Use of pelvic ultrasound to monitor ovarian and uterine maturity in childhood onset anorexia nervosa

Is the Activity-Based Anorexia Model a Reliable Method of Presenting Peripheral Clinical Features of Anorexia Nervosa?

Anorexia nervosa (AN) causes the highest number of deaths among all psychiatric disorders. Reduction in food intake and hyperactivity/increased anxiety observed in AN are also the core features of the activity-based anorexia animal model (ABA). Our aim was to assess how the acute ABA protocol mimics common AN complications, including gonadal and cardiovascular dysfunctions, depending on gender, age, and initial body weight, to form a comprehensive description of ABA as a reliable research tool. Wheel running, body weight, and food intake of adolescent female and male rats were monitored. Electrocardiography, heart rate variability, systolic blood pressure, and magnetic resonance imaging (MRI) measurements were performed. Immediately after euthanasia, tissue fragments and blood were collected for further analysis. Uterine weight was 2 times lower in ABA female rats, and ovarian tissue exhibited a reduced number of antral follicles and decreased expression of estrogen and progesterone receptors. Cardiovascular measurements revealed autonomic decompensation with prolongation of QRS complex and QT interval. The ABA model is a reliable research tool for presenting the breakdown of adaptation mechanisms observed in severe AN. Cardiac and hormonal features of ABA with underlying altered neuroendocrine pathways create a valid phenotype of a human disease.

Eating disorders in children and adolescents

This article provides an overview of classification and outcome of eating disorders, before focusing on current evidence-based treatment for the two main disorders of anorexia nervosa and bulimia nervosa.

Obstetric and gynecologic problems associated with eating disorders

OBJECTIVE

This article summarizes the literature on obstetric and gynecologic complications associated with eating disorders.

METHOD

We performed a comprehensive search of the current literature on obstetric and gynecologic complications associated with eating disorders using PubMed. More recent randomized-controlled trials and larger data sets received priority. We also chose those that we felt would be the most relevant to providers.

RESULTS

Common obstetric and gynecologic complications for women with eating disorders include infertility, unplanned pregnancy, miscarriage, poor nutrition during pregnancy, having a baby with small head circumference, postpartum depression and anxiety, sexual dysfunction and complications in the treatment for gynecologic cancers. There are also unique associations by eating disorder diagnosis, such as earlier cessation of breastfeeding in anorexia nervosa; increased polycystic ovarian syndrome in bulimia nervosa; and complications of obesity as a result of binge eating disorder.

DISCUSSION

We focus on possible biological and psychosocial factors underpinning risk for poor obstetric and gynecological outcomes in eating disorders. Understanding these factors may improve both our understanding of the reproductive needs of women with eating disorders and their medical outcomes. We also highlight the importance of building multidisciplinary teams to provide comprehensive care to women with eating disorders during the reproductive years.

Uterine size and ovarian size in adolescents with functional hypothalamic amenorrhoea

INTRODUCTION

Functional hypothalamic amenorrhoea (FHA) is a condition characterised by the absence of menses due to suppression of the hypothalamic-pituitary-ovarian axis.

OBJECTIVE

The purpose of the study was to estimate uterine and ovarian sizes in adolescents with FHA and to compare these results with findings in peers having regular menstrual cycles.

DESIGN

Prospective case-controlled study.

SETTINGS

Vilnius University Hospital Santariskiu Klinikos, Lithuania.

PATIENTS

Lithuanian adolescents--45 with FHA and 40 comparison group participants.

MAIN OUTCOME MEASURES

We assessed ultrasound measurements of internal reproductive organs, levels of luteinising hormone, follicle-stimulating hormone, prolactin, oestradiol and calculated body mass index (BMI).

RESULTS

The mean age of the participants was 16.3 ± 1.2 years, the mean age after menarche--3.6 years. In adolescents with FHA the BMI was 17.8 ± 1.8 kg/m(2) and 20.4 ± 1.4 kg/m(2) in the comparison group, p < 0.001. The uterine volume (14.7 ± 6.3 cm(3) vs 31.7 ± 10.6 cm(3), p < 0.001), cervical length (2.3 ± 0.4 cm vs 2.6 ± 0.5 cm, p = 0.03), volume of both ovaries (9.3 ± 3.6 cm(3) vs 13.8 ± 4.3 cm(3), p < 0.001) and levels of LH (2.70 ± 2.59 vs 6.01 ± 2.44, p < 0.001) were significantly lower in girls with FHA. A significantly positive correlation between volume of uterus and levels of LH (r = 0.415; p < 0.001) was found. We identified a positive correlation between uterine volume, uterine corpus length, cervical length, ovarian volume and weight, BMI.

CONCLUSIONS

In adolescents with FHA the dimensions of uterus and ovaries were smaller than in girls having regular menstrual cycles. Our study confirmed the influence of oestrogen on uterus size: oestrogen deficiency causes a reduction in uterine size. Uterine size and ovarian size correlate positively with BMI.

Imaging findings in eating disorders

OBJECTIVE

Eating disorders, such as anorexia nervosa and bulimia nervosa, are often undiagnosed but potentially treatable illnesses that, if not identified, can lead to morbidity and death. Often, because of embarrassment or social stigma, patients do not readily admit to these disorders when interviewed by caregivers. Imaging findings can suggest the presence of an eating disorder; understanding these findings allows the radiologist to contribute to the diagnosis of these insidious conditions and alert the referring caregiver. Current concepts in eating disorders and their multimodality imaging findings in several organ systems will be reviewed.

CONCLUSION

After reviewing this article, the radiologist will understand the imaging findings in eating disorders. This knowledge will empower the radiologist to raise the question of a patient's eating disorder, a condition that may be unsuspected by the referring caregiver and could otherwise remain undiagnosed.

Resumption of menses in anorexia nervosa during a course of family-based treatment

BACKGROUND

The resumption of menses (ROM) is considered an important clinical marker in weight restoration for patients with anorexia nervosa (AN). The purpose of this study was to examine ROM in relation to expected body weight (EBW) and psychosocial markers in adolescents with AN.

METHODS

We conducted a retrospective chart review at The University of Chicago Eating Disorders Program from September 2001 to September 2011 (N = 225 females with AN). Eighty-four adolescents (Mean age = 15.1, SD = 2.2) with a DSM-IV diagnosis of AN, presenting with secondary amenorrhea were identified. All participants had received a course of outpatient family-based treatment (FBT), i.e., ~20 sessions over 12 months. Weight and menstrual status were tracked at each therapy session throughout treatment. The primary outcome measures were weight (percent of expected for sex, age and height), and ROM.

RESULTS

Mean percent EBW at baseline was 82.0 (SD = 6.5). ROM was reported by 67.9% of participants (57/84), on average at 94.9 (SD = 9.3) percent EBW, and after having completed an average of 13.5 (SD = 10.7) FBT sessions (~70% of standard FBT). Compared to participants without ROM by treatment completion, those with ROM had significantly higher baseline Eating Disorder Examination Global scores (p = .004) as well as Shape Concern (p < .008) and Restraint (p < .002) subscale scores. No other differences were found.

CONCLUSIONS

Results suggest that ROM occur at weights close to the reference norms for percent EBW, and that high pre-treatment eating disorder psychopathology is associated with ROM. Future research will be important to better understand these differences and their implications for the treatment of adolescents with AN.

Predictors of menstrual resumption by patients with anorexia nervosa

OBJECTIVE

To investigate which factors predict the resumption of menstruation by patients with anorexia nervosa (AN).

METHODS

Participants were AN patients who, even after weight recovery by inpatient treatment, had prolonged amenorrhea (N=11), AN patients who resumed menstruation after weight recovery (N=9), and age-matched healthy controls (N=12). Anthropometric data and the serum levels of leptin, insulin-like growth factor I (IGF-1), cortisol, luteinizing hormone (LH), estradiol (E2), and other hormones were measured at the beginning of the inpatient treatment and after weight recovery.

RESULTS

Of the baseline anthropometric and hormonal factors, logistic regression analysis extracted a high serum cortisol level as a predictor of the inhibition of the resumption of menstruation. After weight recovery, the E2 and leptin levels were significantly higher for eumenorrheic patients than for amenorrheic patients.

CONCLUSION

The baseline serum cortisol level was a predictor of the prolonged inhibition of menstrual recovery.

Current concepts in bone and reproductive health in adolescents with anorexia nervosa

Anorexia nervosa (AN) initiates an adaptive response at the level of the hypothalamus, which results in a complex interplay involving most elements of the neuroendocrine axis. Consequences of onset of disease in adolescence include amenorrhoea, pubertal arrest with potential loss of target height, and osteoporosis with reduced capacity for future attainment of peak bone mass. With recovery, delay in restoration of menses is common. Hormonal therapies for restoration of bone mineral density (BMD) in adolescents have shown limited efficacy. This review will discuss the reproductive endocrine effects of AN in adolescence, and discuss new investigative tools for monitoring restoration of reproductive function and BMD in this population.

Weight and growth requirements for menarche in teenage girls with eating disorders, weight loss and primary amenorrhea

BACKGROUND/AIM

To investigate weight and growth requirements for menarche in girls with eating disorders (ED), weight loss and primary amenorrhea.

METHODS

Growth charts from school health services and measurements of weight and stature throughout treatment were obtained for 47 such girls.

RESULTS

Weight loss started at an age of 12.4 +/- 1.6 years from a top weight of 41.7 +/- 7.1 kg. Approximately a year later they had lost 5.1 +/- 4.3 kg and grown only 2.8 +/- 3.5 cm. Following treatment and weight gain, growth accelerated and the girls reached a peak growth velocity of 4.3 +/- 2.6 cm/year 2 years before menarche which occurred at an age of 15.5 +/- 1.6 years at a weight of 52.2 +/- 5.3 kg. Menarche occurred within a wide range of weights but could be predicted by a linear regression on prepubertal weight (R(2) = 0.39; p < 0.001).

CONCLUSIONS

Following treatment, girls with ED and primary amenorrhea progress through puberty at a slowed rate. The weight required for menarche can be predicted by the prepubertal weight which may represent the individual's normal growth track unaffected by the ED.

Pelvic ultrasonography in anorexia nervosa: what the clinician should ask the radiologist and how to use the information provided

Pelvic ultrasonography is generally regarded as the gold standard for determination of pelvic maturity and hence the need for further weight gain in patients with anorexia nervosa. Many clinicians, however, have limited knowledge of this technique. Here, we describe the use of pelvic ultrasonography in anorexia nervosa and present an algorithm to assist the clinician, both with what questions to ask from the radiologist, and how to use the information provided to determine the morphology and hence maturity of the pelvic organs. We then show how this information can be used to assign the level of pelvic maturity a grade from 1 to 5. Finally, we demonstrate use of this system in two patients who progressively gained weight until pelvic maturity was achieved.

Menstrual dysfunction in anorexia nervosa

Amenorrhea is a hallmark sign of anorexia nervosa. Its cause is multifactorial and its resolution necessitates treatment of the underlying eating disorder. The neuroendocrine changes associated with menstrual abnormalities in underweight and weight recovered anorexia nervosa, recent research on osteopenia, and treatment recommendations are addressed.

Eating disorders in adolescence and their sequelae

Eating disorders are prevalent in adolescents and are associated with significant medical and psychiatric morbidity. Amenorrhoea, one of the cardinal features of anorexia nervosa, is the most likely reason for consulting the gynaecologist. Amenorrhoea in a young woman should alert the gynaecologist to the possibility of an underlying eating disorder. Osteopenia is a potentially irreversible complication of prolonged amenorrhoea and a low oestrogen state. Eating disorders are best managed by a team approach, with the team comprising a physician, nutritionist and therapist. Oestrogen replacement therapy has not been shown to be an effective treatment for osteopenia in anorexia nervosa and the gynaecologist should avoid simply prescribing oestrogen replacement therapy without referring the patient for comprehensive treatment of the eating disorder. Nutritional rehabilitation, weight restoration and resumption of spontaneous menses are the mainstay of medical management. Calcium and vitamin D supplementation and moderate weight-bearing exercise should be prescribed where indicated. Newer therapeutic options for the treatment of osteopenia include DHEA, IGF-1 and alendronate.

Restoration of ovarian and uterine maturity in adolescents with anorexia nervosa

OBJECTIVE

To determine the optimal weight-to-height ratio to achieve maturity of the reproductive organs when visualized by pelvic ultrasound in adolescent girls with anorexia nervosa. To examine the distribution of weight-to-height ratios in the group of adolescents in whom pelvic maturity was attained.

METHODS

Adolescent girls with anorexia nervosa received serial transabdominal pelvic ultrasound scans as they regained weight. A record of their weight-to-height ratio had been noted on each occasion. The scans were defined as mature or immature using strict criteria.

RESULTS

There was a wide range of weight-to-height ratios in both the mature and immature groups of patients with a considerable overlap between the groups. However, 88% of the sample required a weight-to-height ratio of 100% (body mass index [BMI] 20) to achieve reproductive maturity.

CONCLUSION

Previous target weights have been too low to ensure reproductive maturity. The resulting hypoestrogenic state increases the risk of future osteoporosis. Pelvic ultrasound is the safest and most reliable method for determining ovarian and uterine maturity in adolescent girls with anorexia nervosa.

Childhood and adolescent anorexia nervosa

Eating disorders are common during childhood and adolescence. Early intervention is associated with the best prognosis. Treatment interventions that focus on achieving ideal body weight and use various family therapy approaches are most likely to be effective. Much remains to be learned about the origin of AN, but there are promising recent advances.

Eating disorders in school-aged children

It is widely accepted that eating disorders do occur in children. There is a growing literature on childhood-onset AN, and it seems that the core behavioral, psychologic, and physical features are similar to those in adults. The differences between children and adults also must be taken into account, however. Because children have lower levels of body fat, they tend to become emaciated and suffer the effects of starvation for more quickly than adults, which must be taken into account when considering treatment. Although cases of childhood-onset BN have been reported, they are so rare that empirical research is difficult. Clinical features reported regarding the atypical childhood-onset eating disorders generally concur, although empirical testing of these features has yet to be developed. Theories as to why children develop these disorders need further development. The general consensus is that all childhood-onset eating disorders must be considered using a multidimensional model that takes into account physical, psychologic, social, and family factors in origin, assessment, and treatment.

Detection, evaluation, and treatment of eating disorders the role of the primary care physician

OBJECTIVE

To describe how primary care clinicians can detect an eating disorder and identify and manage the associated medical complications.

DESIGN

A review of literature from 1994 to 1999 identified by a MEDLINE search on epidemiology, diagnosis, and therapy of eating disorders, including anorexia nervosa and bulimia nervosa.

MEASUREMENTS AND MAIN RESULTS

Detection requires awareness of risk factors for, and symptoms and signs of, anorexia nervosa (e.g., participation in activities valuing thinness, family history of an eating disorder, amenorrhea, lanugo hair) and bulimia nervosa (e.g., unsuccessful attempts at weight loss, history of childhood sexual abuse, family history of depression, erosion of tooth enamel from vomiting, partoid gland swelling, and gastroesophageal reflux). Providers must also remain alert for disordered eating in female athletes (the female athlete triad) and disordered eating in diabetics. Treatment requires a multidisciplinary team including a primary care practitioner, nutritionist, and mental health professional. The role of the primary care practitioner is to help determine the need for hospitalization and to manage medical complications (e.g., arrhythmias, refeeding syndrome, osteoporosis, and electrolyte abnormalities such as hypokalemia).

CONCLUSION

Primary care providers have an important role in detecting and managing eating disorders.

Pelvic ultrasound scanning of the ovaries in adolescent anorectic patients at low weight and after weight recovery

In sixteen adolescent anorectic inpatients with secondary amenorrhea pelvic ultrasound examination of the ovaries was performed at lowest weight and after weight recovery. The outcome was assessed six months later at follow-up, assigning the patients to the categories of good, intermediate and poor outcome according to the modified Morgan and Russell criteria. At lowest weight all patients' ovaries were smaller than expected for age. After weight recovery the good outcome group had mature and fully developed ovaries whereas the ovarian morphology of patients with poor outcome remained prepubertal. The ovarian volume in the good outcome group was significantly higher than in the poor outcome group. From a threshold BMI of 17.8 upwards we observed a positive linear correlation between BMI and ovarian volume. At BMI 18 the probability for recovered ovaries was 53% rising to 82% at BMI 19.8, which was the highest noting in our study. Nevertheless, we could not find a clear cut-off BMI for definite prediction of recovered ovaries. Therefore, in patients with anorexia nervosa pelvic ultrasound is a very suitable method for determining the target weight required for recovery of ovarian function and resumption of menses. Normalized ovaries indicate favourable outcome and physical recovery.