With a high prevalence of functional hypothalamic amenorrhea occurring in females with eating disorders, one would think that gynecologists would get extensive training on how to properly screen patients who present to their office with lack of a regular menstrual cycle.
Unfortunately, this isn’t always the case.
I learned this the hard way.
After not having my period for almost two years, I made an appointment with my local gynecologist to see what the issue was.
Contrary to the popular belief, it’s actually not okay for adolescents, even those who are involved in athletics, to skip periods. According to Dr. Catherine Gordon, “There may be some irregularity during the first post-menarchal year, but thereafter, an adolescent should get into a regular cycle. If an adolescent’s or young woman’s periods have stopped or are only occurring every two or three months, that should be a red flag that something could be going on.”¹
It was admittedly nice not having a period– it was something I didn’t have to worry about. But after a while, I knew something was off–and I was right.
My gynecologist’s credentials were impressive, and she completed medical school at a very well-respected university. She seemed competent enough.
Immediately upon walking into the room, she introduced herself, and then scanned my body from head to toe. It is likely she noticed the decline in my growth chart and changes in my weight.
Her eyes were cold.
“Do you have an eating disorder,” she blurted out.
“No, I don’t think so…” I murmered back.
And I genuinely didn’t know. I had looked up diagnostic criteria for eating disorders on the internet. At that point, I had actually convinced myself that I didn’t have an eating disorder because I didn’t meet the criteria for anorexia, bulimia, or binge-eating disorder. I was uneducated and unaware of what was really going on.
I didn’t think I had lost enough weight to have a problem. I didn’t think I was “skinny” enough to deserve help. My unhealthy dieting and exercise habits were easily justified and praised by everyone around me.
“I will ask you again,” she said, “DO YOU HAVE AN EATING DISORDER?”
“NO!” I retorted back.
What was this lady’s problem?
“Okay, you have denied it. So I guess I believe you.” she said.
And that was that. No further screening. No questions about my attitude towards my body, dieting behaviors, binging / purging, exercise routine, or mental health.
Here’s the thing, whether it was a full-blown eating disorder, chronic dieting, disordered eating, or relative energy deficit syndrome, my gynecologist should have been able to recognize that something was off. She should have dug deeper.
My lab work looked great. My pelvic ultrasound was clear. I wasn’t pregnant. What else could have caused my once very, very regular periods to suddenly disappear for almost two years?
Let me remind you that this doctor was trained at one of the top teaching hospitals in the country. But I’m not sure if she was trained on how to screen for eating disorders.
Sure, her clinical judgment and bedside manner needed work.
But this experience highlights the need for eating disorder screening protocols to be taught in medical schools. It’s simply neglected and overlooked.
And then there are people like me, who fall through the cracks, and wait years before entering treatment and getting the help they truly deserve.
She told me that she didn’t want me to lose anymore weight or there would be consequences.
What exactly were those consequences? She didn’t say.
And then she put me on birth control to “protect my bones”, which is actually the opposite of what is recommended to do in this type of situation.
Listen to what top eating disorder treatment experts have to say on this issue:
“It had been generally accepted that low estrogen was the cause of low bone density in anorexia nervosa patients. The logical concluding was that bone loss could be prevented by starting anorexia nervosa patients on oral contraceptives (aka birth control). But even with this practice, anorexia nervosa patients were not being protected from bone loss if they remained underweight and with low body fat. It has since been learned that loss of bone mineral density is multifactorial, and related to multiple hormonal aberrations in addition to low serum estrogen, including elevated serum cortisol, deceased insulin-like growth factor 1, and decreased DHEA. Currently, it is not advisable to start anorexia nervosa patience on oral contraceptives unless required for contraception. The onset of birth control periods can lead to a false sense of security as the patient may not understand that the periods are “artificial”, and not evidence of improving physical health. The treatment for decreased bone mineral density is first and foremost weight restoration, normalizing body fat stores, calcium supplementation, and moderate weight bearing exercise.”²
She recognized that I had functional hypothalamic amenorrhea. She knew that my bones “needed protection”, and that she didn’t want me to “lose another pound.” Yet she didn’t give me a referral to a dietitian or a therapist. She didn’t ask the right questions. She didn’t express her concern for me. She was uncomfortable, and she looked the other way.
She simply wrote me a prescription and sent me on my way.
So there I was, oblivious to the danger that I was putting my body in + the damage I was doing, all because a practitioner that I trusted my health with was not trained properly. My period returned, just like expected, but nothing changed about what I was eating or the amount of exercise I was doing.
7 months later I started treatment for my eating disorder.
All health care practitioners need training on how to prevent, screen for, and detect eating disorders. It’s too prevalent of an issue to be ignored or overlooked.
I can’t help but wonder what would have happened if she had approached me during that appointment with compassion, rather than accusation. What would have happened if she had asked me more about the frequency of my exercise routine, the type of food that I ate, or the weight I had lost? How would that have changed my college experience if I was able to start recovery sooner rather than later?
It would have changed a lot.
Knowledge is power. If the medical community is truly interested in cutting down on health care costs and improving patient outcomes, education is a good place to start.
1. Seaborg E. No Easy Answers: New Functional Hypothalamic Amenorrhea Treatment Guidelines Released. Endocrine News. https://endocrinenews.endocrine.org/no-easy-answers-new-hypothalamic-amenorrhea-treatment-guidelines/. Published June 2017. Accessed September 20, 2018.
2. Woods BK. Biological Dimensions of Eating Disorders. In: Eating Disorders: A Handbook of Christian Treatment. Nashville, TN. 2008: Remuda Ranch; 2:41.
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