Mental Health Concerns and Eating Disorders During Perimenopause

What is Perimenopause?

Perimenopause is the life stage when a woman’s body transitions toward menopause (the end of her reproductive years, when the body no longer produces eggs). Perimenopause typically begins sometime in a woman’s 40’s, but there can be significant variance with some women noting changes in their 30’s, and some not until their 50’s.

The perimenopause period usually lasts between 5-10 years, and in Australia the average age for reaching menopause is 51 years.

Menopause is most often a natural life event, but it can also be triggered by gynaecological surgeries or the use of certain medications (including some treatments for cancer). Perimenopause can be experienced by all people assigned female at birth (AFAB) who sill have their ovaries, including trans-men.

Why is it important that we know about Perimenopause?

Perimenopause can bring a variety of physical and emotional changes which significantly impact on wellbeing and quality of life. These changes vary in severity from person to person, and across the perimenopausal period. There’s a lot that can be done to support women during perimenopause, and it’s important that everyone is aware of the symptoms associated with this time, considering how they can support women during the transition. Some of the compounding factors which can exacerbate the experience of perimenopause are isolation, misinformation, judgement, and a lack of care or support.

There are numerous mental health concerns which women transitioning through menopause may experience, along with increasing risk of cardiovascular disease and reduced bone density. Women at midlife also have significantly increased risks of mental health concerns such as depression and anxiety, and an increased risk for the development or re-occurrence of an eating disorder.

Common symptoms of Perimenopause

According to a 2023 study conducted by the Jean Hailes Foundation for Women’s Health, approximately 20% of women experience no symptoms of perimenopause at all. For those who do experience symptoms, these can be triggered by fluctuating hormone levels, which often coincide with major life changes and stressors associated with midlife. The range of symptoms which may be attributed to perimenopause can include, but are not limited to, those below.

Some possible physical symptoms of perimenopause:

• Irregular or missed periods, or changes in menstrual flow

• Changes in ovulation patterns

• Hot flushes and night sweats

• Sleep disturbance

• Fatigue and headaches

• Muscle and joint aches

• Vaginal dryness and breast tenderness

• Bladder weakness and more frequent urge to urinate

• Skin dryness and sensitivity

• Loss of libido or reduced sexual pleasure

• Altered digestive patterns and tolerance of foods

• Changes in body shape, size and composition

Some possible mental and emotional symptoms of perimenopause:

• Feeling anxious or irritable

• Low mood or mood swings

• Forgetfulness or ‘brain fog’, difficulty concentrating

• Difficulty coping with life events

• Challenges adjusting to your changing body

Perimenopause and Mental Health

The emotional challenges of perimenopause should not be underestimated. Hormonal fluctuations associated with this life phase are linked to an increased risk of anxiety and depression, even for those without a prior history of mental health issues.

Research has found an increase in suicidal thoughts for women at midlife, and completed suicide rates for women in Australia are highest in the perimenopause period.

Physical symptoms like night sweats, brain fog and fatigue can exacerbate mood disturbances. Additionally, perimenopause often coincides with major life changes such as retirement, family and relationship changes, increased caregiving responsibilities, and personal loss, which can all contribute to increased stress.

The changing relationship with the body during menopause can also present a significant change for many women. There may also be a period of adjustment as women come to terms with no longer experiencing monthly reproductive cycles, which can impact on identity and the experience of femininity.

Body size and shape changes during Perimenopause

Perimenopause often brings significant changes in body weight, shape and composition. While hormonal changes contribute to these shifts, other factors such as lifestyle changes also have an impact. Women transitioning through menopause may also notice changes in their appetite and digestive patterns. The aging process, which naturally decreases lean muscle tissue, can make it more challenging to maintain muscle mass and manage weight. Additionally, weight cycling, or repeated dieting, can lead to further muscle loss and fat gain over time.

All of these factors can add more stress for women in perimenopause, especially when faced with diet culture messaging about body ideals and fear of weight gain.

A balanced perspective on understanding and accepting the naturally occurring body changes, while also focusing on nutrition and activity levels for optimal wellbeing is important, particularly to avoid extreme or all-or-nothing responses to the changing body.

Eating Disorders and Perimenopause

Eating Disorders can be experienced by people of all ages and all genders. Traditionally thought of as conditions impacting young women, we now know that the rates of eating disorders being experienced by older women are increasing, and are a significant concern at midlife. These mid life eating disorders can be triggered by the changes of perimenopause, and may be either a first presentation at midlife, or a re-occurrence of a condition which had been experienced earlier in life.

According to the Butterfly Foundations ‘Paying the Price’ report (2024), almost one in four people experiencing an eating disorder in Australia each year are aged between 40-59. When sub-threshold eating concerns are included, 15% of perimenopausal women report at least some elements of disordered eating.

Major hormonal shifts experienced by women during perimenopause, like those experienced during puberty, pregnancy and postpartum periods, combine with pressures on women to meet cultural ideals of thinness and ‘anti-ageing’ to create a high risk period for the development of an eating disorder. Significant life events and stressors such as increased caregiving responsibilities or significant lifestyle changes can also trigger challenging eating behaviours and body image dissatisfaction in midlife.

Eating disorders during perimenopause are often overlooked by health professionals, who may not be aware of the prevalence of these conditions for women at midlife.

This is particularly notable when the full range of eating disorder presentations is considered, including Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, and Other Specified Feeding and Eating Disorders. Midlife eating disorders can have complex and serious health consequences, as the body is more vulnerable to complications such as digestive issues, osteoporosis, and dental problems, and fluctuating eating patterns can also exacerbate many of the symptoms of perimenopause.

“Drawing on a summary of evidence by Samuels, Maine & Tantillo (2019), factors which contribute to body dissatisfaction and eating disorder prevalence in midlife include:

• Stress and anxiety in relation to the physiological changes of ageing, which can contribute to feelings of loss of control in the context of a culture that valorises youthfulness

• The impact of weight suppression and disordered eating over many decades of life

• The lack of older women role models amidst ageist social norms which frame ageing as something to defy and combat with diet, exercise and medication regimes

• The ongoing impact of diet culture, where disordered eating is framed as normal behaviour from a young age

• High levels of body dissatisfaction among women aged 50 and over

• Experiences of shame, stigma and isolation, given that eating disorders are stereotyped as illnesses affecting young people, and health professionals may perceive older people as ‘too old to have an eating disorder’.”

(From The Butterfly Foundation: ‘Eating Disorders and Body Dissatisfaction During Menopause’.)

Seeking help during Perimenopause

The hormonal and life changes associated with perimenopause can be challenging, with the difficulties exacerbated for people who feel isolated and unsupported during this time. If you or someone you know is struggling with the symptoms of perimenopause, or may be experiencing body dissatisfaction or eating disorder symptoms during midlife, the team at Mind Body Well can offer support and guidance to help navigate this phase. We also recommend the links below for further information.

• Australasian Menopause Society

• Jean Hailes Foundation for Women’s Health

• Perimenopause Symptom Checker

• Eating Disorders Victoria free online course - Menopause and Eating Disorders

• Butterfly Foundation - ‘Paying the Price for Eating Disorders’

Our Director Janet Lowndes reflections after attending the Asia Pacific Conference on Women’s Mental Health in October, 2024. (General information only, please consult your health professionals for individualised medical or psychological advice).

Body Image and Eating Disorders Awareness Week 2024

September 2-8, 2024 is Body Image and Eating Disorders Awareness Week

Body Image and Eating Disorders Awareness Week (BIEDAW) is an annual health promotion campaign raising awareness about body image concerns and eating disorders. This year the focus is on communication - assisting people to consider the impact of what they say about bodies - both their own and others.

The following statements from The Butterfly Foundation provide some helpful alternatives to diet culture talk.

Head over to The Butterfly Foundation website to see more information and helpful resources including a very useful script to help you advocate for yourself when visiting health professionals, including Doctors.

Ramadan and Eating Disorders

What is Ramadan?

Ramadan is a holy month of significance for Muslims. It is a period of 29-30 days where Muslims are challenged to increase in all forms of worship, revive their awareness of God and in turn, achieve a deeper connection. An integral expression of this is demonstrated through spiritual fasting (sawm).

Spiritual fasting involves abstaining from eating or drinking from dawn until sunset. The intention behind spiritual fasting distinguishes the act from other forms of fasting which may be intended for weight control or influencing metabolism.

For Muslims, fasting in Ramadan is a shared experience and therefore increases community connection. It is obligatory on all those who are capable (physically, financially, mentally etc) and of mature age (passed age of puberty). There are many conditions and circumstances, however, that exempt followers from needing to fast, especially if it poses a significant threat to a person’s health and well-being.

Every year, there will be millions of Muslims around the world who are unable to or struggle to fast due to their situation (including an active eating disorder). There are concessions that exist and can be verified by local religious leaders (e.g. an Imam). Nevertheless, the nature of an eating disorder is inherently encouraging of fasting and restriction and an eating disorder gaining control can be seamlessly disguised as religious practice. This can make seeking help extremely difficult and lead to feelings of shame, dismay and isolation.

Things to consider around Ramadan and eating disorder recovery

Eating disorders exist in all community groups and Ramadan can be a challenging time for Muslims who have an active eating disorder, or a lived experience of one.

A daily cycle exists of waking up early to eat, fasting during daylight, followed by breaking the fast at sunset. For a person who is unwell with an eating disorder, this cycle can trigger eating disorder thoughts and can even be contrary to their prescribed treatment. If this is the experience for you or someone you know, it is important to consider the following:

• You are not alone

• Speak to your GP about accessing professional support if you’ve not yet done so

• It is recommended to discuss your concerns with your treatment team and religious leader (e.g. an Imam) ahead of time in order to plan for Ramadan

• You may be able to decide on an adapted fasting schedule according to your needs and progress in recovery (e.g. fasting alternate days or fasting on shorter days of the year)

• Reflect on your intention behind fasting – are you fasting to express your religious beliefs or are you intending weight loss? Are you finding it impossible to eat sufficiently before dawn? Are you feeling this urge to delay breaking fast at sunset?

• If there is a supportive person in your family or community that you can talk to, it can be helpful to do so. There can be a lot of focus and conversation around food during Ramadan which is anxiety-provoking and having someone to turn may help you navigate that.

• It may be that you are not medically safe to participate in fasting at your current stage of recovery and that’s OK. Focusing on recovery today can mean that you can observe Ramadan more fully in the future.

Even if you are currently unable to fast, you can choose to explore the many other ways of practicing your faith that are also encouraged in Ramadan.

Other ways to participate in Ramadan

• Prayer and practicing mindfulness

• Donating time/clothes/food/money to people in need

• Preparing meals for others

• Attending Friday or night prayers at the local Mosque

• Appreciating that seeking treatment, taking steps towards recovery is honourable and an act of worship itself

Eid celebrations

As with Ramadan, Eid can be wonderful celebration with family and friends for millions of people worldwide. However, for people with an eating disorder, it can be a challenging time. They may even dread the day.

Festivities like Eid, will almost always involve special food in abundance and cultural traditions which can be triggering. In the lead up to Eid, it’s important that you express any fears you have with your support network (e.g. your treatment team, partner or family member). This can help you feel prepared and provide a sense of safety.

Journaling is a great way to put words to some of the emotions we feel and a useful release in addition to voicing our concerns with others. We can also use a journal to plan ahead for the festive day which could involve setting reminders to eat regular meals and snacks, scheduling time to check-in with ourselves and rest.

If there are some aspects of Eid that are more confronting for you (e.g. menu planning/cooking), then you might like to involve yourself with other aspects instead (e.g. decorating your home or organising gifts).

We can accept that some level of anxiety is to be expected and that it’s okay to have these feelings. Remind yourself that, like any other day, the day will pass. Try your best to be kind to yourself.

Blog post written by Aneela Panhwar, Accredited Practising Dietitian at Mind Body Well.

Challenging Stereotypes: Masculinity and Eating Disorders

For far too long, eating disorders have been stereotypically associated with women, most commonly young women. However, the truth is that eating disorders do not discriminate based on gender, size, sexual orientation, cultural background, age, or ability. Men, too, grapple with these complex mental health conditions, and it's time to break the stigma surrounding men and eating disorders. In this article, we shed light on the prevalence of eating disorders among men, the unique challenges they face, and how we can challenge societal norms to support those in need.

Eating Disorders in Men: The Numbers Speak

Recent statistics from Australia's Butterfly Foundation revealed a significant presence of eating disorders among men. It is estimated that over one-third of eating disorder presentations are seen among men, with 360,131 Australian men living with an eating disorder (Butterfly, 2019).

According to the National Eating Disorders Collaboration, it is estimated that men account for:

• 20% of people in Australia who experience Anorexia Nervosa

• 30% of people in Australia who experience Bulimia Nervosa

• 43% of people in Australia who experience Binge Eating Disorder

• 55-77% of people in Australia who experience Other Specified Feeding or Eating Disorder (OSFED)

• 67% of people in Australia who experience Avoidant Restrictive Food Intake Disorder (ARFID)

Heightened Risk Among Certain Groups

Certain groups of men face a higher risk of developing eating disorders. This includes queer men, transmen, gender diverse groups, and men involved in fields that promote specific body ideals or physiques, such as athletes, bodybuilders, and actors.

Unique Presentations in Men

Eating disorder presentations among men may differ from those commonly associated with women, or they may also be very similar. Men may focus on low body fat and high muscularity as well as weight. They might also be more concerned with high protein foods and counting macros, as well as engaging in excessive or compulsive exercise with an emphasis on muscle appearance. Concepts like ‘bulking’ and ‘shredding’ and the use of supplements and performance-enhancing drugs can also be prevalent.

The Impact of Stigma

Unfortunately, eating disorders among men are often underreported due to the stigma surrounding these conditions. The stigma can lead to a lack of awareness of symptoms, misdiagnosis, delayed diagnosis, difficulty accessing appropriate treatments, and a feeling of exclusion from available treatments.

Cultural Expectations and Norms

Cultural expectations and ideals surrounding body size and appearance can play a significant role in the development of eating disorders among all genders, including men. Society's narrow definition of masculinity, characterised by being muscular, strong, stoic, and independent, contributes to the pressure men face to conform to unrealistic body ideals. ‘Diet culture’ preys on this by promoting fasting, high protein products, and ‘biohacking’ – all of which contribute to the normalisation of disordered eating behaviours and a focus on gaining muscle.

Challenging Stereotypes: Redefining Masculinity

To address the stigma and promote a healthier understanding of masculinity, it’s important that we challenge existing stereotypes and societal norms. Here are some prompts to think differently:

1. Question the origins of the narrow definition of masculinity, and how this impacts the lives of men and masc folk

2. Develop media literacy skills to recognise how masculinity is portrayed

3. Notice how diet culture products are marketed toward men and women

4. Learn about the gendered and socialised nature of emotions

5. Explore and redefine masculinities, encouraging a broader and more inclusive sense of identity

Seeking Help: An Act of Courage

Remember that all people are worthy of support, and seeking treatment is a brave and essential step for anyone struggling with an eating disorder, regardless of gender. At Mind Body Well, our team of Psychologists and Dietitians is here to support you on your journey to a healthier relationship with food, exercise, your body, and identity. We welcome people of all genders, ages, sexual orientations, and cultural backgrounds.

Getting Away for the Holidays?

Many people have mixed feelings about the holiday season - while it can be a time of joy there can also be significant challenges for people with eating disorders or body image concerns.

These challenges can be even more intense when you’re planning to go away for holidays, or to visit family. Time away from home can bring changes to routine and daily activities; spending time with different or more people than usual; different food availability or access; increased social eating; and reduced access to usual coping strategies or activities. We’ve put together some suggestions to help prepare for the holiday season.

Food and eating suggestions

• Discuss your holiday with your treatment team, and problem solve to make a plan together

• Where possible, plan at least some of your meals, and think about when you might eat out or do your food shopping

• Have some easy options available while travelling, pack snacks or foods you’re more comfortable and familiar with and use these as a back-up when needed

• Work with your Dietitian to consider what a balance of safe and challenging foods might be like for you during the trip

• Pack clothing you feel most comfortable in

Support suggestions

• Have a trusted person you can debrief with - a friend or family member. It’s ok if the person isn’t with you on the trip, plan some phone check-ins with them if needed

• If you know you need plenty of alone or quiet time, let the people around you know and plan it in advance

• Think about different types of supports outside your immediate network, e.g. helpful social media accounts, helplines or online chats (see below)

• When you’re in social eating situations, trying to focus your attention on being present with the people around you and use this as a distraction to help you avoid over-thinking about food

Coping suggestions

• Think about distractions or activities you find helpful at home which you could take with you, e.g. journalling, knitting, reading, puzzles

• Write yourself a list of helpful coping strategies which you can use as a reminder when things get difficult, e.g. distraction, urge surfing, challenging thoughts, mindfulness or self-compassion practices

• Prepare some resources to keep you motivated while you’re away, e.g. podcasts, books, social media accounts. Check out our inspiring links

• Where possible, try to pay attention to things you enjoy or feel grateful for while you’re away, e.g. being able to travel, basking in the sunshine, spending time with people you care about

• Remember this is a temporary situation and you will soon be back in your familiar comfort zone

Useful Services

• Eating Disorders Victoria Hub

• Butterfly Foundation Helpline

A Non-Diet Understanding of PCOS

September is Polycystic Ovary Syndrome (PCOS) awareness month. PCOS is a very common condition which affects between 12-21% of cisgender women and transgender/gender diverse people with ovaries during their reproductive years, with around 21% of First Nations people in this group being impacted. For many people diagnosed with PCOS the automatic recommendation from their medical team is to lose weight, or to prevent weight gain. This recommendation can however be highly problematic, so let’s explore the rationale behind weight loss advice for PCOS, and whether this is helpful management strategy (spoiler alert: it’s not!).

Summary of PCOS

• Symptoms of PCOS may include irregular or absent menstrual periods, fatigue, excess hair growth on the face and body, hair loss on the scalp and difficulties with fertility. Contrary to popular belief, you do not need to have cysts on your ovaries to have PCOS, however this is a common symptom

• Hormones play a big role when it comes to PCOS symptoms. People with PCOS often have higher levels of androgens including testosterone, as well as insulin resistance which means that our bodies are not able to use insulin to get glucose from our blood into our cells as effectively

• PCOS can cause chronic inflammation which can further disturb our hormones and increase risk of chronic health conditions including cardiovascular disease. Other factors that are common in PCOS and can increase inflammation include poor sleep and stress

• PCOS is also linked with a range of mental health conditions including depression, anxiety and eating disorders

• There is currently no cure for PCOS, however there are a range of options for managing PCOS symptoms and for enhancing quality of life

PCOS and weight

A significant proportion of people with PCOS live in larger bodies or report struggling to ‘manage’ their weight. Folks with PCOS often report that they find it hard to lose weight but very easy to gain it. One of the contributing factors to this is high levels of insulin and insulin resistance. Insulin is a growth hormone, so high levels tend to cause increases in weight.

One of the most common recommendations for PCOS management is to lose weight, often without taking peoples previous weight history into account. PCOS treatment guidelines often recommend reducing weight to improve PCOS symptoms and related biomarkers (i.e. blood test results such as testosterone or blood glucose), however sustained weight loss is very challenging and in many cases not possible, including for those with PCOS.

The good news? Other management strategies that don’t require weight change can be very effective in improving symptoms and biomarkers. And let’s not forget that people in bodies of all sizes can have PCOS, so it’s very important that weight loss not be focused on as a ‘one size fits all’ treatment.

Do weight loss diets work for PCOS?

Diets are unhelpful for the majority of people with PCOS for a number of reasons:

1. Diets don’t work for the absolute majority of people. 95-97% of people who engage in dieting to lose weight regain most or all of the weight within 2-5 years. 2/3 of those people gain more weight, and end up with a higher weight than where they started. For the majority of people of diet, this results in weight cycling with weight trending upwards over time. Weight cycling can increase the risk of chronic conditions such as cardiovascular disease.

2. Dieting increases the risk of developing an eating disorder. Eating disorders and disordered eating are common in PCOS, and dieting behaviour can add further fuel to the fire by creating an environment of restriction and preoccupation with food, weight and shape. Restrictive eating patterns or cutting out certain foods can actually increase the risk for binge eating – due to the all or nothing cycle which is stimulated by food restriction. This is often followed by an ongoing restrict-binge cycle, which creates an unhelpful eating pattern and relationship with food which can evolve into an eating disorder.

3. Some PCOS diet plans recommend cutting out entire food groups to manage PCOS. This can increase the risk of nutritional deficiencies, and as with any other restrictive diet can increase fixation on food and either further restrictive eating, or responsive binge eating episodes.

4. Insulin resistance is a common symptom of PCOS. With insulin resistance comes high insulin levels in the blood, which can impact our hunger and fullness signals because it stimulates our appetite. People with insulin resistance often report experiencing intense food cravings, particularly for foods rich in carbohydrates. This is because your body is not able to use the insulin in your body effectively to transport glucose from your blood into the cells, so it can literally feel like you are starving. The extreme hunger and food cravings often lead to binge eating episodes, which can then further increase insulin levels – and so the cycle continues.

5. What about carbs? You wouldn’t be alone in thinking that reducing your carbohydrate intake will prevent high insulin levels or insulin resistance. On the contrary - the stress experienced when following a restrictive diet can increase inflammation, which is actually linked with insulin resistance. Most people who have tried low carb diets find them to be too restrictive and ultimately unsustainable long term. Our bodies need carbohydrates from our food because carbs provide every cell and organ in our body with the energy they need to function. You know that pounding headache you get when you’ve eaten a low carb meal or haven’t eaten for a long time? That’s your brain screaming out for glucose. Low carb diets can lead to low energy, brain fog and mood changes, and also create a high risk of binge eating episodes.

So, if not dieting for PCOS what can I do instead?

• Discuss treatment options with your GP. There are a range of different medications, supplements and treatments that may help with managing your PCOS symptoms. It could also be helpful to see a reproductive specialist as part of your PCOS treatment team for more specialised advice and treatment options.

• Eating regular meals and snacks can assist to improve insulin sensitivity, regulate blood glucose levels and help to support energy levels. Giving your body adequate and consistent fuel can also help to regulate appetite and reduce binge eating.

• See a Dietitian who specialises in PCOS nutrition using a non-diet and weight inclusive approach. The Dietitian will be able to tailor recommendations to manage your PCOS symptoms and to support you to improve your relationship with food.

• Find a way to move your body that’s comfrotable, accessible and enjoyable for you. Movement is linked with improve insulin sensitivity, mood and sleep quality, as well as reducing long term risk related to chronic health conditions.

• Managing your stress levels can assist with reducing inflammation and improving overall mental health and wellbeing. You could also consider seeing a Psychologist to assit with developing healthy emotional coping and stress management strategies.

• Get enough sleep! Inadequate or poor quality sleep can increase inflammation, and feeling tired can contrinute to binge eating, so don’t underestimate the power of getting a good night’s sleep.

See also:

• Let’s get some perspective on food addiction

• What does it mean to be a ‘Non-Diet Dietitian’?