Is amenorrhea a useful criterion for the diagnosis of anorexia nervosa?

Unit of Clinical Dietetics, Department of Internal medicine, “Alma Mater” University of Bologna, Policlinico S. Orsola, Via Massarenti, 9, I-40138 Bologna, Italy
Behaviour Research and Therapy (Impact Factor: 3.85). 12/2008; 46(12):1290-1294. DOI: 10.1016/j.brat.2008.08.007


Aim of the study was to evaluate the clinical characteristics and the treatment outcome of underweight patients with eating disorder (ED) not otherwise specified without amenorrhea (EDNOS-WA), compared with classical anorexia nervosa (AN) cases. Seventy-three consecutive female patients (57 AN, and 16 EDNOS-WA) were evaluated before and after a 20-week cognitive behaviour inpatient treatment (CBT-I). Assessment included anthropometry, the Eating Disorder Examination (EDE), the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), and the Temperament and Character Inventory (TCI). At logistic regression analysis, amenorrhea was only predicted by baseline BMI and intense exercise, not by psychopathological variables. Response to CBT-I was good and similar between groups, without differences in the dropout rate or time-to-dropout. Our data lend support to the hypothesis that the criterion “amenorrhea” is of no clinical utility in the diagnosis and treatment of AN and could be removed in the forthcoming DSM-V proposal.

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    • "Although impairments in gonadotropin secretion following weight loss, often associated with dieting and exercising (Montero et al. 1996; Mendelsohn and Warren 2010), have been implicated in the onset of MD, evidence on the role of low body mass index (BMI), often associated with these behaviors, in causing menstrual irregularities is contradicting (Vyver et al. 2008). Some studies suggest that low BMI is the only predictor of MD in women with ED (Dalle Grave et al. 2008). Others, however, have shown that amenorrhea often precedes weight loss and persists after weight recovery (Brambilla et al. 2003) or is independent from weight loss (Gendall et al. 2000) suggesting that other factors, such as neuroendocrine and psychological aspects (i.e., the persistence of anorexia-related symptoms such as body dissatisfaction), could be involved in the pathogenesis of amenorrhea (Brambilla et al. 2003). "
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    ABSTRACT: We explored associations between lifetime eating disorder (ED) diagnoses and behaviors and menstrual dysfunction using logistic regression models. Body mass index (BMI) fully explained differences in the odds of secondary amenorrhea (SA) across diagnoses. Women with dieting behaviors had borderline significantly higher odds of SA than those without after accounting for BMI. We suggest the presence of a strong association between BMI and SA and that dieting might represent a risk factor for SA regardless of BMI and ED diagnosis.
    Archives of Women s Mental Health 09/2015; DOI:10.1007/s00737-015-0576-2 · 2.16 Impact Factor
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    • "Our secondary goal was to examine demographic and psychosocial characteristics associated with ROM. As the relationship between amenorrhea and psychosocial variables remains unclear, we did not expect any differences between patients with and without ROM in terms of psychosocial characteristics at baseline evaluation [10,25]. We did, however, anticipate that patients with binge/purge behaviors would be more likely to resume menses during treatment than patients without such behaviors. "
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    ABSTRACT: 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.
    Journal of Eating Disorders 04/2013; 1(1). DOI:10.1186/2050-2974-1-12
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    • "The diagnostic relevance of amenorrhoea is highly questionable (Abraham et al. 2005 ; Dalle Grave et al. 2008 ; Garfinkel et al. 1996 ; Keating, 2009). However, from a treatment perspective there may be important implications for the hormonal milieu of the patient and their capacity to respond to pharmacotherapy. "
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    ABSTRACT: Major depression (MD) and anorexia nervosa (AN) often present comorbidly and both share some affective symptoms, despite obvious phenotypic differences. In the illness phase, pathophysiological evidence indicates similar abnormalities in both clinical groups including dysfunction in the serotonin (5-HT) system (of which some abnormalities persist following recovery) and between 60% and 80% of patients in both groups present with significant hyperactivity of the hypothalamo-pituitary-adrenal (HPA) axis. First-line approach to treatment for MD involves modulation of the 5-HT system using selective serotonin reuptake inhibitors (SSRIs). For AN, treatment with SSRIs has been shown to be considerably less effective compared to MD. Both illnesses show marked dysregulation in the HPA axis. A consequence of SSRI treatment is a reduction and/or normalization of indices of the HPA axis [i.e. cortisol, adrenocorticotropic hormone (ACTH)], which is consistent with recovery levels in both clinical groups. Oestrogen (in high doses) has been shown to exert antidepressant effects and positively impact on MD symptoms as a treatment in its own right, or in combination with antidepressants, in women of menopausal age. It is proposed that a combination of SSRIs and oestrogen therapy may facilitate physiological normalization in MD in women of non-menopausal age and in AN. Preliminary evidence suggests oestrogen treatment alone is of some benefit to patients and it is proposed that a combination of SSRI and oestrogen will precipitate and potentially accelerate symptomatic remission. Should this approach be successful, it offers the capacity for improvement over traditional antidepressant use in women diagnosed with MD and a novel strategy for the treatment of AN, a serious clinical illness associated with the highest mortality of any psychiatric condition.
    The International Journal of Neuropsychopharmacology 05/2011; 14(4):553-66. DOI:10.1017/S1461145710000982 · 4.01 Impact Factor
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