Written by Tamara J. Aitken, RN, MSN, Kimberli McCallum, MD, CEDS, FAPA, and Ginger Nicol, MD
Bulimia Nervosa: The Basics
Individuals who suffer from Bulimia Nervosa (BN) struggle with recurrent episodes of binge eating, followed by compensatory behaviors to reverse or avoid weight gain. Binge eating is defined as consumption of a large amount of food – as much as a whole day’s worth of calories or more – in a discrete period of time (perhaps over 2-3 hours). Binge episodes are associated with emotional distress, shame, and most of all are associated with a loss of control over eating. Compensatory behaviors can include self-induced vomiting or misuse of laxatives, periods of fasting or restricted food intake, and excessive exercise are also common. The diagnosis of BN is based on the above criteria occurring at least once a week for 3 months (American Psychiatric Association, DSM-V, 2013).
Hormone Regulation in Eating Disorders
Hormones like estradiol, progesterone and testosterone, so-called sex hormones, regulate ovulation and menses in women, and sperm count in men. Both women and men with BN can experience a reduction in sex hormone production, primarily related to fluctuating body weight. Blood levels of other hormones, vitamins and minerals important for regulating metabolism and normal menstrual functioning can also be abnormal in BN. For example, thyroid functioning, measured by thyroid stimulating hormone (TSH), can be either low or high. Leptin, a hormone made by fat cells that helps to regulate appetite, can be low. Follicle stimulating hormone (FSH) and luteinizing hormone (LH), both important for regulating normal menstrual functioning, can be low. Vitamin D and calcium, both critical for bone and tissue formation, can also be low in BN. Finally, minerals critical for maintaining normal metabolic functioning such as potassium, sodium, magnesium and phosphorous can be abnormal related to active binge and purge behavior.
Bulimia, Fertility and Conception: Cause for Caution and Hope
While individuals with Anorexia Nervosa (AN) may cease ovulation altogether related to low body weight. In fact, the ovaries and uterus can shrink to pre-pubertal size in women with AN. Evidence of shrinking reproductive organs has not been found in BN patients, who can have normal or near normal body weight. However, amenorrhea (absence of a period) or oligomenorrhea (infrequent or unpredictable menstruation) is seen in 60% of BN patients despite being normal weight. The good news is that hormone regulation can be preserved in patients with BN, thereby allowing for conception. The bad news is that unpredictable or inconsistent ovulation can cause women and their healthcare providers to underestimate the risk for unplanned pregnancy. (Easter et al, 2011) (Linna et al, 2013) Unfortunately, it is common for patients with eating disorders (ED) not to disclose ED history to reproductive health care providers due to shame and secrecy related to the ED, putting both mother and unborn child at risk (Freizinger, et al, 2010). Table 1 summarizes the literature available on fertility and conception in women with eating disorders. These studies highlight the importance of discussions about fertility, sexual activity, contraception and safer sex practices between women with BN and their healthcare providers.
Recent Studies on Reproduction and Eating Disorders
|Authors||Title of Study||Type of Study||Subjects (N)||Results||Recommendations|
|Freizinger,M.,Franko, D., Dacey, M., Okun, B., & Domar, A. (2010)||The prevalence of eating disorders in infertile women||Descriptive, comparative two-group design (US)||N=82||Fertility clinics are seeing women with past and current eating disorders in higher rates than general population.||Eating disorder screening tool need to be included in the initial intake because they are at higher risk for negative maternal and fetal outcomes.|
|Micali, N., Silva, I., Graaf, J., Jaddoe, V., Hofman, A., Verhulst, F., …Tiemeier, H. (2014)||Fertility treatment, twin births, and unplanned pregnancies in women in eating disorders: findings from a population-based birth cohort||Longitudinal population birth cohort (Netherlands)||
N – AN =160N – BN = 265
N – AN+BN = 130
|Women with BN had an increase rate of having undergone fertility treatment. Women with all ED had an increase incidence of twin births. AN was associated with increased unplanned pregnancies and negative feelings about pregnancies.||Fertility specialists need to become aware of more ED patients using their services and recognize the physical and psychological issues surrounding the ED and fertility.|
|Pasternak, Y., Weintraub, A., Vardi, I., Sergienko, R., Guez, J., Wiznitzer, A., ….Sheiner, E. (2012)||Obstetric and perinatal outcomes in women with eating disorders||Retrospective study cohort with normal control group (Israel)||N = 122 with ED||Eating disorders were associated with fertility treatment, intrauterine growth restriction, low birth weight, preterm delivery and C-sections.||Eating disorders are associated with increased risk of adverse pregnancy outcomes. Careful surveillance is needed for early detection of complications|
|Easter, A.., Treasure, J. & Micali, N. (2011)||Fertility and prenatal attitudes towards pregnancy in women with eating disorders: Results from the Avon longitudinal study of parents and children.||Longitudinal prospective birth cohort (UK)||
N – AN = 171N –BN =199
N – AN+BN = 82
|Women with AN and women with AN + BN were more likely to have seen a dr. for fertility problems. Women with AN + BN were more likely to take over 6 months to conceive. All ED groups experienced negative feelings upon pregnancy discovery and remained so at 18 months with AN group.||Lifetime ED are associated with problems with fertility, unplanned pregnancy, and negative attitudes towards pregnancy. Reproductive and primary care health professionals need to be aware of ED when assessing fertility.|
Pregnancy in Bulimia Nervosa: Challenges and Opportunities
There is hope for women with BN to experience motherhood by working with a team of healthcare providers (ideally including both reproductive and psychiatric specialists) to overcome the challenges of fertility. Careful planning, good prenatal care, and psychological support can ensure a healthy baby. However, it is important for patients with BN to know they may be at higher risk for prenatal complications than non-eating disorder patients. For example, hyperemesis gravidarum or intractable nausea and vomiting, can lead to severe dehydration, requiring additional medical support and creating extreme discomfort during the pregnancy. Multiple births, low birth weight and increased risk for cesarean section due to complications experienced in labor have also been reported in women with eating disorders (Paternak, Y. et al, 2012) (Micali, et al, 2014). The establishment of an open and honest relationship with health care providers is the first step to having a successful pregnancy in BN.
American Psychiatric Association. (2013). Feeding and eating disorders. Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.
Easter, A., Treasure, J., & Micali, N. (2011). Fertility and prenatal attitudes towards pregnancy in women with eating disorders: Results from the Avon longitudinal study of parents and children. British Journal of Obstetrics and Gynecology, 118 (3). 1491- 1498. doi: 10.1111.j. 1471-0528.2011.03077.x
Freizinger, M., Franko, D., Dacey, M., Okun, B., & Domar, A. (2010). The prevalence of eating disorders in infertile women. American Society of Reproductive Medicine, 93(1), 72-78. doi: 10.1016/j.fertnstert. 2008.09.055
Linna, M., Raevuori, A., Haukka, J., Suviaari, J., Suokas, J. & Gissler, M. (2013). Reproductive health outcomes in eating disorders. International Journal of Eating Disorders, 46(8), 826-833.
Micali, N., Silva, I., De Stavola, B., Steenweg-de Graaf, J., Jaddoe, J., Hofman, A., …Tiemeirer, T. (2014). Fertility treatment, twin births, and unplanned pregnancies in women in eating disorders: findings from a population-based birth cohort. British Journal of Obstetrics and Gynecology, 121(4), 408-416. doi: 10.111/1471-0528.12503
Paternak, Y., Weintraub, M., Shoham-Vardi, I., Sergienko, R., Guez, J., Wiznitzer, A., … Sheiner, E. (2012). Obstetric and perinatal outcomes in women with eating disorders. Journal of Women’s Health, 21(1), 61-65. doi: 10.1089/jwh.2011.2907
About the authors:
Tamara J. Aitken, RN, MSN
Tamara J. Aitken, RN, MSN is an advanced practice nurse at McCallum Place in St. Louis, focusing on the medical complications of eating disorders. She is completing a post-master’s certificate program at the University of Missouri – Columbia in May, 2015. Tamara graduated with her master’s in Nursing Care of Children from the University of Pittsburgh.
Kimberli McCallum, MD, FAPA, CEDS
Dr. McCallum is a psychiatrist, board certified in both child, adolescent, and in adult psychiatry. She is a fellow of the American Psychiatric Association (FAPA) and a Certified Eating Disorders Specialist (CEDS) and remains an Associate Professor of Clinical Psychiatry at Washington University. She received her Bachelor of Science from Brown University, her medical degree from Yale University, completed her adult training at UCLA Neuropsychiatric Institute, and her Child and Adolescent Psychiatry Fellowship at Washington University School of Medicine.
Dr. McCallum is passionate about education, family support, research and advocacy. She serves on the board of directors of the National Eating Disorder Association (NEDA), the advisory board of the International Association of Eating Disorders Professionals (IAEDP) and the Global Foundation of Eating Disorders (GFED). She has been an active member of the Academy of Eating Disorders (AED). Dr. McCallum is the co-founder of The Missouri Eating Disorders Association (MOEDA), a non-profit organization for family support and advocacy and a NEDA affiliate in St Louis. Dr. McCallum has developed several eating disorder treatment programs, including inpatient, partial hospital and intensive outpatient programs.
Ginger Nicol, MD
Dr. Ginger Nicol graduated with her bachelor’s in Journalism and Mass Communications from the University of Iowa in 1998, and received her medical degree from the University of Iowa Carver College of Medicine in 2002. She fulfilled both residency in General Psychiatry and fellowship in Child & Adolescent Psychiatry at Washington University School of Medicine (WUSM) in 2007. In 2010, she completed a National Institute of Drug and Alcohol Abuse (NIDAA) post-doctoral research fellowship in obesity and metabolic disorders in psychiatric populations at WUSM. Dr. Nicol is Assistant Professor of Psychiatry WUSM and has served as teaching and research faculty at the WUSM Department of Psychiatry since 2007.