Diagnosis and care of patients with anorexia nervosa in primary care settings

Anorexia nervosa is a psychiatric disorder characterized by abnormal eating behaviors that results in weight loss and has serious potential medical consequences. Most of these complications are readily treatable if diagnosed and attended to early in the course of the illness. In caring for patients with anorexia nervosa, the primary care physician has several critical roles. Because patients deny the severity of their illness, they delay seeking psychiatric treatment. The primary care physician must be skilled in recognizing this disorder, as well as in diagnosing and effectively treating the medical complications while educating the patient about them. The primary care physician is also involved with arranging and coordinating a comprehensive and multidisciplinary program, including dietary and mental health treatment. The multidisciplinary team is responsible for ensuring safe weight restoration and a judicious refeeding treatment plan. In addition to establishing the diagnosis and treating the multiple medical complications associated with anorexia nervosa, the primary care physician plays a central role in maintaining continuity of care despite the fact that successful care may require a variety of treatment settings. Factors that foster good prognoses for this increasingly common and often protracted eating disorder include early diagnosis and skilled medical intervention to prevent the inexorable physical decline that marked weight loss can cause.

The female athlete triad

The female athlete triad is defined as the combination of disordered eating, amenorrhea and osteoporosis. This disorder often goes unrecognized. The consequences of lost bone mineral density can be devastating for the female athlete. Premature osteoporotic fractures can occur, and lost bone mineral density may never be regained. Early recognition of the female athlete triad can be accomplished by the family physician through risk factor assessment and screening questions. Instituting an appropriate diet and moderating the frequency of exercise may result in the natural return of menses. Hormone replacement therapy should be considered early to prevent the loss of bone density. A collaborative effort among coaches, athletic trainers, parents, athletes and physicians is optimal for the recognition and prevention of the triad. Increased education of parents, coaches and athletes in the health risks of the female athlete triad can prevent a potentially life-threatening illness.

Use of the copper intrauterine device in the management of secondary amenorrhea

OBJECTIVE

To determine whether the insertion of a copper intrauterine device can restore regular menses in patients with functional secondary amenorrhea.

DESIGN

Prospective, observational study.

SETTING

Clinical practices.

PATIENT(S)

Forty-eight volunteers with functional secondary amenorrhea.

INTERVENTION(S)

Insertion of a copper intrauterine device.

MAIN OUTCOME MEASURE(S)

Restoration of menses.

RESULT(S)

In 40 patients, regular menses were restored within a few weeks after insertion of the device. Normal menses were maintained as long as the copper intrauterine device remained in place. After removal of the device, normal menses persisted for 1 year.

CONCLUSION(S)

Insertion of a copper intrauterine device restores regular menses in women with functional secondary amenorrhea. The mechanism of action of the device probably is related to the release of prostaglandins from the endometrium.

Menstrual disorders. Amenorrhea

Adolescent patients with amenorrhea often present to primary care providers. A basic understanding of menstrual and pubertal physiology enables clinicians to initiate the clinical evaluation. A thorough history and physical examination focusing on pubertal development indicate the appropriate diagnostic algorithm. Usually, an accurate diagnosis can be obtained quickly. Management includes restoring ovulatory cycles if possible, replacing estrogen when necessary, reassurance, and re-evaluation.

Amenorrhea in the athlete

Amenorrhea in the athlete is commonly encountered in clinical practice. The work-up of an athlete with amenorrhea should include consideration of all the physiological and pathological conditions that give rise to amenorrhea in any adolescent. Delay or failure to recognize and manage these patients may result in the emergence of athletic triad with potential serious consequences of increased stress fractures, scoliosis, and thin body mass. This article reviews amenorrhea in the adolescent athlete with respect to body composition, disordered eating, osteoporosis, psychological factors, warning signs, treatment, and outcomes. Need for further strategies specific to prevention, surveillance, research, health consequences, medical care, and public and professional education is addressed.

Treatment of reduced bone mineral density in athletic amenorrhea: a pilot study

There is considerable concern about the adverse effects on the skeleton of loss of menstrual function as a result of athletic activity, as well as uncertainty as to how it should be managed clinically. In a pilot intervention study 34 elite middle and long-distance runners, aged 18-35 years, with menstrual irregularity due to their athletic activity were randomized to three groups: (A) to receive hormone replacement therapy (HRT) and 1000 mg calcium per day (n = 10), (B) to receive 1000 mg calcium per day (n = 14), (C) a control group who received no treatment (n = 10). Bone mineral density (BMD) was measured in the left hip and lumbar spine (L2-4) using dual-energy X-ray absorptiometry. Results were first analyzed according to whether menstruation returned, either naturally or secondary to HRT (EU), and compared with those from subjects who remained amenorrheic (AM). During the first year BMD increased in the EU group in Ward's triangle (3.8%) and the lumbar spine (4.1%; both P < 0.05). BMD fell in the AM group in all regions and the between-group differences were 5.6% (p < 0.02) in Ward's triangle, 5.8% (p < 0.02) in L2-4 and 3.9% in the trochanter (p < 0.05). An 'intention to treat' analysis was then performed. It was found that the mean relative improvement at 1 year in spinal BMD was only 1.5%, due to return of menses in some of the controls and withdrawals from treatment in the treatment group. In consequence, a trial designed to show, with 80% power and 5% significance, a measurable benefit in lumbar spine BMD resulting from allocation to HRT treatment would require about 1150 athletes with amenorrhea or oligomenorrhea. These numbers could be reduced substantially to 380 subjects by confining the trial to completely amenorrheic athletes, who in this study were less likely to regain menses. For these and other logistical reasons, an HRT trial in amenorrheic athletes could only be successfully organized through international collaboration. This study illustrates the major effects of treatment withdrawals and instability of menstrual status on the design of longitudinal studies on the bony effects of menstrual dysfunction prior to menopause.

[Secondary amenorrhea due to intrauterine adhesions: Asherman's syndrome]

Three women aged 35, 33 and 40 years had secondary amenorrhoea and monthly recurring abdominal pains after curettage for blood loss after a pregnancy. Hysteroscopy revealed intrauterine adhesions. The symptoms disappeared largely or completely after synechiolysis, introduction of an IUD and oestrogen treatment. Changes in the menstrual cycle, infertility or recurrent abortions starting after a puerperal or postabortum curettage should cause the physician to suspect intrauterine adhesions. For the diagnosis hysteroscopy is the method of choice and hysterography should be added for preoperative assessment and classification. Blind procedures for rupturing the adhesions should not be performed because of the risk of perforation and creating false routes.

Analyzing amenorrhea

When menarche has failed to occur or menstrual cycles have stopped, the problem can be traced back to a functional or structural defect in the hypothalamus, pituitary, ovaries, or uterus. In most cases, the history is the principal source of diagnostic information. Necessary laboratory studies include one for the most common cause of amenorrhea: pregnancy.

Sexuality and reproduction in bulimia nervosa patients over 10 years

The reproductive and sexual histories of women who had recovered or were recovering from bulimia nervosa were examined. Of 48 consecutive female patients, 43 were studied 10-15 years after first presenting for treatment. At follow-up, 74% were considered recovered and 26% still had an eating disorder. Only 2 women fulfilled the criteria for bulimia nervosa. A history of amenorrhea was common (81% of women), 63% of women being without their menstrual periods for more than 12 months. Menstruation was present in women at a body mass index of 19 or more who were no longer using the weight loss practices of self-induced vomiting, laxative abuse, and starvation. Bulimia nervosa women are more likely to be investigated for infertility when their eating disorder is active. Bulimia sufferers are sexually active, but have times of withdrawing from their partners and ceasing sexual behavior. They associate their sexual feeling with body weight, pregnancy, breastfeeding, and status of their relationships. Marital breakdown is also more common but only if the eating disorder was active at the time of marriage. Forty-five percent left their relationship had a negative effect on their eating disorder. Short-term episodes of bulimic-free behavior are associated with pregnancy and breastfeeding in some pregnancies. Termination of pregnancy occurs more often. The prevalence of miscarriage, hyperemesis gravidarum, and postnatal depression was greater among women who had not recovered from their eating disorder at the time of their pregnancy. Recovery from eating disorder behavior before attempting conception reduces the prevalence of the gynecologic, obstetric, and psychiatric problems associated with eating disorder behavior.

Evaluation and management of amenorrhea

All women who enter menopause experience amenorrhea unless they receive hormone replacement therapy. In younger women, amenorrhea unrelated to pregnancy and lactation can be a distressing symptom. In addition to its psychologic morbidity, amenorrhea may be the manifesting feature of a wide array of anatomic and endocrine abnormalities. Amenorrhea results in impaired fertility. When estrogen levels are low, changes in mineral, glucose, and fat metabolism accompany amenorrhea. These metabolic changes affect bone and cardiovascular health, increasing the risk of osteoporosis and coronary heart disease in later life. Amenorrhea with hyperandrogenism, most commonly caused by the polycystic ovarian syndrome, may cause endometrial hyperplasia and increases the risk of endometrial adenocarcinoma. Because of the broad differential diagnosis of amenorrhea, establishing an accurate diagnosis can prove challenging. In this article, we outline one approach to the assessment of patients with amenorrhea and to the management of its common causes and consequences.

Endocrine causes of amenorrhea

Amenorrhea is a symptom of a variety of disorders and dysfunctions. It is important for the primary care practitioner to have an understanding of what constitutes normal function and of when to begin a diagnostic assessment of women with amenorrhea. Definitions and the basic principles of menstrual function are reviewed. Causes of amenorrhea are presented, including disorders of the uterus, disorders of the ovary, disorders of the anterior pituitary, and disorders of the central nervous system. The hypothalamic-pituitary-ovarian-uterine axis is used as a framework for the differential diagnosis of amenorrhea. A detailed process for assessing patients with amenorrhea is offered. Components of a amenorrheic-specific history, including menstrual, sexual and contraceptive, life-style, family, and medical histories, are reviewed. A step-by-step laboratory assessment is presented. Management of amenorrhea and health promotion strategies are discussed. The role of primary practitioners caring for amenorrheic women is outlined.

The female athlete

Women's participation in sporting activities is now diverse with new opportunities arising yearly. As a result, care of the the female athlete's unique medical concerns has become an important challenge and issue to the primary care physician. The major focus when caring for the female athlete should be the diagnosis and treatment of the female athlete triad. The components of the triad--disordered eating, amenorrhea, and osteoporosis--can have serious implications for the health of the female athlete. Appropriate prevention and screening methods for early diagnosis of the female athlete triad require future study and improvement. Healthy pregnant, postpartum, and breastfeeding women can continue to maintain physical activity. Musculoskeletal injuries from sports are, in general, not gender specific but are more often sport specific. One exception is the increased prevalence of anterior cruciate ligament injuries occurring in women soccer and basketball players. The exact cause of this is unknown but is continuing to be investigated.

American College of Sports Medicine position stand. The Female Athlete Triad

The Female Athlete Triad is a syndrome occurring in physically active girls and women. Its interrelated components are disordered eating, amenorrhea, and osteoporosis. Pressure placed on young women to achieve or maintain unrealistically low body weight underlies development of the Triad. Adolescents and women training in sports in which low body weight is emphasized for athletic activity or appearance are at greatest risk. Girls and women with one component of the Triad should be screened for the others. Alone or in combination, Female Athlete Triad disorders can decrease physical performance and cause morbidity and mortality. More research is needed on its causes, prevalence, treatment, and consequences. All individuals working with physically active girls and women should be educated about the Female Athlete Triad and develop plans to prevent, recognize, treat, and reduce its risks.

Endometrial pathology and infertility

OBJECTIVE

To call attention to endometrial pathologies, which in addition to causing menstrual problems, are a cause of infertility.

DESIGN

Controlled clinical study.

SETTING

Specialized unit in the management of infertile patients.

PATIENT(S)

Fifteen infertile women between the ages of 26 and 39 years and suffering infertility from endometrial problems for a period of 4 to 18 years were included in the study. Six patients had primary infertility and nine others had secondary infertility.

INTERVENTION(S)

Once the endometrial pathology was diagnosed, treatment was initiated according to the type of problem: hysteroscopy, curettage, and hormonal replacement with or without corticoids or antiphymic drugs.

MAIN OUTCOME MEASURE(S)

Clinical studies, laboratory tests, hormonal serum levels, and endoscopy.

RESULT(S)

After initiating specific treatment for each of the pathologies, menstruation was re-established in 14 of 15 patients. Nine patients became pregnant (8 of 10 cases with bone, squamous cell, or muscular metaplasia).

CONCLUSION(S)

Pathological changes of the endometrium are causes of infertility. These problems are not as rare as thought. They must be searched for carefully and diagnosed promptly. The majority carry a good prognosis when adequately treated.

Ovulation induction in the nonestrogenized patient

Women with nonestrogenized amenorrhea comprise a wide array of clinical problems. Identification and correction of the underlying pathologic process is the most appropriate approach to ovulation induction. Patients with central nervous system (CNS) or hypothalamic amenorrhea are treated with pulsatile gonadotropin-releasing hormone (GnRH) when it is not possible to correct the underlying causes of these disorders. Gonadotropin therapy is needed for pituitary-related amenorrhea after conservative therapy is unsuccessful. However, ovarian hyperstimulation and multiple pregnancies are risks of gonadotropin therapy. The outcome is poor for ovarian failure or gonadotropin-resistant ovaries. An occasional pregnancy is established, but oocyte donation or adoption should be an early consideration. Women with nonestrogenized amenorrhea and a low or normal follicle-stimulating hormone (FSH) level can expect high ovulation and pregnancy rates with gonadotropin therapy when more conservative means are unsuccessful: Treatment is not likely to benefit those with elevated FSH levels.

The female athlete triad

The term Female Athlete Triad has been used to describe the correlation of amenorrhea, osteoporosis, and disordered eating in physically active girls and women. These disorders, recognition of symptoms, consequences, and treatment are summarized.

From physiology to clinics--20 years of experience with pulsatile GnRH

The physiological and the pathophysiological basis of unvariant pulsatile administration of gonadotrophin-releasing hormone (GnRH) as well as the clinical results are reviewed. Pulsatile administration of GnRH not only proved to be a very effective treatment mode but also became an important tool for research in the central control of pituitary and ovarian function under normal and disease conditions.

Evaluation of amenorrhea

This article has focused on the evaluation of amenorrhea. Primary amenorrhea shares some diagnostic considerations with secondary amenorrhea. Having excluded these diagnostic considerations (pregnancy), the patient with primary amenorrhea should be further evaluated in consultation with an endocrinologist. Secondary amenorrhea is a common clinical complaint and an algorithm is proposed to guide the physician through the diagnostic evaluation. The evaluation is centered around excluding significant pathology in the central nervous system and evaluating for the common gynecological disorder of chronic anovulation. The clinical disorders of PCOS and hyperprolactinemia were discussed briefly, and the interested reader may obtain further information from the authors referenced in this article.

A physician survey of therapy for exercise-associated amenorrhea: a brief report

Amenorrheic athletes face an increased risk of osteopenia and stress fractures. Optimal treatment for exercise-associated amenorrhea remains controversial, reflecting limited data on the therapeutic effects of hormonal or nutritional intervention in the prevention of osteopenia. To determine physician opinions regarding preferred management of amenorrheic athletes, members of the American Medical Society for Sports Medicine (AMSSM) were surveyed by questionnaire. Practitioners were asked if they prescribed sex steroid replacement, calcium supplementation, weight gain, or decreased physical activity for amenorrheic athletes. The 159 respondents included predominantly sports medicine (56%) and family medicine (32%) physicians. Sex steroid replacement was endorsed by 92%, calcium supplementation by 87%, increased caloric intake by 64%, decreased exercise intensity by 57%, weight gain by 43%, and vitamin supplementation by 26%. These findings suggest that sex steroids are used commonly to treat amenorrheic athletes, despite the paucity of data demonstrating their efficacy in preserving bone mass in this disorder. Further research is needed to define the benefits of estrogen alone or in combination with nutritional intervention for preserving bone mass in female athletes.