Weight Preoccupation among Infertile Women

Stephen Allison, M.B.B.S., F.R.A.N.Z.C.P. Ross Kalucy, M.B.B.S., F.R.A.N.Z.C.P.

Peter Gilchrist, M.B.B.S., F.R.A.N.Z.C.P. Warren Jones, M.D.B.S., F.R.C.O.G., Ph.D.

An unselected group of 30 women attending an infertility clinic was studied in a preliminary investigation to determine relationships between weight, abnormal eat- ing attitudes, symptomatic distress, and impairment of ovulation. Those women in the group with anovulatory menstrual cycles were compared with the women who were ovulating. The anovultory women were found to be more preoccupied with weight and dieting. This weight preoccupation was not related to significant group differences in body weight or symptomatic distress. There was a tendency for the anovulatory women to be overweight or underweight, but this did not reach signif- icance.

It is well known that disturbances of weight and eating are associated with impaired menstrual functioning and fertility. Amenorrhea is sometimes the presenting symptom of anorexia nervosa. (Holmberg & Nylander, 1971; Fries, 1974). Frisch (1977) has put forward the hypothesis that the continuation of menstruation depends on maintaining weight above a critical level. Weight loss can lead to depressed levels of luteinizing hormone and follicular-stimulating hormone with associated anovulation and amenorrhea. These hormonal effects of weight loss are usually fully corrected when weight is restored (Palmer, 1982). Obesity is also related to menstrual disturbances and changes in gonad- otrophin production (Hartz, Barboriak, Wong, Katayama, & Rimm, 1979; Crisp, 1978). Bates and Whitworth (1982a,b) found that simple weight loss could restore ovulation in obese women with polycystic ovarian disease by reducing plasma androgens. Bulimia and excessive exercise are similarly asso-

Stephen Allison, M.B.B.S., F.R.A.N.Z.C.P., i s Clinical Lecturer in Child Psychiatry, Flinders University, where Ross Kalucy, M.B.B.S., F.R.A.N.Z.C.P., i s Professor of Psychiatry and Peter Cilchrist, M.B.B.S., F.R.A.N.Z.C.P., i s Senior Clinical Lecturer. Warren Jones, M.D.B.S., F.R.C.O.C., Ph.D., is Professor of Obstetrics and Gynaecology, Flinders University, Bedford Park, Adelaide, South Australia. Address re- print requests to Stephen Allison, M.B.B.S., F.R.A.N.Z.C.P., Flinders Medical Centre, Bedford Park, Ade- laide, South Australia, 5042.

International journal of Eating Disorders, Vol. 7, No. 6 , 743-748 (1 988) 0 1988 by John Wiley & Sons, Inc. CCC 0276-3478/88/060743-06$04.00

A((ison et ill . 744

ciated with menstrual disturbance, but the mediating hormonal changes are not as well deIineated (Abraham, Beumont, Fraser, & Llewellyn-Jones, 1982; Abraham, 1983).

This study was prompted by the referral of a number of women from an Infertility Clinic to a Psychiatric Liaison service for the assessment and treat- ment of eating disorders. It was a preliminary investigation, to quantify the importance of certain features of the major weight disorders as risk factors associated with impaired fertility. The risk factors chosen were percentage ideal body weight, eating pattern (especially excessive dieting and bulimia), and the degree of psychological disturbance.

METHOD

Subjects

The original sample consisted of an unselected group of 38 infertile women in treatment with a consultant gynecologist (W.J.) from a major hospital infer- tility unit. Of this original group, 30 returned questionnaires by mail and were included in the study. The ages of the group under study ranged from 23 to 37 years, with a mean of 29.8 years. There was a scatter of weights from 70.5% of Ideal Body Weight (IBW) to 193.5% IBW. Ideal body weight was defined as the average weight for a given height and age, determined from statistics com- piled by the United States Society-of Actuaries. The average weight was 102% IBW.

All 30 women had been screened routinely for infertility. On this basis, they were divided into two groups: Ovulatory and Anovulatory. The weights and heights of the women were recorded by the clinician. The Anovulatory group (Anov. group) consisted of 12 women. Anovulation was determined by assay- ing serum progesterone in at least one cycle. In most cases, repeated assays were done. Basal temperature recordings were also used. All these women exhibited some degree of menstrual disturbance ranging from irregular pro- longed cycles to frank amenorrhea of hypothalmic origin. None had hyperpro- lactinemia. Two women in this group had both anovulation and another impairment to fertility. In one, the husband was infertile, and another had tubal disease and endometriosis.

The other 18 women were found to have normal ovulation by hormone assay and were included in the Ovulatory group (Ov. group). Routine investigations included assessment of male infertility, laparoscopy, and hysterosalpingogra- phy when indicated. Infertility was diagnosed as due to tubal disease in seven cases, endometriosis (six cases), and male infertility (three cases). In one case, male infertility and endometriosis were present. In another, the cause was un- known.

The diagnosis of anovulation was made at first presentation, not at the time of study. By the time of the study, the women had been under management for an average of 2 months. Four women in the anovulatory group were having ovulatory cycles. In three cases, this was induced with clomiphene citrate, and one had begun ovulating spontaneously. All the ovulatory group remained ovulatory at the time of the study.

Infertile Women 745

Procedure

All the women were given two questionnaires by the clinician (W.J.) on a routine clinic visit. These were the (1) Eating Disorder Inventory (EDI) and (2) General Health Questionnaire (GHQ). The ED1 contains demographic data and a 64-item questionnaire with 8 subscales designed to quantify behavioral and cognitive features of anorexia nervosa and bulimia. It has been validated in a Canadian study and a comparison done with obese subjects (Garner, Olm- stead, & Polivy, 1983a,b). The GHQ was given in the 30-item form (Goldberg, 1972). This questionnaire consists of items concerning current symptoms, ab- normal feelings and thoughts, and aspects of observable behavior. It provides a measure of recent exacerbations in these areas rather than measuring chronic complaints. It has been widely used as a measure of symptomatic distress in nonpsychiatric populations including gynecological clinics. (Goldberg, 1972; Tarnopolsky, Hand, McLean, Robert, & Wiggins, 1979; Byrne, 1984).

In the statistical analysis, separate correlations were done between the questionnaire results (ED1 and GHQ), %IBW, and the Anov. and Ov. groups using the Pearson product-moment correlation coefficient. Because of the ex- ploratory nature of the study, significance levels were set at p < .075. Com- parison of the Anov. and Ov. groups with regard to GHQ caseness and weight range was carried out using the chi-squared test with Yates correction for discontinuity. Numbers were small for this kind of analysis. Groups were divided by weight into those <90% IBW, 90-110% IBW, and >110% IBW. For the GHQ, the 415 cut-off was used to determine caseness, as recommended by Golderg (1972).

RESULTS

Although there was not a significant difference in the total ED1 scores of the Ov. and the Anov. groups, anovulatory women were found to score signifi- cantly higher on the Drive for Thinness subscale of the ED1 (as shown in Table 1). There was also a tendency, significant at p<.075, for the Anov. group to have high scores on the Interoceptive Awareness subscale.

The Ov. and Anov. groups showed no significant differences for the other variables: %IBW and GHQ score. Separate analyses were done using group means and for the groups divided according to GHQ caseness and weight. Although the ovulatory women were mostly in the normal weight range and the anovulatory women were mostly <90%IBW or >11O%IBW, the chi-squared test did not reach significance for these group differences. Overall, there was a modest positive correlation between the variables %IBW and GHQ score (cor- relation = 0.30, pc.075).

Over the entire sample there was a positive correlation between %IBW and the total EDI score (correlation = 0.58, p<.Ol). This was reflected in correla- tions with %IBW and the subscales of Body Dissatisfaction ( p < .Ol), Bulimia (p < .05), Interoceptive Awareness ( p < .05), and Drive for Thinness ( p < .075).

The GHQ and ED1 scores for whole sample were also positively related (cor- relation = 0.56, p < 0.01). Correlations reached significance in the subscales of

746 Allison et al.

Table 1. and questionnaire data.

Correlations between ovulatory status

Means (Standard Errors)

%IBW ( n = 28) GHQ score Drive for Thinness Bulimia Body Dissatisfaction Ineffectiveness Perfectionism Interpersonal Distrust Interoceptic Awareness Maturity Fears Total ED1 score

Ovulatory (n = 18)

102.4 (3.67) 2.8 (1.19) 2.5 (0.73) 0.6 (0.42) 8.5 (2.15) 1.6 (0.71) 2.2 (0.56) 1.9 (0.67) 1.2 (0.49) 0.7 (0.32)

20.0 (3.96)

Anovulatory (n = 12)

100.7 (6.51) 3.1 (1.12) 7.6 (2.21)*’ 2.2 (1.78)

10.8 (2.73) 1.66 (0.65) 3.2 (1.16) 1.7 (0.66) 3.1 (0.95)+ 1.4 (0.87)

34.7 (9.69)

* p < ,075. p = .01. **

Drive for Thinness ( p < . O l ) , Body Dissatisfaction ( p < . O l ) , Interpersonal Dis- trust ( p < .05), Interoceptive Awareness ( p < .05), and Maturity Fears (p < .05).

DISCUSS 10 N

This was an exploratory study with a small number of clinic patients and caution must be used when interpreting the results. There were, however, some significant trends within the data. The higher scores of the anovulatory women on the Drive for Thinness subscale of the ED1 showed that they were more concerned with weight and dieting and had a greater fear of fatness. This finding could not be accounted for by group differences in weights or levels of symptomatic distress measured by the GHQ. The Drive for Thinness scale has been used by Garner, Olmstead, Polivy, and Garfinkel (1984) to identify weight-preoccupied women among college students and ballet dancers. Their group of weight-preoccupied women was heterogeneous and included women with ”subclinical anorexia nervosa” and “normal dieters.” This study suggests that there are a proportion of weight-preoccupied women within the infertility clinic population. Restrained eating, particularly with carbohydrates, may be the cause of their hypothalamic anovulation (Crisp, 1978). Infertility patients are weighed routinely because of the known associations between high and low weights and infertility. It may also be important to inquire about dieting and weight-losing behaviors with infertile women, even in those of normal weight. In our next study we plan to make clinical assessments of the weight- preoccupied group, which will provide further information about their dietary restrictions.

The ED1 seemed to be a suitable instrument for detecting weight preoccu- pation, irrespective of %IBW. The instrument was developed for use with an- orectic patients and has been used with normal weight women (Garner et al.,

Infertile Women 747

1984). In our study, total ED1 score was positively correlated with %IBW. The subscales showed a constellation of increasing Body Dissatisfaction, Bulimia, and Interoceptive Awareness scores. As far as we are aware, there is only one comparison study of obese subjects using a version of the ED1 which did not include all the items of the Interoceptive Awareness and Maturity Fears subs- cales (Garner et al., 1983a,b). Obese subjects scored highly on the same scales as this study (excluding Interoceptive Awareness, which was not fully mea- sured).

There was a moderate degree of common variance between the scores on the two questionnaires used in this study: the GHQ and EDI. This fits with pre- vious work where the GHQ was found to correlate with a questionnaire mea- suring the characteristic features of Anorexia Nervosa (Mann, Wakeling, Wood, Monck, Dobbs, & Symuckler, 1983). Although the measures were found to have a degree of interrelatedness, the ED1 showed more promise as an indicator of a specific aspect of psychosomatic infertility. The ED1 gives a multidimensional assessment which is an advantage with a heterogeneous sample, and the subscales for Drive for Thinness and Interoceptive Awareness point towards disordered eating as a risk factor for infertility within an Infer- tility Clinic population

The authors thank Dr. M. Ross for his assistance with the statistical analysis.

REFERENCES

Abraham, S. F. (1983). The challenges of adolescence. In L. Dennerstein and G. Burrows (Eds.), Handbook of psychosomafic obstetrics B gynaecology (pp. 69-104.) Melbourne, Australia: Elsevier Biomedical Press.

Abraham, S. F., Beumont, P. J. V., Fraser, I. S., & Llewellyn-Jones, D. (1982). Menstrual status of ballet dancers in training. British Journal of Obstetrics & Gynaecofogy, 89, 507-510.

Bates, G . W., & Whitworth, N. S., (1982a). Effects of body weight reduction on plasma androgens in obese infertile women. Fertility and Sterility, 38, 406409.

Bates, G. W., & Whitworth, N. S. (1982b). Effects of obesity on sex steroid metabolism. Journal of Chronic Disease, 35, 393-396.

Byrne, P. (1984). Psychiatric morbidity in a gynaecology clinic, an epidemiological study. British Journal of Psychiatry, 144, 28-34.

Crisp, A. H. (1978). Some aspects of the relationship between body weight and sexual behaviour with particular reference to massive obesity and anorexia nervosa. Internation Journal of Obesity, 2 , 17-32.

Fries, H. (1974). Secondary amenorrhoea, self induced weight reduction and anorexia nervosa. Acta Psychiatrica Scandanavia (Suppl), 248.

Frisch, R. E. (1977). Food intake, fatness and reproductive ability. In R. Vigersky (Ed.), Anorexia nervosa (pp. 149-161). New York: Raven Press.

Garner, D. M., Olmstead, M. P., & Polivy, J. (1983a). Development and validation of a multidi- mensional eating disorder inventory for anorexia nervosa and bulimia. International Journal of Eating Disorders, 2 , 15-32.

Garner, D. M., Olmstead, M. P., & Polivy, J. (1983b). The Eating Disorder Inventory. In P. L. Darby (Ed.), Anorexia nervosa: Recent developments in research (pp. 173-184). New York: Alan R. Liss.

Garner, D. M., Olmstead, M. P., Polivy, J., & Garfinkel, P. E. (1984). Comparison between weight preoccupied women and anorexia nervosa. Psychosomatic Medicine, 46, 255-266.

Goldberg, D. P. (1972). The detection of psychiatric illness by questionnaire.. Maudsley Monograph, 21.

Hartz, A. J., Barboriak, P. N., Wong, A,, Katayama, K. P., & Rimm, A. A. (1979). The association of obesity with infertility and related menstrual abnormalities in women. Infernation lournal of Obesity, 3, 57-73.

Allison et al. 748

Holmberg, N. G., & Nylander, I. (1971). Weight loss in secondary amenorrhoea. Acfa Obstetrica Gynecologicia Scundavica, 50, 241-246.

Mann, A. H., Wakeling, A,, Wood, K., Monck, E., Dobbs, R., & Szmukler, G. (1983). Screening for abnormal eating attitudes and psychiatric morbidity in an unselected population of 15-year- old school girls. Psychological Medicine, 13, 573-580.

Palmer, R. (1982). Anorexia nervosa. In R. Granville-Grossman. (Ed.), Recent Advances in Ciinical Psychiatry No. 4 (pp. 102-122). Churchill Livingstone, London, 1982.

Tarnopolsky, A., Hand, D. J., McLean, E. K., Robert, H., & Wiggins, R. D. (1979). Validity and uses of a screening questionnaire (GHQ) in the community. British \ournu/ of Psychiatry, 134, 508-515.