ANOREXIA NERVOSA: THE SHATTERED ROSE - Written by Dr. med. Christina de Almeida dos Santos, Psychiatrist

Background

Menopause, the time in a woman's life when she stops having menstrual periods, can be a distressing period of change in her life. At this time, hormone levels are reduced, causing women to experience large physical and mental changes, which can be difficult to adjust to.

October 18th marks World Menopause Day, a day that serves to raise awareness of menopause and options for improving health and well-being. The theme for this year's World Menopause Day is women's cardiovascular health. Women's reproductive experiences such as menstruation, pregnancy, and menopause influence many aspects of women's health and have recently been found to affect the chances of developing cardiovascular disease.

Anorexia nervosa affects 0.5 to 1% of the population, primarily adolescents (aged 12-15), predominantly females (90%), and is prevalent in professions that excessively prioritise Aesthetics and the body, such as models, actresses, dancers, jockeys, gymnasts, and digital influencers.

The term "anorexia" is inappropriate because patients with anorexia nervosa, at least in the early stages of the disease, feel hungry but deny such feelings and reject all forms of food intake. Furthermore, Anorexia Nervosa (AN) is characterised by a drastic reduction in food intake leading to extreme weight loss, intense fear of gaining weight or maintaining weight within the normal range, and a distortion of body image (even when severely underweight, anorexic individuals perceive themselves as fat, plump). In some cases, patients may experience isolated episodes of binge eating followed by purging behaviours to avoid weight gain, such as self-induced vomiting use of laxatives, diuretics, and weight-loss medications.

Recognising Mental Health Shifts

Hormonal changes that accompany menopause can have a large impact on both mental and physical health. Psychological stress, feelings of anxiety, and depression are common emotional symptoms during menopause. Other menopausal symptoms can include:

• Irritability
• Low mood and mood changes
• Low self-esteem
• Forgetfulness
• Poor concentration, often described as 'brain fog'
• Sleep disruptions

Physical changes in menopause can affect self-confidence and self-esteem, and physical discomfort associated with these changes can be distressing for individuals experiencing menopause. Some physiological changes include:

• Mild to severe hot flashes
• Night sweats
• Weight gain
• Hypertension and cardiovascular disease
• Vaginal dryness
• Hair loss or thinning
• Bone density loss
• Joint and muscle aches
• Urinary incontinence caused by weakened pelvic floor muscles
• Urinary tract infections

• Irritability
• Low mood and mood changes
• Low self-esteem
• Forgetfulness
• Poor concentration, often described as 'brain fog'
• Sleep disruptions

Physical changes in menopause can affect self-confidence and self-esteem, and physical discomfort associated with these changes can be distressing for individuals experiencing menopause. Some physiological changes include:

• Mild to severe hot flashes
• Night sweats
• Weight gain
• Hypertension and cardiovascular disease
• Vaginal dryness
• Hair loss or thinning
• Bone density loss
• Joint and muscle aches
• Urinary incontinence caused by weakened pelvic floor muscles
• Urinary tract infections

Clinical Complications

Anorexia nervosa is associated with a variety of clinical complications stemming from malnutrition or inappropriate compensatory methods (such as induced vomiting, use of laxatives, diuretics, enemas, and weight-loss medications; improper use of insulin and thyroid hormones, breastfeeding to lose weight, self-inflicted bloodletting, among others).

Often, these alterations can be reversed with weight restoration and maintaining a better nutritional status. To ensure survival, the body enters a sort of self-cannibalism, consuming its muscles, bones, brain mass, and even organs. As a result, patients with anorexia nervosa present, among other symptoms:

• Reduction in the grey matter of the brain, leading to cognitive impairments;

• Reduction in bone mineral density, potentially leading to osteoporosis;

• Mitral valve prolapse of the heart, with palpitations;

• Pain, muscle weakness, and paralysis;

• Constipation and delayed gastric emptying;

• Thin and brittle hair;

• Dry, yellowish skin covered in lanugo (fine hair layer all over the body);

• Fertility changes;

• Alterations in sodium and potassium levels, potentially leading to life-threatening cardiac arrhythmias

It is worth mentioning that AN is the psychiatric disorder with the highest mortality rate, with staggering rates reaching 18%. One of the principal causes of death is suicide (which is 18 times higher compared to the general population), followed by renal and cardiovascular complications. Approximately 50% of adult patients with AN report suicidal ideation, and up to 26% attempt suicide.

According to the AED (Academy for Eating Disorders), the risk of premature death in a woman with AN is 6 to 12 times higher than in the general population. The vast majority of anorexic patients (70-90%) have comorbidity with other psychiatric disorders, such as depression, anxiety disorders, ADHD, alcohol and substance use disorder, and personality disorders.

The treatment should be multidisciplinary, with a specialised team in eating disorders, which includes a nutritionist, psychologists, psychiatrists, physicians, and physical educators. The main objectives are the restoration of appropriate weight and the normalisation of eating behaviour.

Coping Strategies

Small lifestyle adjustments like eating a balanced diet, prioritising sleep, and engaging in physical exercise can help alleviate mental health symptoms associated with menopause, improve mood and overall emotional health and well-being.

Mindfulness and relaxation techniques are specifically beneficial during this life stage. Mindful breathing exercises like deep breathing, sometimes called belly-breathing, and 4-7-8 breathing can help.

Deep breathing involves breathing in very fully, allowing the stomach to expand with air. This helps deactivate the stress response and activate a state of rest and digestion. Deep breathing has been shown to be effective in pain management and helping calm the body and mind. Learning to use your breath as an anchor, you can become more aware of and control thoughts, feelings, and emotions during difficult times.

4-7-8 breathing is a type of breath work that involves extending the exhale for longer than the inhale - inhaling for 4 seconds, holding the breath for 7, and exhaling for 8. This technique works to calm the stress response, bringing the body and mind into a state of relaxation amid periods of stress.