## **MAT TERS ARISING Open Access** # The broader implications of menstrual health in eating disorders: Matters Arising from Porter (2025) ![](https://assets.reachrx.ai/images/10.1186%E2%98%8Ds40337-025-01516-3/_page_0_Picture_5.jpeg) Gemma Sharp1,2\* ## **Abstract** Menstrual disturbances are a common yet often overlooked feature of eating disorders, impacting individuals across diagnostic categories and age groups. This Matters Arising piece responds to Porter (2025), a survivor-led qualitative study highlighting that menstruation is often treated as a simple health indicator, with little attention to emotional or psychosocial aspects. Specifically, I discuss broader intersections between eating disorder pathology and menstrual health, including functional hypothalamic amenorrhea, oligomenorrhea and menopause-related changes, illustrating how menstrual irregularities reflect disruptions in hormonal and metabolic regulation and carry psychological and identity-related implications. Current clinical approaches frequently overlook these dimensions, focusing narrowly on the presence or absence of menstruation rather than holistic well-being. Drawing on research evidence and clinical experience, I recommend a patient-centred approach that includes routine assessment of menstrual history and symptoms, integration of menstrual considerations into nutritional, medical and psychological treatment plans and sensitive communication regarding emotional and identity-related experiences. Interdisciplinary collaboration and further research are essential to better understand menstrual experiences across the lifespan. Recognising menstrual health as a meaningful component of overall treatment can enhance recovery and provide more comprehensive, empathetic care. ## **Plain English summary** Menstrual health is an important but often overlooked part of care for people with eating disorders. This article responds to a recent survivor-led study by Porter (2025), which found that eating disorder inpatient services often viewed menstruation simply as a sign of physical recovery, with little attention to the emotional or personal meaning of these changes. Building on these findings, this Matters Arising article discusses how eating disorders can affect menstrual cycles in different ways, including missed or irregular periods (amenorrhea and oligomenorrhea respectively) and changes related to menopause. These menstrual disruptions are linked to changes in hormones, metabolism and mental health, and can influence how people feel about their bodies and recovery. Despite this, menstrual health is seemingly rarely discussed in a sensitive or holistic way in treatment. This This comment refers to the article available online at [https://doi.org/](https://doi.org/10.1186/s40337-025-01266-2) [10.1186/s40337-025-01266-2.](https://doi.org/10.1186/s40337-025-01266-2) \*Correspondence: Gemma Sharp g.sharp@westernsydney.edu.au Full list of author information is available at the end of the article ![](https://assets.reachrx.ai/images/10.1186%E2%98%8Ds40337-025-01516-3/_page_0_Picture_14.jpeg) © The Author(s) 2025. **Open Access** This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit [http://creati](http://creativecommons.org/licenses/by-nc-nd/4.0/) [vecommons.org/licenses/by-nc-nd/4.0/.](http://creativecommons.org/licenses/by-nc-nd/4.0/) Sharp *Journal of Eating Disorders* (2026) 14:3 Page 2 of 4 Matters Arising article recommends that clinicians communicate about menstrual health more openly, assess it regularly and consider it in medical, nutritional and psychological care. A more compassionate and comprehensive approach could improve recovery and overall well-being for people with eating disorders. Collaboration between different health professionals and more research are much needed to better understand how menstrual health is affected by the various types of eating disorders at different stages of life. **Keywords** Eating disorder, Menstruation, Amenorrhea, Oligomenorrhea, Functional hypothalamic amenorrhea, Menopause, Hormones, Mental health, Premenstrual syndrome, Premenstrual dysphoric disorder ## **Introduction** This Matters Arising piece responds to Porter, who conducted a survivor-led qualitative study with the aim of investigating the experiences of menstrual health in people experiencing eating disorders in specialised eating disorder inpatient settings [\[1](#page-3-0)]. While menstrual disturbances are relatively well-documented in people with eating disorders [\[2](#page-3-1)], there is limited research examining experiences of amenorrhoea (absence of menstruation) and how the topic is approached by eating disorder services. Thematic analysis was used to analyse qualitative data generated through questionnaires with 13 people with lived experience of inpatient settings and two staff members and three interviews with people with lived experience. An additional subgroup analysis was conducted to further explore the experiences which were specific to the eating disorder context. Questionnaires and interview schedules were informed by the Global Menstrual Collective's definition of menstrual health, encompassing all domains of menstrual experience, including access to information and a stigma-free environment and framing menstruation as a health, not hygiene, issue [\[1](#page-3-0)]. The study identified two major themes: "Conceptualisations of menstruation and 'health' in relation to eating disorders" and "A lack of support related to eating disorders and menstrual health" [[1\]](#page-3-0). The findings showed that eating disorder services placed particular emphasis on the menstrual cycle as a marker of health, informing patient meal plans and weight targets. However, there was a lack of discussion regarding amenorrhea and how patients' menstrual cycles may be impacted by their eating disorders. Furthermore, the emotional impact of managing the return of menstruation and its significance within the context of their eating disorder was not adequately addressed. Invasive practices, such as requiring patients to display used menstrual products to staff as evidence of menstruation, were reported. Such scrutiny can manifest in unnecessary and distressing practices that violate privacy and autonomy. Porter concluded that while the menstrual cycle is an important consideration in the treatment of people with eating disorders, this should extend beyond monitoring the presence or absence of menstrual cycles to consider a more holistic perspective of menstrual health [\[1\]](#page-3-0). I could not agree more with the conclusions from Porter [\[1](#page-3-0)]. From my own team's research (e.g., [[3–](#page-3-2)[5\]](#page-3-3)) and clinical experiences and the work of other scholars (e.g., [[6–](#page-3-4)[9\]](#page-3-5)), it seems that menstrual health is often overlooked in eating disorder treatment settings, particularly for those older than the adolescent/young adult stages and for eating disorders other than anorexia nervosa. In the interests of promoting a more comprehensive approach to menstrual health, this Matters Arising piece briefly highlights considerations that could be incorporated into both clinical practice and research in eating disorder settings. ## **Menstrual cycle disturbances** Menstrual cycle disturbances are among the most common gynaecological issues associated with eating disorders [[2\]](#page-3-1). These range from oligomenorrhea, where menstrual cycles are infrequent and exceed 35 days, to amenorrhea. Such irregularities occur frequently in both adolescents and adults with eating disorders [[6,](#page-3-4) [7](#page-3-6)]. Studies have shown that 60 to 85% of individuals with anorexia nervosa experience amenorrhea during weight loss, while others develop it before or after significant weight changes [\[6](#page-3-4), [7\]](#page-3-6). Similarly, about half of women with bulimia nervosa experience oligomenorrhea or amenorrhea, and having a higher weight is also linked to menstrual irregularities [\[2](#page-3-1), [8\]](#page-3-7). Different eating disorders are associated with varying rates and mechanisms of menstrual dysfunction. Amenorrhea affects around 66 to 84% of women with anorexia nervosa and 6 to 11% report oligomenorrhea [\[2](#page-3-1), [7](#page-3-6)]. In bulimia nervosa, 7 to 40% of women experience amenorrhea and 36 to 64% report oligomenorrhea [[2](#page-3-1), [7](#page-3-6)], often linked to disruptions in the hypothalamic-pituitarygonadal axis from energy restriction and purging behaviours [[2,](#page-3-1) [6\]](#page-3-4). Binge eating disorder is also associated with menstrual disturbances, likely due to hormonal dysregulation caused by binge eating episodes [[9](#page-3-5)]. These episodes, often high in fats and carbohydrates, trigger insulin release, which can increase testosterone levels and impair ovulation, leading to menstrual dysfunction [\[9](#page-3-5)]. Thus, eating pathology and menstrual irregularities share complex metabolic and hormonal pathways, emphasising the menstrual cycle's role as a crucial indicator of reproductive and metabolic health in eating disorders. Sharp *Journal of Eating Disorders* (2026) 14:3 Page 3 of 4 ## **Functional hypothalamic amenorrhoea** In most cases where amenorrhea is associated with eating disorders, it is secondary, meaning menstruation ceases after menarche (first menstrual period) and a time of relatively regular cycles [\[2](#page-3-1)]. Functional hypothalamic amenorrhoea (FHA) is a common cause of secondary amenorrhea, leading to oestrogen deficiency in otherwise healthy pre-menopausal people [\[10](#page-3-8)]. Though FHA can be reversed, it arises from suppression of the hypothalamicpituitary-ovarian axis due to factors such as psychological stress, restrictive eating, excessive physical activity or a combination of these influences [\[2](#page-3-1), [11\]](#page-3-9). Although FHA is common, it has been deemed a diagnosis of exclusion. Other considerations, such as polycystic ovary syndrome, should be taken into consideration and appropriate treatment offered accordingly - for extensive review, see [\[10](#page-3-8)]. ## **Menopause transition** There is also the issue of amenorrhea and/or oligomenorrhea in midlife and the intersection with the menopause transition, which is typically evidenced by the permanent irreversible cessation of menstrual periods. In my team's own research, we found that women in midlife experiencing eating disorders were particularly confused about their menstrual cycle status with some even mistakenly believing their eating disorder prevented menopause from occurring [[4\]](#page-3-10). While both menopause and FHA involve reduced oestradiol levels, they differ hormonally. Follicle-stimulating hormone (FSH) levels are typically low in FHA but are elevated during the menopause transition and post-menopause and this can be investigated through blood examination [[4,](#page-3-10) [10\]](#page-3-8). However, without blood testing, symptom overlap between FHA and menopause, such as mood disturbances, can make differentiation difficult, though vasomotor symptoms (e.g., hot flushes, night sweats) are characteristic of menopause [\[10\]](#page-3-8). Not all women experience these vasomotor symptoms and those with eating disorder-related FHA may find it difficult to recognise when they have reached menopause, potentially delaying or complicating access to appropriate healthcare. #### **Psychosocial factors** ## **Menstrual status, identity and care legitimacy** As Porter reported, there can be a wide range of psychosocial responses to disruption of the menstrual cycle [[1\]](#page-3-0). Some people with eating disorders may believe that their lack of menstrual period validates that they are "sick enough" for treatment and if their period returns, they are no longer worthy of care [\[1](#page-3-0)]. ## **Emotional, sensory and mood-related consequences of menstrual change** There is also the potential to feel "disgust" or "dirty" when bleeding, particularly when not used to this bodily experience [[1\]](#page-3-0). This may be particularly pronounced and/or distressing for neurodivergent populations, where eating disorders are common, and there may be differences in sensory information processing [\[12\]](#page-3-11). Furthermore, the return of menstrual cycles may also mean the return of potentially undesirable premenstrual syndrome (PMS) symptoms, such as mood disturbances, irritability, bloating, breast tenderness, and even the more severe premenstrual dysphoric disorder (PMDD), which has been linked with greater risk of suicidal behaviours [\[13](#page-3-12)]. Both PMS and PMDD have been associated with greater odds of experiencing binge eating episodes [\[14,](#page-3-13) [15](#page-3-14)]. Some individuals with a history of amenorrhea may have engaged in restrictive eating practices in an effort to prevent the return of menstrual periods, fearing that menstruation could exacerbate binge eating. ## **Menstruation and identity across the lifespan** More broadly, menstruation status can have impacts on self-identity. For example, a young person starting to menstruate may be concerned about transitioning to an adult form of their body and changes in attitudes of those around them, such as unwanted sexual attention [[16\]](#page-3-15). It can also be the case that the permanent cessation of menstruation through menopause can be perceived by some as no longer being of value to society owing to the loss of fertility [\[17](#page-3-16)]. ## **Conclusions** As reported by Porter, menstrual health is a critical yet commonly overlooked aspect of care in eating disorders, extending beyond adolescence/young adulthood and across diagnostic categories [\[1\]](#page-3-0). Current practices frequently reduce menstruation to a binary marker of health, neglecting its broader physical, psychological and social significance. FHA, oligomenorrhea and menopause-related changes intersect with eating disorder pathology, affecting hormonal regulation, metabolic health and self-identity. ## **Clinical recommendations and future directions** Clinicians should adopt a holistic, patient-centred approach which involves routinely and comprehensively assessing pubertal and menstrual history and symptoms. Menstrual health should inform treatment planning, involving nutritional, medical (including endocrinology and gynaecology) and psychological interventions, with attention to emotional impacts such as PMS, PMDD or menopause-related concerns. Interdisciplinary collaboration and ongoing education are essential and further research is sorely needed to explore menstrual experiences across the lifespan and eating disorder spectrum. Integrating these considerations can support recovery, improve well-being and ensure that menstrual health is treated as a meaningful component of overall care. #### **Abbreviations** FHA Functional hypothalamic amenorrhoea FSH Follicle-stimulating hormone PMDD Premenstrual dysphoric disorder PMS Premenstrual syndrome #### **Acknowledgements** Not applicable. #### **Author contributions** G.S. led conceptualisation, writing - original draft, writing - review and editing. #### **Funding** None to declare. #### **Data availability** Not applicable. ## **Declarations** #### **Ethics approval and consent to participate** Not applicable. #### **Consent for publication** Not applicable. #### **Competing interests** The authors declare no competing interests. #### **Author details** School of Psychology, Western Sydney University, Locked Bag 1797, Sydney, Penrith, NSW 2751, Australia Department of Neuroscience, Monash University, Melbourne, Australia ## Received: 4 November 2025 / Accepted: 24 December 2025 ## **References** 1. 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