Reproductive Issues in Anorexia Nervosa

Elizabeth R Hoffman; Stephanie C Zerwas; Cynthia M Bulik

Disclosures

Expert Rev of Obstet Gynecol. 2011;6(4):403-414. 

In This Article

Abstract and Introduction

Abstract

Despite a high prevalence of menstrual irregularities, women with anorexia nervosa are becoming pregnant. The physical and psychological demands of pregnancy and motherhood can represent an immense challenge for women already struggling with the medical and psychological stress of an eating disorder. This article summarizes key issues related to reproduction in women with anorexia nervosa, highlighting the importance of preconception counseling, adequate gestational weight gain, and sufficient pre- and post-natal nutrition. Postpartum issues including eating disorder symptom relapse, weight loss, breastfeeding, and risk of perinatal depression and anxiety are also discussed.

Introduction

Anorexia nervosa is a devastating psychiatric illness marked by extremely low bodyweight, cognitive distortions related to body shape and weight perception, and either severe food restriction or a pattern of binge eating or purging behavior (Box 1). The medical and psychological consequences of anorexia nervosa are extensive; correlates of the eating disorder such as depression, anxiety, social withdrawal, heightened self-consciousness and fatigue, in addition to medical complications such as cardiac abnormalities and osteoporosis, can persist throughout life. The mortality associated with anorexia nervosa is high; the standardized mortality ratio estimates for all causes of death in females with anorexia nervosa range from 1.7 to 12.8.[1–4]

An estimated 0.9% of women in the USA have met the threshold Diagnostic and Statistical Manual IV criteria for anorexia nervosa in their lifetime.[5] The mean age of onset for the disorder is approximately 19 years of age,[5] affecting many women during their childbearing years. It was first believed that pregnancy in women with anorexia nervosa was rare owing to the endocrinological disturbances associated with starvation coupled with the psychological and psychosocial features of the disorder. However, recent studies have failed to find differences in fertility between women with histories of anorexia nervosa and controls, demonstrating that despite high levels of menstrual disturbances, women with anorexia nervosa are becoming pregnant.[6,7] The physical and psychological demands of pregnancy and motherhood can represent an immense challenge for women already struggling with the medical and psychological stress of an eating disorder.[8,9] This article summarizes key issues related to reproduction in women with anorexia nervosa, highlighting the importance of preconception counseling, adequate gestational weight gain, and sufficient pre- and post-natal nutrition. Postpartum issues including eating disorder symptom relapse, gestational weight loss, breastfeeding and risk of perinatal depression and anxiety will also be discussed. In addition, we include a 5-year view that summarizes the emerging psychiatric epigenetics literature and proposes that epigenetics may explain the processes by which maternal undernutrition and anxiety in anorexia nervosa lead to long-term effects on offspring. For each topic discussed, we conducted a search using MEDLINE, PsycINFO and the Cochrane Library database to identify original research articles; we also conducted a secondary search of references from relevant review articles found in each search.

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