Women are more prone to eating disorders than men. Statistics indicate that 80 to 90% of all people who suffer from eating disorders are women. This is usually explained by “cultural” differences: in the fashion industry, media and cinema, female beauty is synonymous with a thin body; girls are brain-washed to believe they must have little or no body fat to be attractive. But this is not the whole story.
New research suggests that the menstrual cycle and the production of sex hormones are equal, or even more important, factors. Although both men and women produce sex hormones, women experience a monthly hormonal cycle from puberty to menopause. And the cyclical nature of sex hormone production has a powerful impact on appetite for both human and non-human female animals.
Although very little has been written on this subject, many women know intuitively that their relation to food changes across the menstrual cycle. It is common in my psychotherapy practice to hear female patients comment, “I was PMSing and couldn’t stop eating”, or “I always binge on chocolate right before I get my period”.
Theresa Kinsella, a nutritionist in New York City who specializes in work with eating disordered women reports, “I have one client who is overweight and a binge eater. She calls her PMS phase, ‘the monster’ and has cravings for chocolate, frozen yogurt and candy. ‘But it’s over’, the client observes, ‘the second I start to bleed’”
Kelly Klump, Ph.D., a research psychologist and professor at Michigan State University, studies the etiology of eating disorders with an emphasis on genetic and neurobiological factors. Dr. Klump and associates have demonstrated empirically that certain hormones are implicated, not only with regard to changes in appetite during the menstrual cycle, but in body image as well.
In a recent issue of the International Journal of Eating Disorders she and her associates examined changes across the menstrual cycle in two independent samples of women and found a direct effect of sex hormones on both appetite and body image.
The researchers found that both binge eating and body dissatisfaction peaked during the pre-menstrual, or luteal phase, when there is increased progesterone production. Estrogen, highest just before ovulation in the follicular phase, has been found to be an appetite suppressant.
In a recent conversation, Klump told me that binge eating during the pre-menstrual phase and appetite suppression during the follicular phase is also found in non-human animals. Animals show the same pattern of binge eating during the pre-menstrual phase, and appetite suppression during the follicular phase. So, in addition to cultural factors, biology clearly contributes to female eating behavior.
Klump also found that during the pre-menstrual phase, when progesterone production is at its highest, women were less satisfied with their bodies. How do hormones affect body (dis)satisfaction? Klump hypothesizes that progesterone leads to binge eating, which then triggers body dissatisfaction. In addition, progesterone contributes to pre-menstrual anxiety, a state that can make women feel more critical of their bodies.
What are the implications of this research for the treatment of eating disorders? Just as women with mood disorders are more prone to an increase in symptoms during the pre-menstrual phase, women who express anxiety and depression through disordered eating, particularly binge eating, would be expected to show an increase in symptoms during the pre-menstrual phase. This is exactly what Klump’s research found!
Jean Petrucelli, Ph.D., Director of the Eating Disorders, Compulsions and Addictions Service at the William Alanson White Institute emphasizes the importance of creative treatment strategies. She asserts that eating disorder symptoms are not something to simply eradicate, but rather part of a story about the patient’s relational experience with caretakers. She stresses the importance of helping patients become aware of all that contributes to their disordered eating.
Dr. Petrucelli often recommends patients keep a food journal as a vehicle for examining symptoms. The journal is a record of eating times, locations, and food choices, as well as associated feelings and eating disorder “behaviors”. She may suggest patients email a report of their weekly food intake and other ingested substances (alcohol, laxatives, diuretics, drugs, etc.) prior to meeting with her. Pictures of plates of food may also be included when portion sizes are in question. Active documentation helps alert the patient to feelings and experiences that trigger disordered eating.
Given the new research findings implicating sex hormones in eating behavior, it’s likely useful to expand the journal to include notes about the timing of menstrual cycle phases.
In recognition of Eating Disorders Awareness Week, let’s make an effort to become aware of the effect of sex hormones and the menstrual cycle on appetite and body image.
Susan Kolod, Ph.D. is a Supervising and Training Analyst, member of the Faculty, co-Editor of the blog, Contemporary Psychoanalysis in Action and on the Steering Committee of the Eating Disorder, Compulsions and Substance Abuse Program (EDCAS) at the William Alanson White Institute. She has lectured and written about the impact of hormones on the psyche with a particular focus on sexuality, menopause and the menstrual cycle. She is in private practice in Brooklyn and Manhattan.