Treatments of Medical Complications of Anorexia Nervosa and Bulimia Nervosa

By Mehler, Philip S.; Krantz, Mori J. et al. | Journal of Eating Disorders, April 5, 2015 | Go to article overview

Treatments of Medical Complications of Anorexia Nervosa and Bulimia Nervosa


Mehler, Philip S., Krantz, Mori J., Sachs, Katherine V., Journal of Eating Disorders


Author(s): Philip S Mehler[sup.1], Mori J Krantz[sup.3] and Katherine V Sachs[sup.2]

Background

As opposed to most other psychiatric disorders where there may be no medical complications associated with those illnesses, anorexia nervosa and bulimia nervosa inherently have many different medical complications. The specific treatments for those associated with anorexia nervosa and bulimia nervosa are described below.

Anorexia nervosa

Treatment of secondary amenorrhoea and infertility

Secondary amenorrhea is a hallmark of anorexia nervosa. Although no longer considered a diagnostic criterion, it is nevertheless a nearly ubiquitous feature of severe weight loss and can often be a presenting feature of the disease [1,2]. The development of amenorrhea is most strongly correlated to loss of body weight. There is variability in the literature regarding the degree of weight restoration needed for resumption of menses, with some sources citing return to ninety percent of ideal body weight, and others seeing a stronger correlation with the weight at which cessation of menses was observed [3,4].

Although weight restoration is the mainstay of treatment for amenorrhea in the setting of anorexia nervosa, there has been some investigation into pharmacologic intervention targeted at the disrupted hypothalamic-gonadal axis. Leptin is a hormone that is secreted by adipocytes and functions as a mediator in the adaptation to energy deprivation. Women with hypothalamic amenorrhea have been shown to have low leptin levels compared to matched controls [5,6]. Two studies have demonstrated that administration of recombinant leptin can restore function of the hypothalamic-gonadal axis, with the resumption of menses [7,8]. However, these studies were performed in subjects, who despite having hypothalamic amenorrhea, had weights which were only in the low-normal range, and therefore the results have limited applicability to the overall anorexia nervosa population.

Therefore given the generally reliable resumption of menses with weight restoration, it would seem that there is generally little role for a pharmacologic intervention to achieve this effect sooner. Hence, it is, once again, inadvisable to use oral contraceptives in this setting singularly for the purpose of inducing a withdrawal bleeding for patients with anorexia nervosa. There has been essentially no clinical benefit demonstrated for estrogen replacement in this population [9]. Moreover, induction of withdrawal bleeding can give a false sense of wellness to these patients which potentially can temper motivation for ongoing necessary nutritional rehabilitation and weight restoration.

Despite lack of menses, it is possible for women with anorexia nervosa to become pregnant, and therefore it should not be assumed that contraception is unnecessary in these patients [10]. However, women with a history of anorexia are more likely to have future problems with fertility, and are more likely to have persistent amenorrhea regardless of weight restoration, as compared to the general population [11]. Women with a history of anorexia nervosa who do become pregnant are at greater risk for pregnancy complications such as hyperemesis gravidum, and spontaneous abortion, as well as adverse neonatal outcomes such as low birth weight [12,13]. Given the lack of clear correlation between features of anorexia nervosa and subsequent pregnancy complications, there is no clear treatment or preventative measure for this issue, other than treatment of the underlying eating disorder and nutritional deficiencies.

Treatment of bone disease

Decrease in bone mineral density is commonly found in anorexia nervosa. Therefore, it is estimated that patients with anorexia nervosa are three times more likely to have a fracture, compared with the general population [14]. The degree of bone loss has been correlated both with body mass index and duration of amenorrhea [15]. …

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