Infertility and eating disorders Donna E. Stewart, MD, G. Erliek Robinson, MD, David S. Goldbloom, MD, and Charlene Wright, BSe

Toronto, Ontario, Canada Sixty-six consecutive infertility clinic patients were prospectively screened with the 26-item Eating Attitudes Test and a study questionnaire. Women identified as being at high risk for an eating disorder were then interviewed to confirm or refute the diagnosis. A total of 7.6% of infertility clinic women were found to suffer from anorexia nervosa or bulimia nervosa. If eating disorders not otherwise specified were included, a total of 16.7% of infertility patients were found to suffer from an eating disorder. Among infertile women with amenorrhea or oligomenorrhea 58% had eating disorders. Because women often fail to disclose eating disorders to their gynecologists and may appear to be of normal weight, it is recommended that a nutritional and eating disorder history be taken in infertility patients, particulary those with menstrual abnormalities. It has previously been shown that disordered eating and nutrition can affect menstruation, fertility, maternal weight gain, and fetal well-being. (AM J OaSTET GVNECOL 1990;163:1196-9.)

Key words: Infertility, eating disorder, anorexia nervosa, bulimia nervosa

Anorexia nervosa, characterized by self-imposed starvation as a result of a relentless pursuit of thinness and a fear of fatness, occurs in a serious form in about 1% of young adult and adolescent women.' A related disorder, bulimia nervosa, is defined as episodic patterns of binge eating followed by a variety of methods to counteract the caloric ingestion, including vomiting, starvation, and laxative abuse; bulimia is also accompanied by an intense preoccupation with weight and shape. This may occur in the context of anorexia nervosa or more commonly as a separate syndrome at an actuarially normal body weight. The prevalence of bulimia nervosa as defined by DSM-UI-R criteria' is 1.7% of adolescent and young adult women. 3 Milder variants of anorexia nervosa and bulimia nervosa that fail to meet criteria for a specific eating disorder, defined by DSM-III-R as eating disorders not otherwise specified, occur in a further 3% to 5% of the female population'" 5 Eating disorders not otherwise specified is characterized by (1) a person of average weight who does not have binge eating episodes but frequently engages in self-induced vomiting for fear of gaining weight, (2) all of the features of anorexia nervosa in a female subject except absence of menses, or (3) all of the features

From the Departments of Psychiatry and Obstetrics and Gynecology, St. Michael's Hospital and Toronto General Hospital, Univenity of Toronto. This work was partially supported by a Canadian Psychiatric Research Foundation grant to Drs. Stewart and Robinson. Received for publication October 17, 1989; revised April 25, 1990; accepted May 18, 1990. Reprint requests: Dr. Donna Stewart, St. Michael's Hospital, 30 Bond St., Toronto, Ontario, Carzad£L M5B 1W8. 611/22461

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of bulimia nervosa except the frequency of binge eating episodes! A careful survey of women aged 16 to 35 attending a family practice found a total prevalence of eating disorders and partial syndrome (eating disorders not otherwise specified) of 4%.5 Eating disorders result in significant morbidity related to episodes of weight loss, vomiting, electrolyte disturbance, gastrointestinal problems, psychiatric sequelae, and reproductive complications.' Although it is known that many of these patients, particularly those with anorexia nervosa, have primary or secondary amenorrhea and are infertile,6 the reproductive aspects of anorexia nervosa and bulimia nervosa have been inadequately studied. Two early studies examined menstruation, fertility, and pregnancy in patients previously diagnosed as having anorexia nervosa.'· B Starkey and Lee' found that most anorexic patients reported weight gain, return of menses, and fertility with successful treatment, but women without weight gain did not experience menstrual return or conception. Hart et al. B described three women with anorexia nervosa who were induced to ovulate with human menopausal gonadotropinhuman chorionic gonadotropin but then experienced significant fetal loss because of miscarriages, multiple pregnancies, premature births, and low birth weights. Investigators have also previously found that some women with amenorrhea or infertility who are seen by gynecologists actually have undisclosed eating disorders. 9-'3 An early study by Fries'3 found a high proportion of women with an eating disorder among 30 women with secondary amenorrhea associated with weight loss. Nillius" reported that 34% of amenorrheic women in his study were found to have amenorrhea caused by self-induced weight loss. The diagnosis of

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such underlying problems may be hampered by the fact that some bulimic women appear to be of normal weight by actuarial or population mean standards. However, longitudinal weight history may reveal premorbid obesity that led to highly restrictive dieting coupled with bulimic behavior. 14 A recent Australian study using the Eating Disorders Inventory also found elevated drive for thinness and interoceptive awareness subscales to point toward disordered eating in 30 infertility clinic patients,15 but these investigators did not conduct confirmatory interviews for eating disorders. Bates et al. 12 found that 47 women with unexplained infertility and menstrual dysfunction were practicing weight control by caloric restriction to maintain a fashionable body habitus. The report did not state whether formal eating disorders were found in any woman in this study. When 36 of these women followed a dietary regimen designed to increase their weight to predicted ideal body weight, menstruation resumed in most, with subsequent spontaneous conception. It is of interest that 97% of these infertile women and their husbands had been evaluated previously for infertility with a variety of diagnostic gynecologic studies without weight loss being identified as the cause of the infertility. The aim of the present study was to ascertain prospectively the prevalence of eating disorders (anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified) in a group of women with infertility attending a university reproductive biology service.

Material and methods Consecutive women with infertility seen at a university reproductive biology service were assessed by means of a standardized, reliable, valid self-report measure, the 26-item Eating Attitudes Test (EAT-26), which is presently in widespread use as a screening instrument for eating disorders.'6 The EAT-26 focuses on specific dysfunctional beliefs and behaviors associated with anorexia nervosa and bulimia nervosa.1 6 The women also completed a study questionnaire on current and past weights, menstrual history, and gynecologic history. All women identified on screening tests as having possible eating disorders (EAT-26 score ~ 20) or who reported a past or current eating disorder were interviewed by one of the investigators (D. E. S.) to confirm or refute the diagnosis of an eating disorder by DSM-III-R criteria. Statistical analyses were performed by one-way analysis of variance. Results Sixty-six women completed the EAT-26 and the study questionnaire. There were three refusals to complete these questionnaires, resulting in a 96% response rate. One woman who refused later acknowledged to infertility clinic staff that she had been treated in the

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past for bulimia nervosa and was still regularly binge eating and inducing vomiting. The three women who refused to complete the questionnaires are not included in the data. The mean age of the women completing the questionnaires was 30.4 years (range 21 to 39). Their mean weight was 103% ideal body weight (range 72% to 143%). Ideal body weight was defined as the average weight for a given height and age, determine9 from statistics compiled in 1979 by the Association of Life Insurance Medical Directors of America and Society of Actuaries. Twelve women had abnormal menses (amenorrhea or oligomenorrhea). According to the cutoff score described above for the EAT-26, 12 women were identified as possible cases of eating disorders. In addition, two women who did not meet the criteria disclosed on the study questionnaire that they were being treated for an eating disorder and one woman who scored zero on all EAT-26 items was identified by a note on her questionnaire saying "I am not bulimic" and an allegation of bulimia made by her sister. Clinical interviews with all 15 women confirmed that 11 had an eating disorder. Utilizing DSM-III-R criteria, four women had bulimia nervosa, one had anorexia nervosa, and six had eating disorders not otherwise specified. This results in a prevalence of a formal specific eating disorder (anorexia nervosa or bulimia nervosa) of 7.6% (16.7% when eating disorders not otherwise specified are included). The four women identified as possible cases on screening but not confirmed by interview were all overweight (ideal body weight = 120%), dieting, and preoccupied by food. Of the 12 women in the total sample with abnormal menses, seven (58.3%) suffered from anorexia nervosa, bulimia, or eating disorders not otherwise specified (Table I). There was no significant difference in the percent ideal body weight between women with eating disorders and women without eating disorders. Analysis of variance was used to compare scores of amenorrheic and oligomenorrheic women with those of women with normal menses. Total scores on EAT-26 were significantly higher (p < 0.0001) in the abnormal menses group than in the normal menses group. Although all four amenorrheic women had significantly lower percent ideal body weight than all other women (p = 0.04), the percent ideal body weight was not significantly different between normal and the total abnormal menses group.

Comment We found a 7.6% prevalence by DSM-III-R criteria of a specific eating disorder (anorexia nervosa or bulimia nervosa) in consecutive women seen in a university hospital clinic for infertility. This rate is two to four

1198 Stewart et al.

October 1990 Am J Obstet Gynecol

Table I. Menses and eating disorder in 66 infertility clinic women Menses Eating disorder

Normal

1

Oligomenorrhea

1

Amenorrhea

Total I 4

Anorexia nervosa Bulimia nervosa Eating disorder not otherwise specified No eating disorder

0 0 4 50

0 2 2 4

I 2 0 I

55

TOTAL

54

8

4

66

times that predicted by population and general practice studies of women in this age group.l.3.5 The 12 women with menstrual abnormalities in our sample had a higher prevalence (58%) of eating disorders than normally cycling women (7%), suggesting that infertile women with menstrual abnormalities are at even higher risk of suffering from an eating disorder. Other investigators have described the endocrine findings associated with menstrual cycle abnormalities in women with anorexia nervosa and bulimia nervosa. In general, these women tend to have fewer luteining hormone secretory spikes and a trend toward lower mean 24hour luteinizing hormone levels than controls.16 Stimulation with gonadotropin-releasing hormone produced elevated luteinizing hormone responses in the bulimic group and blunted luteinizing hormone responses in the anorexic group.16 Estradiol levels were uniformly lower in women with anorexia nervosa, 17 and stimulation with estradiol revealed diminished luteinizing augmentative responses and a trend toward diminished follicle-stimulating hormone augmentative responses in patients with anorexia nervosa and bulimia nervosa as compared with those of controls. 16 Other studies have shown that approximately 50% of normal weight women with bulimia nervosa have menstrual abnormalities with impaired follicular maturation caused by impaired gonadotropin secretion. 17. IS Moreover, it has been shown in normal young women of normal body weight who diet for 6 weeks (800 to 1000 kcal/day) that a variety of changes in endocrinologic function develop with actual disruption of menstrual cycles for 3 to 6 months after dieting in approximately 20%.19 Recently investigators have shown that women with eating disorders not otherwise specified also frequently have menstrual dysfunction. 21 If women with eating disorders not otherwise specified are included in our prevalence figures for an eating disorder in infertility clinic patients, the rate rises to 16.7%, a finding of concern that warrants further study. Eating disorders may play an important etiologic role in infertility because recent work has shown that 73% of normal infertile patients who were below ideal body weight because of caloric restriction conceived spontaneously when their weight was corrected. 12

6

None of the women we identified with eating disorders had divulged this problem to the infertility clinic gynecologist before the introduction of the screening questionnaires. The exposure to these questionnaires appears to have encouraged more open disclosure about eating disorders. Five women wrote notes on their questionnaires stating they were worried that abnormal eating habits had caused their infertility. On psychiatric interview all four women with bulimia nervosa and three of six women with eating disorders not otherwise specified confided that they had previously sought treatment for an eating disorder but failed to report it to the gynecologist. All expressed a concern that they had "damaged" themselves by their disordered eating behaviors but expressed relief at now being able to discuss this further. Patients often fail to volunteer information about eating disorders to their gynecologists and may sometimes appear to be of normal weight (in fact, percent ideal body weight was a poor predictor of an eating disorder in this and other studies)'; therefore, when infertile patients are assessed, especially those with menstrual abnormalities, there is a need for routine careful inquiry into nutritional intake and eating disorder history. Relevant clinical screening inquiries include a history of highest and lowest ever weights, desired body weight, average daily caloric intake, dieting, and alternative attempts at weight control. For routine evaluation, "consciousness raising," or research purposes, screening of infertility clinic patients with the EAT-26 using a cutoff score of 2!:20 will identify a group of women at high risk for an eating disorder. Given the brevity, ease of scoring, and ability of the EAT-26 to correctly identify 73% of patients with eating disorders in our study, it appears to be a fairly useful screening instrument in this population. Women identified as high risk on screening can then be referred for further assessment to confirm or refute the diagnosis of an eating disorder. Women with false-positive results on the EAT-26 were characteristically overweight dieters, a finding confirmed by other investigators."" It should be borne in mind that the EAT-26 will not identify all women with eating disorders, especially those who deny symptoms. However, an awareness of the frequency of

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eating disorders in infertility patients followed by careful clinical inquiry should correctly identify most cases. All women in this study who had a confirmed eating disorder were advised to have psychiatric treatment and nutritional counseling. In clinical practice, women found to have an eating disorder should be treated for this before infertility investigations and treatments are pursued. We have previously shown that women whose eating disorders persist during pregnancy gain less weight, have more complications of pregnancy, have smaller babies with lower 5-minute Apgar scores, experience more difficulties in postpartum adjustment, and have more problems with breast-feeding. lo It is not known if the high rate of spontaneous conception with correction in weight is applicable to formal eating disorders, but our earlier work indicates that successful treatment of eating disorders reduces morbidity of the pregnant woman and her offspring. IO We thank Dr. C. Redmond, Dr. C. Derzko, and Dr. R. Casper for encouraging their infertility patients to participate in this survey, and Dr. M. Morris for contacting the high-risk women identified by the screening instruments.

REFERENCES I. Garfinkel PE, Garner D. Anorexia nervosa: a multidimensional perspective. New York: Bruner/Mazel, 1982: 101, 307-26. 2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed revised. Washington DC: American Psychiatric Associaton, 1987. 3. Ben-Tovim DI. DSM-III, draft DSM-III-R and the diagnosis and prevalence of bulimia in Australia. Am J Psychiatry 1988;145:1000-2. 4. Button EJ, Whitehouse A. Subclinical anorexia nervosa. Psychol Med 1981;11 ;509-16. 5. King MB. Eating disorders in general practice. Br Med J 1986;293: 1412-4. 6. Reid RL, VanVugt DA. Weight-related changes in reproductive function. Fertil Steril 1987;48:905-13.

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7. Starkey TA, Lee RA. Menstruation and fertility in anorexia nervosa. AM J OBSTET GYNECOL 1969; 105:374-9. 8. Hart T, Kase W, Kimball CPo Introduction of ovulation and pregnancy in patients with anorexia nervosa. AM J OBSTET GYNECOL 1970; I 08:580-4. 9. Stewart DE, MacDonald OL. Hyperemesis gravidarium and eating disorders in pregnancy. In: Abraham S, Llewellyn-Jones D, eds. Eating disorders and disordered eating. Sydney: Ashwood House, 1987:52-5. 10. Stewart DE, RaskinJ, Garfinkel PE, MacDonald OL, Robinson GE. Anorexia nervosa, bulimia, and pregnancy. AM J OBSTET GYNECOL 1987;157:1194-8. II. Nillius SJ. Psycho-pathology of weight-related amenorrhea. In: Jacobs, HS, ed. Advances in gynaecological endocrinology. London: Royal College of Obstetricians and Gynaecologists, 1978: 118-30. 12. Bates GW, Bates SR, Whitworth NS. Reproductive failure in women who practice weight control. Fertil Steril 1982;37:373-8. 13. Fries H. Secondary amenorrhea, self-induced weight reduction and anorexia nervosa. Acta Psychiatr Scand 1974;248(suppl): 1-69. 14. Garfinkel PE, Moldofsky H, Garner DM. The heterogeneity of anorexia nervosa: bulimia as a distinct group. Arch Gen Psychiatry 1980;37: 1036-40. 15. Allison S, Kalucy R, Gilchrist P, Jones W. Weight preoccupation among infertile women. Int J Eating Dis 1988;7:743-8. 16. Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The Eating Attitudes Test: psychometric features and clinical correlates. Psychol Med 1982; 12:871-8. 17. Devlin MJ, Walsh BT, Katz JL, et al. Hypothalmicpituitary-gonadal function in anorexia nervosa and bulimia. Psychiatry Res 1980;28: 11-24. 18. Copeland PM, Herzog DB. Menstrual abnormalities. In: Hudson JI, Pipe HG, eds. The psychobiology of bulimia. Washington DC: American Psychiatric Press, 1987:31-54. 19. Pirke KM, Dogs M, Fichter MM. Tuschil RJ. Gonadotrophins, oestradiol, and progesterone during the menstrual cycle in bulimia nervosa. Clin Endocrinol 1988;29:26570. 20. Pirke KM, Ulrich S, Lemmel W, KriegJC, Berger M. The influence of dieting on the menstrual cycle of healthy young women. J Clin Endocrinol Metab 1985;60: 1174-9. 21. Kreipe RE, StraussJ, Hodgman CH, Ryan RM. Menstrual cycle abnormalities and subclinical eating disorders: a preliminary report. Psychosom Med 1989;51:81-6. 22. Wells JE, Coope PA, Gabb DC, Pears RK. The factor structure of the Eating Attitudes Test with adolescent school girls. Psychol Med 1985;15:141-6.