How Eating Disorders Should Influence OB-GYN Care: ACOG’s New Committee Opinion

The American College of Obstetricians and Gynecologists (ACOG) recently published a committee opinion discussing necessary precautions for patients who may have eating disorders. Eating disorders encompass a wide range of conditions in which a person has abnormal feeding habits; often, eating disorders affect physical health in addition to mental and emotional well-being. Some of the most common eating disorders include the following:

  • Anorexia nervosa
  • Avoidant restrictive food intake
  • Bulimia nervosa
  • Binge-eating

Although gynecologists and obstetricians do not typically focus on the diagnosis or treatment of eating disorders, ACOG stresses that it is important for these professionals to be competent in recognizing warning signs, conducting preliminary screenings, and making referrals to specialists when necessary.

ACOG gives an overview of common signs and symptoms of eating disorders, known risk factors, screening procedures, and how gynecologists and obstetricians can participate in a multidisciplinary approach to managing eating disorders.

Signs and Symptoms of Eating Disorders

Although anyone can develop an eating disorder, they occur most frequently in adolescent and young adult females. Therefore, medical professionals who specialize in treating this subset of the population may be especially likely to come across patients with eating disorders. Gynecologists and obstetricians may recognize the following eating disorder symptoms while conducting routine examinations:

  • Menstrual cycle disturbances, such as period irregularity or cessation
  • Vaginal atrophy
  • Breast atrophy
  • Pelvic pain
  • Delayed puberty

The following are some additional signs and symptoms of eating disorders:

  • Decreased cognitive function (this is particularly common in patients with anorexia nervosa)
  • Rapid weight loss or fluctuations
  • Failure of adolescents to meet anticipated growth trajectories
  • Rise in pulse (this can indicate malnourishment)
  • Dental decay, parotid enlargement, and knuckle calluses (these are signs of self-induced vomiting)
  • Dry skin
  • Fine, soft body hair

Risk Factors for Eating Disorders

Gynecologists and obstetricians should also be aware of the risk factors for eating disorders so they can identify patients who require further evaluation. In general, people with perfectionist or obsessive personality types may be at higher risk of developing an eating disorder. Other factors that may be cause for concern include the following:

  • Severe dietary restriction
  • Skipping meals
  • Use of diet pills, diuretics, or laxatives
  • Intentional vomiting
  • An abnormal level of interest in exercise
  • Irritability
  • Lack of social interactions
  • Distorted body image
  • Fear of gaining weight

In order to identify at-risk patients, gynecologists and obstetricians can ask questions about how a patient feels about her weight, what and how much she is eating, and what her exercise habits are. They may also use screening tools such as the SCOFF questionnaire.

Further Evaluations for Patients with Suspected Eating Disorders

Mental Health Assessment

ACOG recommends that patients with suspected or diagnosed eating disorders be screened for other mental health disorders, such as depression and anxiety, because these often co-occur with eating disorders. Moreover, people with eating disorders are at a heightened risk for suicidal behaviors and serious self-harm. If these issues are suspected, patients should be immediately referred to a crisis agency or hospital emergency department, where mental health care professionals can assess and treat them. In some cases, ensuring that a patient is properly monitored and protected may entail breaching confidentiality, and providing information to parents or guardians.

Moreover, ACOG stresses that medical professionals, including gynecologists and obstetricians, should be aware of pro-eating disorder websites and social media accounts and the effect they can have on patients. They note that “These online sites are unlikely to cause an eating disorder, but they do promote an unhealthy body image and may be a barrier to recovery.”

Lab Tests

In addition to a mental health assessment, patients with suspected eating disorders should be given a laboratory assessment/examination which includes the following tests:

  • Complete blood count
  • Measurement of serum electrolytes
  • Calcium, magnesium, and glucose levels
  • Liver function
  • Urinalysis
  • Thyrotropin level
  • Heart activity (electrocardiogram)

If a patient has irregular periods or no periods, they should also be given a pregnancy test, as well as tests of the level of various substances: serum estradiol, follicle stimulating hormone, luteinizing hormone, thyroid-stimulating hormone, and prolactin. Adolescents with eating disorders should be given a dual-energy X-ray absorptiometry (DXA) in order to evaluate bone mineral density.

Role of Gynecologists and Obstetricians in Managing Eating Disorders

Primary treatment for an eating disorder generally occurs outside of a gynecological setting and may involve various types of therapy to address underlying mental health issues. This may include cognitive behavioral therapy (CBT) and family counseling. In some cases, drugs may also be prescribed.

Although gynecologists and obstetricians do not provide these services, they should know to make referrals if they suspect a patient has an eating disorder, and also be aware of the criteria that mandate immediate hospitalization.

Additionally, there are certain gynecological interventions that should be avoided in patients with eating disorders, and others that may be warranted. ACOG makes the following recommendations:

  • Combined oral contraceptive pills (OCPs) should not be used only for the purpose of treating amenorrhea (a lack of periods). This is because the “periods” experienced while on OCPs are from withdrawal bleeding, and not true menstruation. Therefore, they cannot be used as an indication of improved health. The American Academy of Pediatrics and the Society for Adolescent Health and Medicine also recommend against the use of combined OCPs for this purpose.
  • Doctors should take caution when prescribing medroxyprogesterone acetate, a drug used for birth control and other purposes such as menopausal hormone therapy, to patients with anorexia nervosa. This is in part because it affects menstruation, and makes it difficult to track improvement. Moreover, it can cause a reduction in bone mass density, which is especially dangerous in women with anorexia nervosa.
  • Copper IUDs may have advantages for patients with eating disorders. This is because they are a highly effective and long-lasting form of birth control, but do not stop menstruation from occurring or result in withdrawal bleeding.
  • Patients with eating disorders should be carefully counseled on contraceptive options. Women with mental health issues are statistically more likely to have sex without using contraception, use ineffective forms of contraception, or fail to use an effective form as indicated. Many mental health issues manifest in eating disorders, so women with eating disorders may be more likely to engage in risky sexual activities and accidentally become pregnant. Not only are patients with eating disorders at high risk for unplanned pregnancy, but may also be more likely to experience pregnancy complications such as a small fetal head circumference, postpartum depression, and anxiety. For all of these reasons, gynecologists and obstetricians should make sure that women with eating disorders and indeed, all patients are well informed on their contraceptive options and how they should be used.
  • Hormone therapy may play a role in future treatment. ACOG notes that hormone replacement may be a valuable means of increasing bone mass density in patients with anorexia nervosa. Exact combinations of hormones and doses are yet to be determined, but preliminary studies suggest that this may be a promising treatment.

Conclusion: Role of Gynecologists and Obstetricians in the Diagnosis and Management of Eating Disorders

Although diagnosing and managing eating disorders is not a primary focus of their work, it is important for gynecologists and obstetricians to be aware of risk factors, signs, and symptoms that may be indicative of an eating disorder, consider the role of mental health issues, recognize emergencies, and make the appropriate health referrals. If a patient is diagnosed with an eating disorder, this should also influence gynecologic and obstetrical care; for example, it should be taken into consideration when counseling patients about their birth control options. Many of these patients needs’ align with those of the general population, but there are also certain risks and complications that must be taken into account. Future research will provide more information on gynecologic and obstetric care for patients with eating disorders.

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