolescents with major depression: insights from the US Hospitals’, Behav Sci,19;11(5):78. doi: 10.3390/bs11050078. PMID: 34069446; PMCID: PMC8159103).
9. Office for National Statistics (2023) ‘Suicides in England and Wales: 2022 registrations’
10. Nakanishi M. et al. (2023), ‘Association between menopause and suicidal ideation in mothers of adolescents:  a longitudinal study using data from a population-based cohort’, Journal of Affective Disorders, 340: 529-534
11. Baca-Garcia E., Diaz-Sastre C., Ceverino A. et al. (2010), ‘Suicide attempts among women during estradiol/low progesterone states’, Journal of Psychiatric Research, 44(4):209-214.