Screening Recommendations for Adolescent with Primary Amenorrhea and Suspected Eating Disorder
The adolescent with primary amenorrhea, low weight, and signs of an eating disorder should be screened for osteopenia as the highest priority due to the significant risk of bone mineral density loss associated with eating disorders and amenorrhea.
Clinical Assessment and Diagnosis
This 17-year-old female presents with:
- Primary amenorrhea
- Extremely low weight (39 kg at 1.6 m = BMI 15.2 kg/m²)
- Tanner stage 2 sexual development (delayed)
- Parotid gland swelling
- Dental erosion
These findings strongly suggest anorexia nervosa with purging behaviors (self-induced vomiting), as evidenced by the parotid swelling and dental erosion. The extremely low BMI (<17.5 kg/m²) and delayed sexual development further support this diagnosis.
Recommended Screening
1. Osteopenia Screening - HIGHEST PRIORITY
- Bone mineral density testing is essential as amenorrhea in eating disorders is associated with significant bone loss 1
- Studies show up to 52% frequency of osteopenia/osteoporosis in women with adolescent-onset menstrual disorders 2
- Prolonged amenorrhea and low estrogen state lead to potentially irreversible bone loss 1
2. Comprehensive Eating Disorder Assessment
- The American Psychiatric Association recommends a comprehensive assessment including 3:
- Height and weight history
- Patterns of restrictive eating and food avoidance
- Compensatory behaviors (purging, exercise)
- Psychological factors (body image disturbance)
- Prior treatment history
3. Medical Complications Screening
- Complete metabolic panel to assess electrolyte abnormalities from purging
- ECG to evaluate for cardiac complications (bradycardia, arrhythmias)
- Vital signs assessment including orthostatic measurements 3
- Comprehensive review of systems to identify other medical complications 3
4. Hormonal Evaluation
- Follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and thyroid-stimulating hormone (TSH) to evaluate the cause of amenorrhea 4
- These tests help differentiate hypothalamic amenorrhea (common in eating disorders) from other causes
Why Other Screening Options Are Not Priorities
Cervical Dysplasia
- Not indicated as the patient reports no sexual activity
- Cervical cancer screening typically begins at age 21 regardless of sexual activity onset
Chlamydia
- Not indicated as the patient reports no sexual activity
- STI screening is recommended for sexually active individuals
Pituitary Adenoma
- While pituitary disorders can cause amenorrhea, the clinical presentation strongly suggests functional hypothalamic amenorrhea secondary to an eating disorder
- The presence of other eating disorder signs (low weight, parotid swelling, dental erosion) makes a pituitary cause less likely
Stress Fractures
- While patients with eating disorders are at risk for stress fractures, screening should be targeted based on symptoms
- Osteopenia screening is the more appropriate initial evaluation to assess bone health
Management Considerations
A multidisciplinary team approach is essential, including 3:
- Physician for medical monitoring
- Dietitian for nutritional rehabilitation
- Mental health professional for psychotherapy
Nutritional rehabilitation should focus on 3:
- Gradual weight restoration
- Establishing regular eating patterns
- Addressing nutritional deficiencies
Bone health interventions should include 1:
- Calcium and vitamin D supplementation
- Moderate weight-bearing exercise when medically stable
- Weight restoration and resumption of menses as the primary goal
Key Clinical Pitfalls to Avoid
Do not focus solely on amenorrhea treatment without addressing the underlying eating disorder - Hormonal therapy alone will not address bone health without weight restoration 1
Do not delay osteopenia screening - Bone loss can occur rapidly and may be irreversible even after recovery 1, 2
Do not miss the signs of purging - Parotid swelling and dental erosion are classic signs of self-induced vomiting that require specific intervention
Do not underestimate medical risks - Despite stable appearance, patients with eating disorders can have serious medical complications requiring close monitoring 3
Do not focus on weight as the sole indicator of recovery - An athlete could be in energy balance but still in a state of low energy availability 3
By prioritizing osteopenia screening and comprehensive eating disorder assessment, clinicians can address the most significant health risks for this patient while developing an appropriate treatment plan for her eating disorder.