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Editor,—We report two cases of anorexia nervosa in girls with Turner’s syndrome from a group of 34 patients treated with a combination of oxandrolone and oestrogen.
Patient 1 started ethynyl oestradiol 1 μg/day at age 9.8 years, increasing to 20 μg/day over six years. At 10.8 years oxandrolone 1.25 mg/day was started, increasing to 2.5 mg/day after four years. Onset of anorexia nervosa occurred at age 16, before stopping oxandrolone. Weight loss was from 109% to 75% weight for height, and illness features were typical. Body dissatisfaction was not solely related to stature. Illness severity warranted a 10 week admission to a specialist unit. Patient 2 had a similar treatment protocol beginning at age 9 years. Anorexia nervosa began at 15.5 years with weight loss from 107% to 85% weight for height. Oxandrolone was discontinued after 5 kg weight loss. During her illness she also took an overdose of 50 paracetamol. Both patients are now well, with normal weight for height.
Oxandrolone has a long history of use for growth enhancement.1 The anabolic effects include increased appetite and increase in lean body mass rather than fat mass. Obesity as a result of treatment is not usual.
The association of Turner’s syndrome and anorexia nervosa has previously been attributed to chance.2 However, Skuse and colleagues3 recently showed that females with Turner’s syndrome whose X chromosome was maternally derived showed greater adjustment difficulties, poorer verbal and executive function, and poorer social skills, despite normal intelligence quotient. The authors link the dysfunction to disorders of social adjustment and cognition such as autism. More subtle deficits of social cognition may be a risk factor for anorexia nervosa, especially if associated with low self esteem, as is common in Turner’s syndrome.4
The peak incidence of anorexia nervosa is during puberty. When puberty is artificially induced, good psychological support may prevent anorexia nervosa in girls (and boys) with low self esteem. Although oxandrolone is associated with disturbance of appetite and weight gain, we are unclear about the role of anabolic steroids in the association between anorexia nervosa and Turner’s syndrome.