In their excellent article, Reference Henshaw and ProttiHenshaw & Protti (2010) briefly mention the impact that a low body weight can have on menstrual functioning. However, we feel that further discussion is needed regarding the complex relationship between eating disorders and reproductive functioning. Indeed, eating disorders are common and characteristically affect young women at what would otherwise be the peak of reproductive functioning. In anorexia nervosa, poor nutrition leads to a widespread endocrine disorder involving the hypothalamic–pituitary–gonadal axis, resulting in amenorrhoea in women and forming part of the operational diagnostic criteria. Likewise, at least 50% of patients with bulimia nervosa at normal weight suffer amenorrhoea or oligomenorrhoea. Roughly 20% of women attending infertility clinics have a current or previous diagnosis of an eating disorder (Reference Freizinger, Franko and DaceyFreizinger 2010) and are often too ashamed to admit this to their doctors. This is crucial as treatment of the underlying eating disorder may, in fact, lead to a resolution of the infertility problem without the costs and risks of side-effects and multiple gestation pregnancies that complicate infertility treatments. Similarly, the consequences of an undetected eating disorder in pregnant women can severely and negatively affect the health of the mother and the unborn infant (Reference Franko, Blais and BeckerFranko 2001), including higher risk for low birth weight, miscarriage and birth defects.

It also important to consider the sexual health needs of individuals with eating disorders. Anorexia nervosa is associated with a loss of sexual drive but this is not necessarily reflected in sexual behaviour. In contrast, women with bulimia nervosa are generally more sexually active and experienced than women from the general population, with greater lifetime numbers of sexual partners and higher rates of induced abortion and sexually transmitted diseases (Reference Abraham, Bendit and MasonAbraham 1985). Moreover, oral contraception is inappropriate and unreliable in the presence of regular self-induced vomiting.

Clinicians should always consider eating disorders in their differential diagnosis where patients present with menstrual dysfunction or other reproductive pathology. The brief, five-item SCOFF questionnaire (Reference Morgan, Reid and LaceyMorgan 1999) shown at the end of this letter provides a validated and reliable screening tool which is widely used in the UK and the USA. A score of two or more indicates a likely case of anorexia nervosa or bulimia nervosa and warrants further assessment. Furthermore, advising patients on the impact of their eating on fertility can be a crucial motivating factor for treatment, and has wide public health implications.