Reproductive Issues in Anorexia Nervosa

Elizabeth R Hoffman; Stephanie C Zerwas; Cynthia M Bulik

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

Prepregnancy Issues in Anorexia Nervosa

Amenorrhea

Amenorrhea is currently a diagnostic criterion for anorexia nervosa, although this will change with the next diagnostic scheme. Of women presenting with anorexia-like illness, between 68 and 89% report absence of menstruation for at least 3 months during the course of their illness.^[10–13] An additional 6–8% of women may not experience prolonged amenorrhea, but report menstrual irregularity or oligomenorrhea.^[11,13]

These disruptions in the normal menstrual cycle in many women with anorexia nervosa are probably manifestations of decreased systemic estrogen levels resulting from prolonged restriction of caloric intake and/or excessive exercise. Studies using pelvic ultrasonography in postpubertal women with current anorexia nervosa have demonstrated that, after significant weight loss, the uterus regresses back to its prepubertal length and the endometrial stripe seen on ultrasound can be either very thin or undetectable.^[14] The ovaries also regress to their prepubertal, immature size and some may not be visualized at all.^[14]

Fertility

The high prevalence of menstrual disturbances led many to hypothesize that women with anorexia nervosa would be unlikely to conceive. However, outcome studies have consistently reported that fertility rates in women with a lifetime history of anorexia nervosa do not differ from women in the general population.^[6,7,15,16] Two small studies have reported a high prevalence of lifetime eating disorder diagnoses (not exclusively anorexia nervosa) among women attending infertility clinics,^[17,18] but other studies have found no differences in the rates of fertility treatment in women with anorexia nervosa compared with women in the general population.^[6,7] Thus, it appears that despite the high prevalence of menstrual irregularities, women with anorexia nervosa are becoming pregnant.

Some women with anorexia nervosa may become pregnant during one of several intermittent phases (few months) of 'regular' ovulation and accompanying menstruation that may occur throughout the course of their illness. In others, pregnancy may occur in the absence of menstruation and can be explained similarly to rare cases of pregnancy in premenstrual adolescents (on menarche), nursing mothers and perimenopausal older women.^[10] When ovulation occurs for the first time after a period of amenorrhea and anovulation, it is possible for this first egg to become fertilized. The endometrial lining will then be maintained by the newly fertilized egg, and menstruation will not occur. Thus, a woman with anorexia nervosa may become pregnant without having experienced a resumption of menstruation.

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Cite this: Reproductive Issues in Anorexia Nervosa - Medscape - Aug 01, 2011.

Abstract and Introduction
Prepregnancy Issues in Anorexia Nervosa
Prenatal Issues in Anorexia Nervosa
Perinatal Issues in Anorexia Nervosa
The Postpartum Period
In Practice: Reproductive Counseling for Women With Anorexia Nervosa
Expert Commentary
Five-year View
References
Sidebar

Box 1. Diagnostic and Statistical Manual-IV criteria for anorexia nervosa.
Failure to maintain bodyweight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of bodyweight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to bodyweight less than 85% of that expected) Intense fear of gaining weight or becoming fat, even though underweight Disturbance in the way in which one's bodyweight or shape is experienced, undue influence of bodyweight or shape on self-evaluation, or denial of the seriousness of the current low bodyweight Amenorrhea in postmenarcheal females Restricting type During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics or enemas) Binge-eating/purging type During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)
DSM-IV: Diagnostic and Statistical Manual IV.

Sidebar

Key Issues

Despite a high prevalence of menstrual irregularities, women with anorexia nervosa are becoming pregnant, and the risk of unplanned pregnancy is higher in these women than in women without eating disorders.
Eating disorder symptoms may remit during pregnancy in women with anorexia nervosa, but there is often a resurgence of symptoms postpartum and rapid postpartum weight loss.
Women with anorexia nervosa are more likely to experience pregnancy-related nausea and vomiting requiring close monitoring to ensure adequate nutrition and weight gain.
Birth outcomes in women with anorexia nervosa are largely dependent on adequate gestational weight gain; women with more severe symptoms of anorexia nervosa prior to pregnancy may have lower gestational weight gain, an increased risk of cesarian section and babies with lower birthweights than women without eating disorders.
Postpartum depression is common in women with anorexia nervosa.
Literature on breastfeeding in women with anorexia nervosa suggests that there are two different patterns:
- Women with anorexia nervosa may stop breastfeeding earlier based on an inability to sustain breastfeeding owing to severe restriction or other extreme weight-loss measures, or owing to anxiety about breastfeeding and/or postpartum distress;
- Women with anorexia nervosa may breastfeed for longer in an effort to lose pregnancy weight more quickly.
Clinicians should pay particular attention to gestational weight gain and postpartum mental health of individuals with current and past anorexia nervosa.
Future research should focus on nutritional status and markers of stress in women with anorexia nervosa before and during pregnancy in an effort to better understand intrauterine and epigenetic effects on the physical and mental health of their offspring.

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