ABSTRACT
Eating disorders (EDs) are common among female adolescents and young adults and can have serious and diverse health consequences. Pediatric gynecology providers have the opportunity to play a vital role in the recognition of EDs in this population. Early medical detection and referral for appropriate evidence-based treatment can lead to better health outcomes for youth. In this article we aim to increase the awareness of the pediatric gynecologist of typical and subtle presentations of EDs, provide guidance for screening, discuss common and serious medical complications, and review treatment considerations for gynecologic issues in patients with EDs.
Key Words
Introduction
Eating disorders (EDs) are one of the most common chronic illnesses among adolescents and young adults.
1.
, 2.
, 3.
EDs are serious, debilitating illnesses that considerably impair physical health, quality of life, and disrupt psychosocial functioning of adolescent patients and their families.4.
In this review, we describe the most common EDs that pediatric and adolescent gynecologist (PAG) providers might encounter with a summary of diagnostic criteria, epidemiology, medical complications, and treatment issues. Although formal diagnosis and treatment of EDs are outside the scope of practice for PAGs, it is essential that providers are comfortable in recognizing, screening, and facilitating appropriate referral to at-risk patients. Patients who present with weight changes, amenorrhea, oligomenorrhea, and gender diverse identities are among groups who might be potentially at high risk of EDs.Epidemiology and Risk Factors
Counter to prevailing cultural narratives, EDs affect youth of all genders, sizes, ethnicities, and socioeconomic backgrounds. Globally, the prevalence of EDs has more than doubled from estimates of 3.5% to 7.8% in the past 10 years
5.
, 6.
, 7.
with 40% of cases appearing in adolescents between 15 and 19 years of age.3.
The age of onset of anorexia nervosa (AN), bulimia nervosa (BN), and binge ED (BED) has now shifted to early adolescence (median age, 12 years) from previous trends indicating mid to late adolescence.8.
,9.
The prevalence of avoidant restrictive food intake disorder (ARFID) and atypical AN (AAN), although not yet clearly measured, are estimated to comprise 14% and 33% of new diagnoses in adolescent ED centers, respectively.1.
,10.
The high mortality rate of EDs make their prompt recognition critical. AN has the highest mortality rate of all psychiatric disorders at 5%-6%.
3.
,11.
One in 5 deaths in those with AN occur because of suicide, with other causes of death including medical complications due to malnutrition or substance use.12.
The underlying mechanisms of ED development continue to be the ongoing subject of research.
13.
,14.
EDs are not the result of an individual's choice but rather result from interactions between genetic and environmental factors at critical time points in development. In an effort to provide clarification of what is known about EDs, the Academy of Eating Disorders developed “nine truths about eating disorders” (Table 1).15.
Academy for Eating Disorders. Nine truths about eating disorders 9/9/2020. Available: https://www.aedweb.org/resources/online-library/publications/nine-truths.
Table 1The 9 Truths About Eating Disorders
| Nine truths |
| 1. Many people with eating disorders look extremely healthy, yet may be extremely ill. |
| 2. Families are not to blame, and can be the patients’ and providers’ best allies in treatment. |
| 3. An eating disorder diagnosis is a health crisis that disrupts personal and family functioning. |
| 4. Eating disorders are not choices, but serious biologically influenced illnesses. |
| 5. Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses. |
| 6. Eating disorders carry an increased risk for both suicide and medical complications. |
| 7. Genes and environment play important roles in the development of eating disorders. |
| 8. Genes alone do not predict who will develop eating disorders. |
| 9. Full recovery from an eating disorder is possible. Early detection and intervention is important. |
Adapted from the Academy of Eating Disorders.
15.
Academy for Eating Disorders. Nine truths about eating disorders 9/9/2020. Available: https://www.aedweb.org/resources/online-library/publications/nine-truths.
Diagnostic Criteria
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
16.
describes diagnostic criteria for each ED in detail.AN is characterized by low energy intake relative to requirements, leading to significant weight loss or poor growth. The energy restriction is usually driven by weight or shape concerns and body image distortion. In contrast to the previous diagnostic criteria, there is now no cutoff for low body mass index (BMI) and amenorrhea is not required for diagnosis. AN can manifest as restrictive or binge-purge type.
AAN is diagnosed in individuals who have lost a significant amount of weight but remain above or within a normal weight range. However, AAN is similar to AN with regard to medical complications, cognitions, and behaviors.
ARFID applies to patients who present with malnutrition without body image concerns. Dietary restriction can be secondary to sensory (taste, texture), temperament (little interest in food, poor appetite), fear (choking, vomiting), emotional (anxiety, somatic complaints), or medical symptoms (food allergies, gastrointestinal disorders).
17.
BN is characterized by frequent (at least once weekly for 3 months) episodes of bingeing followed by a compensatory behavior due to body dissatisfaction. Bingeing is defined as consuming a large amount of food while feeling out of control and compensatory behaviors might include self-induced vomiting, laxative use, excessive exercise, fasting, or misuse of insulin. Patients with BN are typically within or above a normal weight range. BED is diagnosed using criteria similar to BN but without compensatory behaviors.
Clinical Presentation
Children and adolescents with EDs might manifest various signs and symptoms. PAGs should be aware that no matter where a patient's weight or BMI falls on the growth curve, the presence of an ED is possible. An ED should be suspected in any patient who presents with weight loss, functional hypothalamic amenorrhea, unexplained growth or pubertal delay, restrictive or abnormal eating behaviors, overexercising, or recurrent vomiting. EDs in youth with history of overweight or obesity tend to present with longer duration of illness and higher weight suppression.
18.
,19.
Weight suppression is defined as the difference between highest weight and weight at presentation.20.
Studies have shown that transgender youth are particularly vulnerable to EDs.
21.
These youth might experience body image dissatisfaction resulting from having a body that is not aligned with their gender identity.22.
Screening for EDs and promptly initiating appropriate referrals might improve the quality of care and health outcomes of these patients.23.
,24.
A recent study showed that youth at risk for or meeting criteria for ARFID might present to the gynecologist for concerns related to pelvic pain or menstrual problems.
25.
These youth are more likely to have low BMI and anxiety symptoms. Thus, PAGs should be aware of signs and symptoms consistent with risk of ARFID.PAGs frequently encounter the young athlete without significant weight loss who presents with amenorrhea and other symptoms related to relative energy deficiency. Relative energy deficiency in sports (RED-S), introduced in 2007 as a new entity that replaced the term, “female athlete triad,” that consisted of disordered eating, amenorrhea, and osteoporosis.
26.
RED-S is a more inclusive entity referring to impaired menstrual function, metabolic rate, and bone and cardiovascular health resulting from relative energy deficiency.27.
It is often difficult to exclude a coexisting ED in athletes with RED-S. If unable to reverse RED-S with sports nutrition counseling, the athlete should be referred for ED assessment.Medical Complications
Medical complications associated with EDs are listed in Table 2. Malnutrition underlies most of the complications and affects every body system, whereas purging and electrolyte disturbances lead to the remaining. Most complications are reversible with nutritional rehabilitation and weight restoration. However, osteopenia, growth stunting, and cognitive changes might become irreversible. A brief overview of the most common complications follow.
Table 2Common Complications of Eating Disorders
| Type | Complication |
|---|---|
| Constitutional | Cachexia, fatigue, hypothermia |
| Cardiovascular | Hemodynamic changes Bradycardia, hypotension, orthostatic changes Electrocardiogram findings Prolonged QTc, increased PR (electrolyte abnormalities) Pericardial effusion (due to refeeding syndrome), mitral valve prolapse, decreased LV mass (chronic severe malnutrition) |
| Gastrointestinal | Functional changes Dyspepsia, delayed gastric emptying, constipation, GERD, esophagitis, Mallory Weiss tear, Barrett esophagus (self-induced vomiting) Rectal prolapse, melanosis coli, cathartic colon (laxative abuse) SMA syndrome (severe malnutrition) |
| Endocrine growth and bone | Amenorrhea (functional hypothalamic amenorrhea) Low testosterone Decreased libido Euthyroid sick syndrome Elevated cortisol level Hyperaldosteronism (purging behaviors) Puberty delay, growth retardation/stunting Osteopenia/osteoporosis Stress fractures |
| Skin | Acrocyanosis, orange skin discoloration (carotenoderma), xerosis Lanugo, hair loss, poor wound healing, easy bruising Edema (refeeding syndrome) |
| Neurologic, cognitions and mental health | Dizziness, peripheral neuropathy Cerebral atrophy (severe malnutrition) Seizures (hyponatremia), Wernicke encephalopathy (B1 deficiency) Cognitive decline, decreased attention span Flat affect, irritability, social Isolation, Depression, anxiety, OCD |
| Laboratory abnormalities | |
| Hematologic | Anemia, neutropenia, thrombocytopenia (bone marrow atrophy) |
| Renal and electrolytes | Hyponatremia (water overload) Hypokalemia, metabolic alkalosis (purging) Hypochloremia (self-induced vomiting), hyperchloremia (laxative use) Hypophosphatemia (refeeding syndrome) Hypoglycemia Azotemia (dehydration) Impaired urine concentration, alkaline urine |
| Hepatic, pancreas | Elevated transaminases (malnutrition or refeeding) Elevated amylase (self-induced vomiting) Gallstones (abrupt and significant amount of weight loss) |
GERD, gastroesophageal reflux disease; LV, left ventricular; OCD, obsessive compulsive disorder; QTc, corrected QT; PR Interval; SMA, superior mesenteric artery.
Cardiovascular
Hemodynamic changes such as bradycardia, hypotension, and orthostasis are very common in restrictive EDs. Bradycardia is theorized to reflect an adaptive response to conserve energy in the setting of poor energy intake.
28.
Bradycardia in malnourished athletes can be misinterpreted as the result of intense conditioning instead of a concerning manifestation of RED-S. Hypotension and orthostatic changes are very commonly seen in patients with EDs and represent autonomic nervous dysfunction.29.
Abnormalities on electrocardiogram often occur as a result of electrolyte abnormalities or medications. It is recommended that patients with severe sinus bradycardia, junctional rhythm, prolonged QTc, and syncope be admitted for cardiac monitoring (Table 3). In patients with chronic severe ED, the heart rate might be increased, which reflects a shift of the autonomic balance to sympathetic dominance.30.
This change, when combined with conduction defects and structural changes in chronic severe malnutrition, can lead to sudden death.Table 3Society for Adolescent Health and Medicine Criteria Supporting Inpatient Hospitalization for Eating Disorders
| Criteria |
| One or more of the following could justify hospitalization: |
| 1. Less than 75% median body mass index for age and sex |
| 2. Dehydration |
| 3. Electrolyte disturbance (hypokalemia, hyponatremia, and hypophosphatemia) |
| 4. Electrocardiogram abnormalities (eg, prolonged QTc or severe bradycardia) |
| 5. Physiological instability |
| Severe bradycardia (heart rate <50 at daytime; <45 at night) |
| Hypotension (<90/45 mm Hg) |
| Hypothermia (body temperature <96°F or 35.6°C) |
| Orthostatic increase in pulse (>20 beats per minute) or decrease in blood pressure (>20 mm Hg systolic or >10 mm Hg diastolic) |
| 6. Arrested growth and development |
| 7. Failure of outpatient treatment |
| 8. Acute food refusal |
| 9. Uncontrollable bingeing and purging |
| 10. Acute medical complications of malnutrition (eg, syncope, seizures, |
| cardiac failure, pancreatitis, etc) |
| 11. Comorbid psychiatric or medical condition that prohibits or limits appropriate outpatient treatment (eg, severe depression, suicidal ideation, obsessive compulsive disorder, type 1 diabetes mellitus) |
QTc, corrected QT.
Adapted from Golden et al.
51.
Gastrointestinal
Bloating, constipation, and gastrointestinal discomfort are common manifestations of EDs. Gastroparesis and constipation are often the result of autonomic dysfunction that affects gastrointestinal motility. Functional disorders are usually reversible with nutritional rehabilitation although constipation might persist even after weight restoration.
31.
In severe cases of malnutrition patients might present with vomiting due to superior mesentery artery syndrome,32.
or gingivitis and glossitis due to vitamin deficiencies (vitamin C, B1, B6, B12).33.
Patients with self-induced vomiting can develop gastroesophageal reflux, esophagitis, enamel erosions of the upper incisors, and sialadenosis due to decreased parotid salivary flow. If purging behaviors persist for more than 2 years, patients are at risk for Barrett esophagus.34.
Patients who engage in laxative abuse might develop melanosis coli or cathartic colon; additionally it can lead to secondary hyperaldosteronism resulting in edema if laxatives are abruptly discontinued.31.
Menstrual Issues
Restriction in energy intake, excessive exercise, stress, and loss of fat mass can all lead to hypothalamic hypogonadotropic hypogonadism in youth with EDs.
35.
,36.
This can cause primary or secondary amenorrhea. Secondary amenorrhea occurs in 66%-84% of patients with AN and up to 40% of patients with BN.37.
,38.
Self-induced vomiting has also been shown to be associated with 3 times the rates of irregular menses.39.
Binge eating can also lead to menstrual irregularity even after controlling for factors such as BMI and polycystic ovarian syndrome.40.
Menstrual function typically recovers after patients reach a healthy weight.41.
Youth with history of overweight need to be at a higher BMI percentile than youth without history of overweight.42.
,43.
Osteopenia
In a study of young adult women with AN with average duration of illness of 70 months and amenorrhea of 20 months, 92% developed osteopenia and 38% osteoporosis.
44.
The pathophysiology of decreased bone mineral density (BMD) is multifactorial such as nutritional deficiencies (calcium, vitamin D), reduction in lean bone mass, reduction in gonadal hormones (estradiol, testosterone), increase in cortisol levels, growth hormone resistance, and changes in hormones that regulate appetite (leptin, ghrelin, oxytocin).45.
Because adolescence is a critical period of bone formation and mineralization, those with AN during adolescence are at even higher risk for osteopenia.45.
,46.
In addition to decreased BMD, geometry and microarchitecture of the bone are impaired, which leads to increased fracture risk.47.
,48.
Resumption of menses is critical for lumbar spine (LS) BMD recovery and weight gain for hip BMD recovery.49.
Similar effects on bone health have been observed in athletes with RED-S.26.
Athletes with recurrent or high-risk fractures (femoral neck) should be screened for EDs.Screening and Diagnosis
PAGs should be able to recognize red flags for EDs in history, physical examination, and laboratory results.
History
When taking a history, red flags include changes in eating behaviors such as slow eating, discarding food, new veganism, spitting, secretive or excessive exercising, frequent weighing and body-checking. Proposed clarifying questions are included in Table 4. Although it is important that an adolescent be interviewed alone, history from a parent or caregiver can be critical, because this might uncover behaviors the adolescent might not report. Parents and caregivers might be the first to notice changes, and their concerns should be carefully considered.
Table 4Suggested Screening Questions for Eating Disorders
| Subject | Question |
|---|---|
| Weight loss | • Have you done anything in the past 6 months to change your weight or shape? • Do you have a goal weight in mind? Has this goal changed? • How much weight have you lost and how quickly? • Are you bothered by the weight loss? |
| Exercise | • How much do you exercise? • How do you feel if you miss a workout? • Have you experienced a decline in your athletic or sports performance? |
| Diet | • Have you stopped eating any specific types of foods? • Do you skip meals or snacks? • Do you eat meals with your family? • Do you track calories or have a specific calorie goal in mind? |
| Body image | • How do you feel about your weight or shape? • Are there any particular areas of your body you would like to change? |
Physical Examination
The aforementioned findings in the oral cavity and cardiovascular system could represent red flags for EDs. Skin findings such as acrocyanosis, lanugo, thinning hair, easy bruising, calluses on the knuckles due to purging can also serve this role.
Laboratory Evaluation
The primary aim of laboratory workup is to exclude medical conditions that might have contributed to presenting symptomatology of malnutrition, weight loss, amenorrhea, growth retardation, or mood changes. Such conditions are listed in Table 5. Laboratory inquiries can also detect abnormalities secondary to malnutrition or ED behaviors (Table 2).
Table 5Differential Diagnosis of Malnutrition and Suggested Laboratory Workup
| Differential diagnoses |
| Gastrointestinal |
| IBD, celiac disease, malabsorption (CF), SMA syndrome, gastroparesis |
| Endocrine |
| Diabetes mellitus, Addison disease, hypo- or hyperthyroidism, hypopituitarism |
| Malignancies |
| Lymphoma, GI tumors, CNS tumors |
| Mental health disorders |
| Depression, OCD, anxiety, psychosis, substance use and abuse |
| Rheumatologic conditions |
| SLE |
| Other chronic diseases or infections |
| Kidney failure, HIV, CF |
| Screening bloodwork |
| Complete blood count |
| Inflammatory markers (ESR or CRP) |
| Electrolytes, Mg, PO4, Ca |
| Celiac screen (total immunoglobulin A and tissue transglutaminase) |
| TSH |
| If amenorrhea: estradiol, LH, FSH, HCG |
| Consider free testosterone (for patients with clinical concerns of PCOS) |
| Consider: |
| Prolactin |
| Cortisol (AM level) |
| Consider vitamin or micronutrient levels (for patients with severe malnutrition) |
| Ferritin |
| Methylmalonic acid/B12 |
| 25-OH vitamin D2 |
| Zinc |
| Thiamine |
CF, cystic fibrosis; CNS, central nervous system; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; FSH, follicle stimulating hormone; GI, gastrointestinal; HCG, human chorionic gonadotropin; IBD, inflammatory bowel disease; LH, luteinizing hormone; OCD, obsessive compulsive disorder; PCOS, polycystic ovary syndrome; SLE, systemic lupus erythematous; SMA, superior mesenteric artery; TSH, thyroid stimulating hormone.
Treatment Considerations
When concerned that a patient has an ED, the gynecologist should initiate conversations about referral for evaluation and treatment. Urgent referrals are needed when signs of medical instability are present (Table 3). Children and adolescents with EDs are best managed by a multidisciplinary team with level of care (outpatient, inpatient, day treatment, or residential) best suited to the individual patient's needs.
50.
This team might include a medical provider, dietitian, and a psychotherapist trained in evidence-based psychotherapies. A psychiatrist might be involved in cases with comorbid mental health conditions that complicate treatment.51.
Most adolescents can be managed in the outpatient setting with ongoing medical monitoring.Family-based treatment (FBT) is an outpatient-based model that has the strongest evidence associated with recovery and is recognized as the first-line approach by many US and international guidelines in treatment of youth with AN.
52.
,53.
Cognitive behavioral therapy has been shown to be helpful for adolescents with BN and BED. Preliminary studies of treatment approaches for ARFID so far have included cognitive behavioral therapy, a manualized behavioral approach, and FBT.54.
,55.
Psychotropic medications are often prescribed to youth with EDs despite limited studies supporting their use.
56.
Atypical antipsychotic medications are the most studied medications for AN. Selective serotonin reuptake inhibitors appear to have some benefit in patients with BN.57.
,58.
Lisdexamphetamine has evidence of benefit in adults for BED.59.
More research is needed to determine which groups of young patients would best respond to each medication class.Prognosis and Recovery
Although there remains a lack of consensus in defining recovery in pediatric EDs, studies have shown that important components of recovery include weight restoration, normalized eating patterns, and improvement in psychological well-being.
60.
Studies suggest that more than three-quarters of youth with AN recover, develop normal eating and weight control habits, and return to activities including school, work, and social relationships.61.
However, despite established efficacy of FBT and the treatable nature of EDs in pediatrics, as many as 50%-65% of adolescent patients with AN and 42% of those with BN might not initially fully recover.62.
Less is known about recovery outcomes for youth with other EDs. Clinicians should focus on early diagnosis and treatment, which is associated with a favorable prognosis.Specific Treatment Considerations for PAGs Treating Youth with EDs
Contraceptive Management
Patients with ED who are at risk of pregnancy need contraception. Contraceptive counseling should be on the basis of contraceptive effectiveness, taking into consideration medication adherence, cost, and patient preference. The effect of the contraceptive method on bone accretion and BMD should be given extra consideration.
63.
Long-acting reversible contraceptives are considered first-line contraceptive options for adolescents because of their safety and effectiveness. The levonorgestrel intrauterine device has no negative effect on BMD.
64.
Studies on the effect of the etonogestrel implant on the BMD of the LS and femoral neck have shown mixed results. Some show no difference in users of the implant and another showed a decrease in BMD in the LS compared with copper intrauterine device users.65.
Combined oral contraceptives (COCs) remain the most popular method of choice for healthy adolescents.
66.
COCs that contain greater than 30 μg of ethinyl estradiol (EE) seem to have a more favorable effect on bone accretion and should be preferred to EE pills with a lower dosage.67.
, 68.
, 69.
, 70.
The contraceptive patch and vaginal ring are effective methods of contraception that do not seem to negatively affect BMD.71.
, 72.
, 73.
Depot medroxyprogesterone acetate is an effective contraceptive method but leads to decreased BMD in teens and should be used cautiously in malnourished patients.74.
,75.
Hormonal Replacement for Bone Health
Weight restoration and resumption of menses are imperative for preserving bone health in youth with AN. The use of COCs has been reported to be ineffective in increasing BMD in adolescents with AN.
76.
This is attributed to the fact that EE is not a physiologic form of estrogen and because of hepatic first pass it downregulates the immunoglobulin IGF-1 which has an anabolic effect on the bone.77.
Hormonal replacement of adrenal (dehydroepiandrosterone) and gonadal (COC) steroids were also ineffective in preserving bone health in patients with AN despite promising results of a previous study.78.
In contrast, hormonal replacement with 17-β estradiol, a physiologic form of estrogen via a transdermal route (to bypass hepatic effect) has been reported to increase spine and hip BMD in adolescents with AN.
79.
A recent study showed that the 17-β estradiol patch increased BMD in the tibia in adolescent oligoamenorrheic athletes.80.
In addition to weight restoration, bone health might be further optimized with optimum calcium (1300 mg/d) and vitamin D (600 U/d) intake, while avoiding soda, alcohol, and smoking.
63.
Obstetrical Care
There is a paucity of research focused on fertility and pregnancy outcomes for adolescents with EDs.
81.
Multiple large observational studies82.
, 83.
, 84.
, 85.
have shown that women in recovery from an ED (AN and BN) have significantly higher rates of unplanned pregnancy compared with the general population. In one case series81.
4 cases of pregnancy in adolescents complicated by EDs were summarized. A range of experiences were described, from detection of ED in the setting of a concealed unplanned pregnancy, escalation of ED symptoms during pregnancy, to remission of symptoms during pregnancy and subsequent relapse in the postpartum period. Pregnancy and perinatal complications might be higher among women in ED recovery. Evidence is mixed, with some reports that there can be increased risk for higher rates of miscarriage,86.
preterm deliveries,87.
and smaller head circumference in babies88.
born to women with history of EDs. In contrast, other researchers have reported that birth outcomes for women with a history of AN are similar to that of the general population.88.
Conclusion
EDs are common illnesses that peak during adolescence and are associated with high rates of morbidity and mortality. PAGs are well positioned to screen for EDs in youth who present for concerns such as pelvic pain, menstrual problems, or gender-affirming hormonal care. A provider should have high suspicion of an ED in any youth who presents with significant weight loss, bradycardia, or with a very low BMI. When selecting a contraceptive method for youth with EDs, its effect on bone health should be considered. Weight restoration is the recommended treatment for amenorrhea associated with malnutrition. EDs are treatable conditions and the earlier they are recognized leads to better health outcomes for youth.
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Article info
Publication history
Published online: January 21, 2021
Accepted:
January 14,
2021
Received:
November 13,
2020
Footnotes
The authors indicate no conflicts of interest.
Identification
Copyright
© 2021 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.
