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Adolescent Gynecology
Early Detection and Management of Eating
Disorders in Adolescent and Young Adult Females
Martin Fisher, MD
Clinicians who treat young adult women in gynecologic
settings will undoubtedly see many patients with eating disorders,
especially since menstrual irregularity is one of the hallmarks
of the condition.
Early detection and management of eating disorders are key
factors in improving the course and outcome of the illness.
It has been estimated that the prevalence of anorexia nervosa
is 0.5% in high school and college-aged women and that 1% to
3% of young women meet criteria for the diagnosis of bulimia
nervosa. In addition, many more women display evidence of milder
forms of eating disorder behaviors.1,2
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DIAGNOSIS
The first step in detecting the onset of an eating disorder is
to be familiar with the diagnostic criteria for the major types
of eating disorders that have been described,3 including: anorexia
nervosa (AN), identified most simply by significant weight loss
and a decrease in nutritional input; bulimia nervosa (BN), marked
by binge and purge behaviors, with or without weight loss; and “eating
disorder not otherwise specified” (EDNOS), which is a category
that includes patients with eating disorder behaviors and thoughts
who do not meet all of the official criteria for AN or BN.
The 4 criteria for the diagnosis of AN include significant weight
loss to a level at least 15% below the expected weight for height
(Note: A simple way to estimate expected weight in young women
is to use the mnemonic of 100 lbs for a height of 5 feet and to
add 5 lbs for every inch above that); an intense fear of gaining
weight or becoming fat; disturbance in the way weight or shape
are experienced (Note: All eating disorders must be precipitated
by a fear of weight gain and/or obsession with body image. Otherwise,
alternative medical or psychiatric diagnoses must be considered);
and amenorrhea for at least 3 months. There has been talk that
the final criterion above may be eliminated in the future because
it does not apply to males or premenarchal females, but it is currently
an important part of the diagnosis and a key indicator in adolescent
and young adult women.
There are 5 criteria for a diagnosis of BN, 3 of which refer to
binge eating (defined as eating a large amount of food in a short
period of time during which there is a sense of lack of control).
Binge eating must occur at least twice a week for 3 months or more.
There must also be a method to prevent weight gain (such as vomiting,
laxative use, starvation or excessive exercise), without which
the patient would be significantly overweight. As in the case of
AN, the behaviors must be driven by a fear of weight gain, but
cannot occur only during episodes of AN. Patients with BN can be
normal weight, overweight, or underweight.
Patients who clearly have eating disorder behaviors and thoughts
but who do not meet the official criteria for AN or BN are considered
to have EDNOS. This includes those who have not fallen to 15% below
expected body weight (such as those who have started out overweight
and who have lost a large amount but are not officially 15% underweight),
those who purge or use laxatives but do not binge, and those who
have not yet had amenorrhea for 3 months. Studies have shown that
approximately 50% of adolescents and young adults who present with
an eating disorder fall into the EDNOS category.2,4 They have the
same psychological profile as patients with AN or BN, and the approach
to treatment is the same. The complications of EDNOS can be the
same as those seen in patients with AN and BN, but the symptoms
may be more subtle, making diagnosis of EDNOS especially important
in the early detection and management of eating disorders.
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SYMPTOMS
Symptoms may be expressed by the individual personally or may be
brought up by friends or relatives, and in addition to those mentioned
above, include obsessive thoughts about food or weight, decreased
nutritional intake (sometimes expressed as a newfound desire to “eat
healthy”) or evidence of binging or purging behaviors. Symptoms
experienced by individuals with eating disorders may include feeling
cold, being constipated, or sometimes feeling faint.
If an individual displays evidence of an eating disorder based on
signs and symptoms or the answers to any of these questions, medical
evaluation and management should be started immediately.
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EVALUATION
Since many, if not most, individuals with eating disorders attempt to hide their
symptoms, it is useful to ask about a patient’s “food, mood, and
attitude” once the suspicion of an eating disorder has been raised. One
can explore with a few short questions what an individual has been eating and
whether it has changed over time; whether there have been changes in mood, including
symptoms of depression and/or anxiety; and what the patient thinks about her
weight (ie, does she consider herself underweight, normal weight or overweight;
does she want to lose weight, gain weight, or stay the same?). Even an individual
trying to hide an eating disorder will display some of her true thinking if these
questions are asked sensitively and firmly. If possible, answers should be confirmed
by friends or family.
Vital signs are important, as bradycardia and/or orthostatic hypotension may
be initial indicators of both the presence and severity of an eating disorder.
It is also important to measure both weight and height, and to do so with the
patient barefoot and in a gown, since patients with eating disorders may play
tricks with the scale.
Initial laboratory tests include a complete blood count and metabolic panel,
thyroid function tests and, in those with amenorrhea, LH/FSH, prolactin and estradiol.
A urinalysis can be helpful in detecting those who are water-loading (which will
appear as a low specific gravity) or vomiting (which can appear as a high pH).
An EKG can be performed in those with significant bradycardia or bulimic behaviors.
Bone mineral density evaluation may be performed in those with amenorrhea, but
is generally reserved for those without periods for at least 6 to 12 months.
An MRI of the brain and/or gastrointestinal studies may be performed in those
in whom the etiology of the weight loss and/or vomiting is not clearly due to
an eating disorder but may instead be due to another diagnosis.
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MANAGEMENT
Aside from electrolyte disturbances, which require immediate attention,
most medical complications respond well to nutritional rehabilitation.
Management for patients with AN should include both nutritional
counseling and a behavioral plan that ensures that the patient
is compliant.5-7 As a general rule, a goal weight is established
(most commonly used is the weight at which regular menses are likely
to return, which is often approximately 10% below expected body
weight) and systems are put into place to help the individual achieve
that goal weight. Included in those systems is psychological counseling.
Most patients with eating disorders require individual therapy
to help uncover underlying causes of the eating disorder and to
manage day to day requirements of treatment; some patients may
also benefit from family and/or group therapy; medications, especially
the selective serotonin uptake inhibitor antidepressants, have
also been increasingly used.5 These have been shown to help alleviate
the anxiety and depression that usually accompany AN, although
having no direct affect on weight gain, and to help decrease the
binge and purge behaviors of BN.5
The roles of the individual practitioner in the initial stages
of management are to detect the presence of the eating disorder,
to perform an initial evaluation, and to refer the patient to the
appropriate level of care.1 The
latter can at times be difficult to accomplish. Coordination with
the patient’s family, primary
care physician, nutritionist, and/or mental health provider is
often necessary. This coordination can be complicated by issues
of confidentiality and the patient’s reluctance to undergo
treatment. Consultation with an eating disorders specialist, sometimes
on the telephone just to get advice, can help practitioners accomplish
these initial stages in referral and management.
The author reports no actual or potential conflicts of interest in
relation to this article.
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Martin Fisher, MD, is Chief, Division of Adolescent
Medicine, Schneider Children’s Hospital, North Shore-Long Island
Jewish Health System, New Hyde Park, New York; and Professor
of Pediatrics, New York University School of Medicine.
References
- American Academy of Pediatrics.
Committee on Adolescence. Identifying and treating eating disorders.
Pediatrics. 2003;111(1):204–211.
- Fisher M. Treatment of eating
disorders in children, adolescents, and young adults. Pediatr
Rev. 2006;27(1):5–16.
- American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders. 4th ed.
Washington, DC: American Psychiatric Association;1994.
- Bunnell DW, Shenker IR, Nussbaum
MP, Jacobson MS, Cooper P. Subclinical versus formal eating disorders:
Differentiating psychological features. Int J Eating Disord.
1990; 9(3):357–362.
- American Psychiatric Association
Work Group on Eating Disorders. Practice guideline for the treatment
of patients with eating disorders (revision). Am J Psychiatry.
2000;157
(1 Suppl.):1–39.
- Schebendach J,
Nussbaum MP. Nutrition Management in Adolescents with Eating
Disorders. Adolesc Med. 1992;3(3):541–558.
- Rock CL, Curran-Celentano J.
Nutritional management of eating disorders. Psychiatr Clin
North Am. 1996;19(4):701–713.
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