My friend is hoping that her niece, who has managed to become pregnant despite the fact that she has been battling anorexia for years, will have a healthy pregnancy.
Anorexia nervosa — a disease characterized by a distorted body image and low body weight — can have significant effects on fertility and pregnancy. It is primarily a disorder of young women, affecting ten times as many females as males. The average age of onset is in the late teenage years, and anorexia nervosa affects up to one percent of women overall.
Individuals with anorexia nervosa see themselves as overweight, even when they are extremely thin or malnourished. They also share an intense fear of gaining weight or becoming fat, and a denial of the medical complications of starvation. Lastly, women suffering from anorexia nervosa experience amenorrhea, defined as the absence of at least three consecutive menstrual cycles, which may lead to infertility.
Women suffering from anorexia maintain low body weight by restricting what they eat, forcing themselves to vomit, using laxatives and diuretics and/or exercising excessively. In contrast, women with bulimia nervosa usually are of normal (or above average) weight, and participate in binge eating and purging behaviors.
Although anorexia nervosa is a very serious disease, health and nutritional status can be restored and a successful pregnancy achieved when patients adhere carefully to a multidisciplinary treatment program.
Anorexia and Fertility
Because a lack of normal menstrual cycles is characteristic of anorexia nervosa, many women have difficulty getting pregnant and seek referral to fertility centers. However, anorexia nervosa is only one of the many causes of irregular menstrual cycles, so before attributing infertility to this condition, other abnormalities must be eliminated. Prior to undergoing any assisted reproductive therapy, a woman’s weight must be normalized, which may also normalize menstrual cycles when anorexia nervosa is the cause of irregularity.
Treatment and Programs
Pregnancy can offer an opportunity to recover from anorexia nervosa for many women. A woman who is planning to become pregnant or already has become pregnant should be referred to a comprehensive eating disorders program if possible, which includes nutritional counselors and psychotherapists. Treating anorexia nervosa can be a difficult journey that may include relapses as part of the road to recovery. Additionally, it is important for pregnant women with anorexia nervosa to be aware that symptoms may worsen in pregnancy as the body changes, which can increase the risk for relapse if not addressed. At this time, there are no FDA-approved medications to treat anorexia nervosa specifically; however, any associated anxiety and depression should be treated with medications and/or therapy as indicated. The treatment plan for anorexia nervosa is a stepwise process and includes many specialists, but by following a recovery plan, a woman with this disease may achieve remission and restored health.
Anorexia and Pregnancy
Women with anorexia nervosa require special care from providers during pregnancy to monitor for both maternal and fetal effects. These women are at greater risk of first-trimester hyperemesis gravidarum (a severe form of morning sickness) and miscarriage. The risk of preterm delivery and having a low-birth-weight infant is roughly doubled, due to inadequate maternal nutrition. Therefore, special attention to nutrition must be given and fetal growth should be monitored at regular intervals, especially in the third trimester. Furthermore, delivery by C-section is higher in women with anorexia. Finally, these women must be monitored closely for symptoms of depression, especially in the postpartum period, as they may be at higher risk.
How to Decrease Complications
Women with anorexia nervosa should be educated that proper diet and nutrition can minimize pregnancy complications. Caloric intake is the single-most important nutritional factor in determining infant birth weight. A well-balanced diet including healthy grains, lean proteins, pasteurized dairy and vegetables is recommended for all pregnant women, and especially important in women who may be malnourished due to anorexia nervosa. Nutrition should also include prenatal vitamins with iron and extra calcium, as women with anorexia nervosa often have low bone density. Recommended weight gain is 28 to 40 pounds if the body mass index (BMI) is less than 18.5 (underweight); in contrast, the goal for normal-weight women is 25 to 35 pounds. Balanced energy supplements were associated with a small increase in birth weight in some studies, and may be considered if weight gain is difficult. The good news is that with careful attention to nutrition, women with anorexia nervosa may have a healthy pregnancy, and may see pregnancy as a reason to improve their health and conquer this disease.
Margaret Chory, MD, is completing her residency in Obstetrics & Gynecology at Beth Israel Deaconess Medical Center. Her interests include general obstetrics and gynecology, well-woman care, and management of both low-risk and high-risk pregnancies.