Eating disorders. (Drugs, Pregnancy, and Lactation).

Eating disorders are highly prevalent in the general population, certainly more so in women, appearing to peak during the childbearing years. While we tend not to see pregnant women with anorexia nervosa because they have secondary reproductive endocrine dysfunction, we do see those who have been successfully treated and are contemplating pregnancy or who are pregnant. Far more often, we see patients with bulimia or other binge-eating disorders on the less severe end of the spectrum.

There is very little information in the literature on the course of these disorders as women try to conceive or in pregnancy--and even less on the treatment of symptomatic women during pregnancy or the postpartum period.

The few data that are available include studies reported in the last several years suggesting that pregnancy is associated with improvements in eating disorders followed by postpartum exacerbation of symptoms. A limitation of these studies was that there were very few women included in the samples with active illness who were on medication.

The two drug classes used most frequently in patients with eating disorders are selective serotonin reuptake inhibitors (SSRIs), most commonly fluoxetine and sertraline, and antianxiety agents, typically lorazepam and clonazepam. In our experience, many women have a recurrence of symptoms of the eating disorder when they stop their medication while trying to conceive or while pregnant--consistent with what we see when women with mood and anxiety disorders stop their medications.

So what is the best way to manage patients? There are two avenues of treatment, group- and individual-based cognitive-behavioral therapy and pharmacologic interventions. We have found that patients who have been on pharmacologic therapy may be able to successfully switch from medication to cognitive-behavioral therapy in conjunction with state-of-the-art nutritional counseling while trying to conceive or during pregnancy.

Patients who do well using this approach are on the less severe ends of: the spectrum, for example those who engage in some binge-eating behaviors, followed by some restrictivelike behavior (calorie restriction), or who have intermittent bulimic symptoms when they experience anxiety. Cognitive-behavioral interventions can help these patients justify the need to consume calories and gain weight to sustain a healthy ...