Main Article Content

Samira Traboulsi
Leila Itani
Hana Tannir
Dima Kreidieh
Dana El Masri
Marwan El Ghoch


Anorexia nervosa, Body fat percentage, Dual-energy X-ray absorptiometry, Weight restoration, Menstrual resumption


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).
Abstract 1576 | pdf Downloads 696 html Downloads 42 xml Downloads 731


1. Brown C, Mehler PS. Medical complications of anorexia nervosa and their treatments: An update on some critical aspects. Eat Weight Disord. 2015;20:419–25.
2. Mehler PS, Krantz MJ, Sachs KV. Treatments of medical complications of anorexia nervosa and bulimia nervosa. J Eat Disord. 2015;3:15.
3. Gravina G, Milano W, Nebbiai G, Piccione C, Capasso A. Medical complications in anorexia and bulimia nervosa. Endocr Metab Immune Disord Drug Targets. 2018;18:477–88.
4. Nakamura Y, Yoshimura Y, Oda T, Kamei K, Iizuka R. [Amenorrhea due to weight loss]. Nihon Sanka Fujinka Gakkai Zasshi. 1984;36:727–35.
5. Stewart DE, Robinson E, Goldbloom DS, Wright C. Infertility and eating disorders. Am J Obstet Gynecol. 1990;163:1196–9.
6. Hoffman ER, Zerwas SC, Bulik CM. Reproductive issues in anorexia nervosa. Expert Rev Obstet Gynecol. 2011;6:403–14.
7. El Ghoch M, Gatti D, Calugi S, Viapiana O, Bazzani PV, Dalle Grave R. The association between weight gain/restoration and bone mineral density in adolescents with anorexia nervosa: A systematic review. Nutrients. 2016;8:1–16.
8. Idolazzi L, El Ghoch M, Dalle Grave R, Bazzani PV, Calugi S, Fassio S, et al. Bone metabolism in patients with anorexia nervosa and amenorrhoea. Eat Weight Disord. 2018;23:255–61.
9. LaBan MM, Wilkins JC, Sackeyfio AH, Taylor RS. Osteoporotic stress fractures in anorexia nervosa: Etiology, diagnosis, and review of four cases. Arch Phys Med Rehabil. 1995;76:884–7.
10. Murray SB, Quintana DS, Loeb KL, Griffiths S, Le Grange D. Treatment outcomes for anorexia nervosa: A systematic review and meta-analysis of randomized-controlled trials – Corrigendum. Psychol Med. 2019;49:701–704.
11. Dempfle A, Herpertz-Dahlmann B, Timmesfeld N, Schwarte R, Egberts KM, Pfeiffer E, et al. Predictors of the resumption of menses in adolescent anorexia nervosa. BMC Psychiatry. 2013;13:308.
12. Jacoangeli F, Masala S, Staar Mezzasalma F, Fiori R, Martinetti A, Ficoneri C, et al. Amenorrhea after weight recover in anorexia nervosa: Role of body composition and endocrine abnormalities. Eat Weight Disord. 2006;11:e20–6.
13. Katz MG, Vollenhoven B. The reproductive endocrine consequences of anorexia nervosa. BJOG. 2000;107:707–13.
14. Golden NH, Lanzkowsky L, Schebendach J, Palestro CJ, Jacobson MS, Shenker IR. The effect of estrogen-progestin treatment on bone mineral density in anorexia nervosa. J Pediatr Adolesc Gynecol. 2002;15:135–43.
15. Bergstrom I, Crisby M, Engstrom AM, Holcke M, Fored M, Jakobsson Kruse P, et al. Women with anorexia nervosa should not be treated with estrogen or birth control pills in a bone-sparing effect. Acta Obstet Gynecol Scand. 2013;92:877–80.
16. El Ghoch M, Alberti M, Capelli C, Calugi S, Dalle Grave R. Resting energy expenditure in anorexia nervosa: Measured versus estimated. J Nutr Metab. 2012;2012:652932.
17. El Ghoch M, Calugi S, Lamburghini S, Dalle Grave R. Anorexia nervosa and body fat distribution: A systematic review. Nutrients. 2014;6:3895–912.
18. El Ghoch M, Pourhassan M, Milanese C, Muller MJ, Calugi S, Bazzani PV, et al. Changes in lean and skeletal muscle body mass in adult females with anorexia nervosa before and after weight restoration. Clin Nutr. 2017;36:170–8.
19. El Ghoch M, Milanese C, Calugi S, Muller MJ, Pourhassan M, Ruocco A, et al. Regional fat distribution in adolescent and adult females with anorexia nervosa: A longitudinal study. Clin Nutr. 2015;34:1224–32.
20. El Ghoch M, Calugi S, Milanese C, Bazzani PV, Dalle Grave R. Body composition in men with anorexia nervosa: Longitudinal study. Int J Eat Disord. 2017;50:856–60.
21. Probst M, Goris M, Vandereycken W, Van Coppenolle H. Body composition of anorexia nervosa patients assessed by underwater weighing and skinfold-thickness measurements before and after weight gain. Am J Clin Nutr. 2001;73:190–7.
22. Probst M, Goris M, Vandereycken W, Van Coppenolle H. Body composition in female anorexia nervosa patients. Br J Nutr. 1996;76:639–47.
23. Polito A, Cuzzolaro M, Raguzzini A, Censi L, Ferro-Luzzi A. Body composition changes in anorexia nervosa. Eur J Clin Nutr. 1998;52:655–62.
24. Scalfi L, Polito A, Bianchi L, Marra M, Caldara A, Nicolai E, et al. Body composition changes in patients with anorexia nervosa after complete weight recovery. Eur J Clin Nutr. 2002;56:15–20.
25. Mayer L, Walsh BT, Pierson RN, Jr., Heymsfield SB, Gallagher D, Wang J, et al. Body fat redistribution after weight gain in women with anorexia nervosa. Am J Clin Nutr. 2005;81:1286–91.
26. Mayer L. Body composition and anorexia nervosa: Does physiology explain psychology? Am J Clin Nutr. 2001;73:851–2.
27. Bodell LP, Mayer LE. Percent body fat is a risk factor for relapse in anorexia nervosa: A replication study. Int J Eat Disord. 2011;44:118–23.
28. El Ghoch M, Calugi S, Chignola E, Bazzani PV, Dalle Grave R. Body mass index, body fat and risk factor of relapse in anorexia nervosa. Eur J Clin Nutr. 2016;70:194–8.
29. Mayer LE, Roberto CA, Glasofer DR, Etu SF, Gallagher D, Wang J, et al. Does percent body fat predict outcome in anorexia nervosa? Am J Psychiatry. 2007;164:970–2.
30. El Ghoch M, Milanese C, Calugi S, Pellegrini M, Battistini NC, Dalle Grave R. Body composition, eating disorder psychopathology, and psychological distress in anorexia nervosa: A longitudinal study. Am J Clin Nutr. 2014;99:771–8.
31. Prioletta A, Muscogiuri G, Sorice GP, Lassandro AP, Mezza T, Policola C, et al. In anorexia nervosa, even a small increase in abdominal fat is responsible for the appearance of insulin resistance. Clin Endocrinol (Oxf). 2011;75:202–6.
32. Aguera Z, Romero X, Arcelus J, Sanchez I, Riesco N, Jimenez-Murcia S, et al. Changes in body composition in anorexia nervosa: Predictors of recovery and treatment outcome. PLoS One. 2015;10:e0143012.
33. Winkler LA, Frolich JS, Schulpen M, Stoving RK. Body composition and menstrual status in adults with a history of anorexia nervosa-at what fat percentage is the menstrual cycle restored? Int J Eat Disord. 2017;50:370–7.
34. Tinahones FJ, Martinez-Alfaro B, Gonzalo-Marin M, Garcia-Almeida JM, Garrido-Sanchez L, Cardona F. Recovery of menstrual cycle after therapy for anorexia nervosa. Eat Weight Disord. 2005;10:e52–5.
35. Golden NH, Jacobson MS, Schebendach J, Solanto MV, Hertz SM, Shenker IR. Resumption of menses in anorexia nervosa. Arch Pediatr Adolesc Med. 1997;151:16–21.
36. Richardson WS, Wilson MC, Nishikawa J, Hayward RS. The well-built clinical question: A key to evidence-based decisions. ACP J Club. 1995;123:A12–13.
37. Attia E, Roberto CA. Should amenorrhea be a diagnostic criterion for anorexia nervosa? Int J Eat Disord. 2009;42:581–9.
38. El Ghoch M, Calugi S, Pellegrini M, Chignola E, Dalle Grave R. Physical activity, body weight, and resumption of menses in anorexia nervosa. Psychiatry Res. 2016;246:507–11.
39. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. Ann Intern Med. 2009;151:W65–94.
40. Davies S. The importance of PROSPERO to the National Institute for Health Research. Syst Rev. 2012;1:5.
41. Age limits and adolescents. Paediatr Child Health. 2003;8:577–8.
42. El Ghoch M, Soave F, Calugi S, Dalle Grave R. Eating disorders, physical fitness and sport performance: A systematic review. Nutrients. 2013;5:5140–60.
43. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25:603–5.
44. Popay J, Roberts H, Sowden A, Petticrew M, Britten N, Arai L, et al. Developing guidance on the conduct of narrative synthesis in systematic reviews. J Epidemiol Community Health. 2005;59:A7.
45. Review Manager (RevMan) [computer software] Version 5.1. Cochrane Collaboration: Copenhagen D, 2011.
46. Misra M, Prabhakaran R, Miller KK, Tsai P, Lin A, Lee N, et al. Role of cortisol in menstrual recovery in adolescent girls with anorexia nervosa. Pediatr Res. 2006;59:598–603.
47. Arimura C, Nozaki T, Takakura S, Kawai K, Takii M, Sudo N, et al. Predictors of menstrual resumption by patients with anorexia nervosa. Eat Weight Disord. 2010;15:e226–33.
48. Pitts S, Blood E, Divasta A, Gordon CM. Percentage body fat by dual-energy X-ray absorptiometry is associated with menstrual recovery in adolescents with anorexia nervosa. J Adolesc Health. 2014;54:739–41.
49. El Ghoch M, Calugi S, Chignola E, Bazzani PV, Dalle Grave R. Body fat and menstrual resumption in adult females with anorexia nervosa: A 1-year longitudinal study. J Hum Nutr Diet. 2016;29:662–6.
50. Karountzos V, Lambrinoudaki I, Tsitsika A, Deligeoroglou E. The role of total body fat mass and trunk fat mass, combined with other endocrine factors, in menstrual recovery and psychopathology of adolescents with anorexia nervosa. Gynecol Endocrinol. 2017;33:757–62.
51. Tokatly Latzer I, Kidron-Levy H, Stein D, Levy AE, Yosef G, Ziv-Baran T, et al. Predicting menstrual recovery in adolescents with anorexia nervosa using body fat percent estimated by bioimpedance analysis. J Adolesc Health. 2019;64(4):454–60.
52. Cochrane Handbook for Systematic Reviews of Interventions Edited by Higgins JPT GS 2011.
53. El Ghoch M, Alberti M, Milanese C, Battistini NC, Pellegrini M, Capelli C, et al. Comparison between dual-energy X-ray absorptiometry and skinfolds thickness in assessing body fat in anorexia nervosa before and after weight restoration. Clin Nutr. 2012;31:911–16.
54. Favaro A, Santonastaso P. Seasonality and the prediction of weight at resumption of menses in anorexia nervosa. Fertil Steril. 2009;91:1395–7.
55. Frisch RE. Body fat, menarche, fitness and fertility. Hum Reprod. 1987;2:521–33.
56. Brambilla F, Monteleone P, Bortolotti F, Dalle Grave R, Todisco P, Favaro A, et al. Persistent amenorrhoea in weight-recovered anorexics: Psychological and biological aspects. Psychiatry Res. 2003;118:249–57.