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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    • "In conclusion, whilst the hypothesis that amenorrhea is primarily due to low BMI or behavior influencing energy balance seems to be the most prevalent ones [8], the etiopathogenesis of amenorrhea in patients with AN could be more complexly related to multiple factors. It is commonly accepted that low BMI is a crucial mediator in the development of amenorrhea, but also the interplay between physical exercise, percentage of body fat, leptin levels, cortisol levels and comorbid symptoms could have an important role. "
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    ABSTRACT: Menstrual dysfunction is a common correlate across women with Eating Disorders. The onset of Eating Disorders commonly occurs during adolescence and it can lead to severe medical complications, such as pubertal delay, deficits in peak bone mass acquisition, altered physical and cognitive development. The pathogenesis of menstrual dysfunction in Eating Disorders is complicated and involves several factors such as hypothalamic-pituitary-ovarian axis impairment, low body fat, hypoleptinemia, increase of androgen levels, abnormal eating behaviors, physical exercise and psychological stressors. This chapter aims to provide a clinical overview of the several pathogenetic mechanisms underlying menstrual dysfunction.
    Full-text · Chapter · Dec 2015
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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.
    Full-text · Article · Sep 2015 · Archives of Women s Mental Health
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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.
    Full-text · Article · Apr 2013 · Journal of Eating Disorders
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