Transdermal Estrogen in Women With Anorexia Nervosa

Anorexia nervosa is a prevalent psychiatric with a lifetime prevalence of up to 2.2%. Among the many medical co-morbidities associated with anorexia nervosa, the most common is significant bone loss, which can persist despite weight recovery. Nearly 90% of women with anorexia nervosa have osteopenia and this low bone mass is associated with an increased fracture risk. Nearly 30% of women with anorexia nervosa report a history of a fracture and a prospective study demonstrated a 7-fold increased risk of fracture in women with anorexia nervosa compared to age-matched controls. Because anorexia nervosa is a chronic disease that can persist despite psychiatric and nutritional counseling, the bone loss and increased fracture risk can persist and lead to lifelong morbidity. Therefore, finding a treatment for bone loss associated with anorexia nervosa is of critical importance.

This 18-month randomized, placebo-controlled study will investigate in women (ages 20 to 45 years old) with anorexia nervosa whether treatment with transdermal estrogen replacement will increase bone mineral density (BMD).

Inclusion criteria

• Female
• 19-45 years of age
• DSM-5 psychiatric criteria for anorexia nervosa
• <85% of ideal body weight as defined by the 1983 Metropolitan Life Insurance Height and Weight Tables
• Amenorrhea
• T-score of < -1.0 at spine or hip

Exclusion criteria

• Diseases known to affect bone metabolism, including untreated thyroid dysfunction, vitamin D deficiency, Cushing's syndrome, diabetes mellitus or renal insufficiency (eGFR < 60)
• Personal history of venous or arterial clot
• History of stroke or myocardial infarction
• History of hypercoagulable disorder
• Personal history or history of a first-degree relative with breast cancer
• History of hereditary angioedema
• Any medication known to affect bone metabolism, including systemic glucocorticoids within three months of the baseline visit, depot medroxyprogesterone within 6 months of the baseline visit, oral bisphosphonates within one year of the baseline visit or IV bisphosphonates within three years of the baseline visit
• Bone fracture within the prior 12 months
• Serum potassium < 3.0 meq/L, serum ALT > 3 times the upper limit of normal or Hemoglobin < 10 g/dL
• Fasting serum triglyceride level > 150 mg/dL
• Pregnant or breastfeeding (or desiring pregnancy within the next 18 months)
• Active substance abuse
• Elevated PTH level
• 25-OH vitamin D level < 20 ng/mL
• Low phosphorus level