Diagnosis: period

One of the big debates for the next edition of the Diagnostic and Statistical Manual (DSM) is the use of amenorrhea as a criterion for anorexia. Some of the issues raised include:

--Girls who haven't reached puberty
--Women in menopause
--Women on oral contraceptives

Furthermore, even women who meet the weight criteria for anorexia might not lose their periods. This is especially true as women get older. My very well researched slightly random opinion is that menstruation is better established once women hit 20 and older. Which means that it takes more damage to the body before menstruation ceases. There are also plenty of teens who don't lose their periods, and there are plenty of older women who do.

So what are we to make of this? Can amenorrhea be a clinical criterion for anorexia? If it can, should it be?

Researchers at the New York State Psychiatric Institute looked at this issue in recent research published in the International Journal of Eating Disorders. From a clinical standpoint, does amenorrhea really make a difference? They found that women who had lost their periods had a lower lifetime BMI and a lower BMI when admitted to the inpatient unit. However, no other significant differences were found. The researchers concluded:

"These results indicate that amenorrhea does not distinguish between groups on a number of important measures of clinical severity. It may be that amenorrhea reflects weight and nutritional status, rather than providing useful diagnostic information. Future studies are needed to examine the potential prognostic value of menstrual status."
(Emphasis mine)

The bolded sentence leads me to a second study in the Journal of Adolescent Health titled "Irregular menses linked to vomiting in a nonclinical sample." The title basically reflects what they saw: girls who vomited even one to three times per month were 1.5 times more likely to have irregular periods. And this is far from the clinical criteria for bulimia. The risk for irregular menses was 3 times higher for girls who vomited once a week. These findings held true even when underweight and overweight girls were excluded from the sample. The researchers also controlled for "other eating disorder symptoms, weight status, age, race/ethnicity, and school clusters."

Remember: these are not girls with clinical eating disorders. Certainly vomiting for weight control is a HUGE sign for disordered eating. But amenorrhea may be a sign that something is going wrong with your endocrine system.

So perhaps maybe amenorrhea isn't useful as a diagnostic criterion. But it can (and perhaps should) be used as an indicator of issues with physical and mental health.

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fighting_forever said...

I think that the diagnosis criteria should put almost all of the emphasis on the mental and behavioural symptoms. This is a mental illness!

I think that maybe including a mention that periods may be lost as a symptom is good, but it shouldn't be needed.

I have a similar issue with weight. A person's weight can fluctuate by pounds a day just from drinking water, so someone might be anorexic or not depending on what time of day they get on the scales. And what about people who start acting anorexic when they're severely overweight? They have a long way to go before their body weight puts them in the anorexic category, even if they are anorexic in every other way.

Laura Collins said...

You're both right. We need better tools of all kinds: for cognitive and affective symptoms, and for medical stability and health.

Right now we're stabbing at ghosts. And it is the patients who suffer from this lack of clarity.

Anonymous said...

This issue always puzzles me. When I was at my sickest I lost my period for about a year or so. Then it came back out of the blue at a severely emaciated weight. Not just below or underweight, but a very sick weight. And yet according to the DSM, I was no longer anorexic! At the time this "fact" fed my e/d tremendously. I kept telling people I was no longer sick/anorexic and it was all okay because my period came back! This ended up quite an argument with my treatinging physicians. I know quite a lot "older" women (in our 30s and 40s) who can be at very low weights/intake and still have periods. It's definitely a criteria that I think needs to go. It can be a sign, but an absolute criteria? No way.

jessie said...

I agree that it is sometimes dangerous to consider the cessation of regular periods as a vital sypmtom of anorexia. I was diagnosed at 43 with an eating disorder. I remained in denial for sometime as I believed that the fact that I was still menstruating was a sign that I was 'safe' and couldn't possibly have an eating disorder , this was besides meeting every other criteria for anorexia. Being told I was striclty EDNOS according to DSM-IV did little to convince me for some time that I really had a problem. This then impacted on seeking and accepting treatment and I believe has prolonged recovery.

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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nour·ish: (v); to sustain with food or nutriment; supply with what is necessary for life, health, and growth; to cherish, foster, keep alive; to strengthen, build up, or promote


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