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

In Practice: Reproductive Counseling for Women With Anorexia Nervosa

Preconception

As previously discussed, women with anorexia nervosa do become pregnant and are more likely to have unplanned pregnancies. It may be that menstruation absence or irregularity leads women with anorexia nervosa to believe that they are infertile when at a low weight, and that conception is unlikely or impossible. However, amenorrhea does not indicate conclusively an absence of ovulation. Therefore, special attention should be paid at routine obstetrician–gynecologist visits to inform patients about the possibility of pregnancy in order to ensure that patients are making informed decisions about their reproductive health and understand their need for family planning even when at a low weight.

Although oral contraceptives are often prescribed in order to restore menses and prevent bone loss in women with anorexia nervosa, data do not support this clinical practice.[99] However, in addition to preventing sexually transmitted diseases, barrier contraceptive use is also necessary to prevent unplanned pregnancy in sexually active women with anorexia nervosa.[100] Furthermore, given the fact that women with anorexia nervosa who experience unplanned pregnancies are likely nutritionally depleted at conception, routine visits should also include counseling about the need for daily vitamins and adequate fat and protein intake to ensure optimal absorption.

Reproductive counseling is also needed in cases of infertility. One study found that, of patients who present for treatment to an infertility clinic with oligomenorrhea or amenorrhea, 58% met clinical indicators for eating disorders, but none had disclosed these problems to their providers.[18] In another clinic sample, 60% of infertile women with ovulatory dysfunction had anorexia nervosa, bulimia nervosa or eating disorders not otherwise specified. Therefore, appropriate infertility treatment includes adequate treatment of the eating disorder. Treating anorexia nervosa first, through proper nutrition, weight restoration and psychotherapy could probably also treat infertility without the significant costs, stress and complications associated with assisted reproductive technology.[10] In addition, when patients with active eating disorders pursue infertility treatment, assisted reproductive technologies may also be less effective.[101]

Screening

Adequately assessing eating disorder history early in pregnancy is necessary in order to forestall the possible physical and mental health consequences for women suffering with anorexia nervosa during the perinatal period, and the long-term physical and mental consequences for her children. Routine perinatal care offers providers a unique window of opportunity for mental health screening,[102,103] which could facilitate improved detection of anorexia nervosa during this critically important time.

Standardized instruments such as the Eating Disorders Examination Questionnaire (EDE-Q)[104] and use of the SCOFF questionnaire[105,106] could assist obstetrician–gynecologists in assessing eating disorders. The EDE-Q is a 36-item self-report instrument that requires approximately 15 min to complete. Questions assess the presence and severity of symptoms including eating restraint, and eating, weight and shape concerns over the past 28 days. It is a reliable measure that could be used by clinicians who want to screen for an undiagnosed or unreported eating disorder and requires little mental health training.[107] The SCOFF questionnaire includes just five short yes/no questions about possible eating disorder symptoms:[106]

  • Make yourself SICK when you feel uncomfortably full?

  • Worry you have lost CONTROL over how much you eat?

  • Recently lost more than 14 pounds within 3 months? (ONE stone's worth of weight)

  • Believe you are FAT when others say you are too thin?

  • Would you say that FOOD dominates your life?

A positive screen on either instrument would indicate that referral to an eating disorder specialist is necessary. In addition, clinical assessment could also include a thorough menstrual history, including age at onset, the number of cycles in the past 12 months, cycle regularity and length of flow.[100]

Unfortunately, individuals with anorexia nervosa are often hesitant to bring their eating disorder status to their providers' attention and their providers are often hesitant to ask about eating disorder status. In a survey of obstetrician–gynecologists, just over half (54%) believed that eating disorder assessment fell within their scope of practice and a large majority (88.5%) rated their training in assessing eating disorders as barely adequate.[108] However, almost all generalists (90.8%) agreed or strongly agreed that eating disorders can negatively impact pregnancy outcome.[108] Furthermore, most mothers (64%) do not reveal their eating disorder status to their obstetrician–gynecologists and had negative reactions towards the routine weighing common in obstetric care.[22] Of those who did discuss their eating disorder with their provider, only half perceived it to be beneficial.[22] Furthermore, the typical frequent measurement of pregnancy-related weight gain in the clinic can exacerbate symptoms or trigger long dormant weight concerns and eating disorder behaviors in women with anorexia nervosa. Lectures about weight gain, and even well-meaning appearance-based comments by clinical staff can also be triggers.[100] Armed with the knowledge about a patient's eating disorder history, clinicians could make appropriate accommodations including reducing appearance-based comments by clinicians and staff, and modifying weight assessments to include blind weigh-ins.

Mental Health Treatment

Mental health professionals have noted that pregnancy and the transition to motherhood may be an opportune window for recovery in women with eating disorders. Engaging women with anorexia nervosa in treatment at this time and encouraging appropriate gestational weight gain could lead to permanent change in eating behavior.[109] In results from the MoBa study, on average women with anorexia nervosa shifted from the underweight BMI range to the normal weight range at 36 months postpartum and maintained a 9% increase in BMI [Zerwas SC et al.; Submitted Manuscript]. Treatment may be especially necessary in the immediate months following birth, as the 'justification' for gestational weight gain and weight maintenance are no longer operative. Increased attention and social support in the postpartum period would be critical to prevent the re-emergence of symptoms.[34,110]

Following a comprehensive medical evaluation to rule out another cause, the first goal of anorexia nervosa treatment is weight restoration to bodyweight within the normal range for BMI (18.5–24.9). Proper nutrition and refeeding is critical. Individuals who fall to 75% of their ideal bodyweight or have complicating medical or psychiatric comorbidities may require inpatient care in order to achieve weight restoration. Treating anorexia nervosa can be complicated and requires multidisciplinary evidence-based programs with medical coverage by providers, including dieticians, internal medicine dieticians, nurses, social workers, psychologists and psychiatrists who are specialists in the management of eating disorders. Furthermore, for adolescents and adults, recruiting the additional support of the patient's partner, spouse, parents or other family members in the therapeutic process can be vital.[111,112]

Given the increased risk of perinatal depression and anxiety in women with anorexia nervosa histories, additional screening for symptoms of depression and anxiety is also important.

Treatment of depression and anxiety is critically important for the well being of both mother and the newborn-to-be.

The American Psychiatric Association and the American College of Obstetricians and Gynecologists practice guidelines recommend outpatient psychotherapy such as cognitive behavioral therapy or interpersonal psychotherapy alone in cases of mild-to-moderate depression and anxiety.

However, women with more severe depression and anxiety symptoms may require pharmacological treatment including antidepressants and anxiolytic medications. They recommend that psychiatrists carefully assess maternal–fetal risk and discuss these risks with their patient before initiating psychotropic medication use during pregnancy and the postpartum.[113] These practice guidelines were developed for women with perinatal depression without consideration of eating disorder status. No data exist to guide the treatment of depression and anxiety in pregnant women with anorexia nervosa.

In summary, effective care in the obstetrician–gynecologist setting during the preconception and perinatal period should include:

  • Screening, assessment and documentation of eating disorder history and other comorbid psychiatric history;

  • Education about the possibility for pregnancy in the presence of amenorrhea, the need for vitamin supplementation and the increased risk of perinatal depression and anxiety in women with anorexia nervosa;

  • A collaborative discussion of patient emotions and weight assessment options at clinic visits;

  • Referral to a multidisciplinary team of mental-health providers and dieticians for treatment as appropriate.

However, it is also critical that a system of referral algorithms and connection to mental-health treatment be developed in order to encourage mental-health screening by the community of obstetrician–gynecologists.

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