Reproductive Issues in Anorexia Nervosa

Elizabeth R Hoffman; Stephanie C Zerwas; Cynthia M Bulik


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

In This Article

The Postpartum Period

The transition to motherhood is accompanied by dramatic physical and environmental changes. The following section will discuss issues related to anorexia nervosa during the postpartum period, including postpartum dieting and body image, perinatal mental health and breastfeeding.

Postpartum Dieting & Body Image

Caring for a newborn baby can be stressful and lead to disruptions in sleep and eating patterns.[48] Mothers of newborns are also often home alone for long periods of time, which gives them ample opportunity to return to familiar eating disorder behaviors in secret in order to cope with the stress of this life transition.[49] Increased concern over shape and weight in the first 6 months postpartum is generally normative. A significant proportion of new mothers (40%) report dissatisfaction with their weight during this time.[50] Furthermore, increased body fat and abdominal muscle loss from pregnancy may aggravate long-standing dissatisfaction with body shape and composition.

Women with anorexia nervosa lose weight more quickly during this period,[30] which suggests that they may be resorting to restriction, compensatory measures or other extreme weight-control behaviors. In women who had experienced recovery during pregnancy but relapsed during the postpartum period, 80% attributed the relapse to a desire to lose weight and feeling fat.[22] Without the motivation to eat 'for the baby', women with anorexia nervosa may find it difficult to continue to eat for their own health.[48] In one study, women who had struggled with anorexia nervosa immediately before conception experienced symptom re-emergence during the postpartum period and returned to prepregnancy levels of psychiatric severity by 9 months postpartum.[51,52] For women who had been in recovery from anorexia nervosa prior to conception, adjustment to a postpartum body may also trigger dormant weight and shape concerns.

Postpartum Depression & Relapse

Overall, anorexia nervosa is highly comorbid with depressive and anxiety disorders[53–57] and is particularly comorbid during the perinatal period.[19,23,58–63] In a population-based sample, 36.1% of those with a lifetime history of anorexia nervosa reported experiencing depression during their pregnancy and 45.5% reported postpartum depression.[60] In comparison, 36.8% of women with a lifetime major depression diagnosis and no eating disorder endorsed experiencing depression during pregnancy and 41.2% endorsed postpartum depression.[60] Furthermore, women with a history of anorexia nervosa were over-represented in a clinical sample of women seeking treatment for postpartum depression. Approximately 10% of women seeking treatment for postpartum depression in a tertiary care clinic had a previous history of anorexia nervosa.[64] Women with anorexia nervosa may have an equal or greater risk of developing perinatal and postpartum depression compared with women with a history of major depressive disorder and no eating disorder.[60,65]

Trauma & Abuse History

Women with anorexia nervosa binge–purge subtype are also more likely to report a history of childhood sexual abuse and physical abuse than women with nonbulimic eating disorders.[66–73] Both are considered nonspecific risk factors for the development of eating psychopathology.[74–76] Trauma and abuse histories also independently increase the risk of perinatal and postpartum depression and other psychiatric comorbidity.[77–81] Women with comorbid perinatal depression and lifetime anorexia nervosa are significantly more likely to report a history of sexual trauma abuse in comparison to women with perinatal depression and no eating disorder history (62.5 vs 29.3%; p < 0.05).[64] Traumatic life events are independently associated with pregnancy complications including miscarriages, high-risk pregnancy, hyperemesis, preterm contractions[82] and delivery complications.[83–88] Thus, special care should be taken to educate women about the increased risk for postpartum depression and pregnancy complications in women with comorbid anorexia nervosa and trauma history. Proactive mental healthcare before symptoms appear could be the optimal way to prevent both perinatal mental health issues and obstetric complications.


Research evidence on the frequency and duration of breastfeeding in women with anorexia nervosa is inconsistent. While one study reported that women with a history of anorexia nervosa are more likely to initiate breastfeeding and breastfeed for just as long, or longer, than women in the general population,[33] several others have reported that women with anorexia nervosa stop breastfeeding earlier than women with no eating disorder.[51,89,90] The following section will discuss possible reasons why women with anorexia nervosa may continue breastfeeding longer or stop breastfeeding earlier than women without eating disorders.

Breastfeeding Anxiety Some studies report that breastfeeding is anxiety-provoking to women with eating disorders. Mothers report worrying that their breast milk will be insufficient for their infants' needs or that their infant may be allergic to their breast milk.[91] Furthermore, breast milk quantity and quality is difficult to measure and intake cannot be visually estimated. Women with anorexia nervosa may worry that they are giving their children 'enough' to eat and may turn to formula feeding in order to have reassuring visual cues about their infant's intake. Women with eating disorders who do breastfeed have been reported to be more likely to adhere rigidly to a prescribed feeding schedule as recommended by their children's physician and to experience anxiety when their infant signals hunger cues outside of the prescribed feeding window.[91] In addition, women with anorexia nervosa in general experience heightened self-consciousness and social anxiety,[53,54] and some have reported embarrassment about the opportunity for self-exposure that accompanies breastfeeding in public.[63]

Postpartum Distress & Breastfeeding Difficulties with breastfeeding may also be due to the increased risk for postpartum depression and anxiety in women with anorexia nervosa.[60,64] Epidemiologic studies have identified an association between breastfeeding difficulty and perinatal depression, with depressive symptoms often preceding difficulty with lactation. In women with eating disorders, maternal distress from perinatal depression and anxiety partially mediates the relationship between eating disorder status and early infant feeding difficulties.[92] Thus, the relationship between maternal eating disorders and trouble with infant feeding is partially due to maternal perinatal depression and anxiety.[92]

Weight Concerns & Child Outcomes For women with anorexia nervosa, the postpartum period and accompanying gestational weight retention could potentially trigger a relapse of eating disorder cognitions and a desire to lose weight rapidly. While some have found that women with eating disorders may choose to breastfeed in order to lose pregnancy weight more quickly,[93] others have found that when women with eating disorders are focused on weight loss in the immediate postpartum, they are less likely to intend to breastfeed.[94]

These conflicting findings are mirrored in the contradictory literature on postpartum weight retention and breastfeeding. While some research has demonstrated that women who exclusively breastfeed for 6 months and continue supplemental feedings across the first 12 months postpartum do sustain greater long-term weight loss,[95] others report that breastfeeding women lose whole-body, arm and leg fat at a slower rate in the first 6 months than women who chose not to breastfeed.[96] There are no studies that measure the association between breastfeeding, weight loss and body composition in women with anorexia nervosa.

Some women with anorexia nervosa may be unwilling to consume the additional 500–600 kcal per day to sustain breastfeeding,[97] and may be uncomfortable with the fat retention associated with breastfeeding in the first 6 months postpartum. They may stop breastfeeding in order to engage in more extreme weight-loss measures, or engaging in extreme weight-loss measures could jeopardize their lactation. Other women with anorexia nervosa may find that breastfeeding does result in a reduction in weight and fat, and thus breastfeed for longer than women without eating disorders.

Considerably more work needs to be done to understand breastfeeding patterns in women with anorexia nervosa. Food restriction during this time could result in suboptimal breast milk quality, and more specifically, could reduce breast milk fat content. Poor maternal nutrition predicts less volume and lower fat content in breast milk.[98]

Suboptimal maternal and child nutrition during this early period could be especially critical as it may inform children's future weight trajectories. There are no studies to our knowledge that have examined milk volume and breast milk composition in women with anorexia nervosa.


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