1. Depression in Women: From PMS to Post-partum Blues
Kimberley Guida, MD
Pullman Family Medicine

2. Case Presentation
Julie is a 25 year old female who just delivered her second child 3 weeks ago. She breaks down in tears for no reason and is irritable with her 3 year old. She is having trouble sleeping, and has no appetite. She admits that she feels guilty for not feeling happy about the new infant in her life. She feels she is not an effective parent to either child. She is returning to work next week and wonders how she will be able to cope.

3. Statistics Depression is twice as common in women as in men
20% of women will experience depression at some point during their life
One out of 10 childbearing women will experience post-partum depression
40% of women have premenstrual symptoms, 5% of these experience premenstrual dysphoric disorder (PMDD)

4. Risk Factors For Depression
Family history of mood disorder
Loss of a parent before age 10
History of sexual or physical abuse
Use of hormones (contraception/HRT/fertility treatments)
Persistent life stressors (i.e. loss of job)
Loss of social support system

5. What Is Depression? Psychological Physical symptoms Depressed mood
Decreased interest in activities
Feelings of guilt, hopelessness
Suicidal thoughts
Physical symptoms
Sleep disturbance
Appetite/weight changes
Difficulty concentrating
Fatigue
Decreased energy

6. Gender Differences Women have earlier onset of depression
Episodes may last longer and recur more often
More atypical symptoms
Suicide attempts more frequent but less successful
Less substance abuse than men
More anxiety symptoms than men
More associated eating disorders
More associated migraine headaches
More feelings of guilt
More seasonal depression

7. Treatment For Depression
Psychosocial (counseling)- cognitive behavioral therapy
Medications- used with counseling in cases of moderate to severe depression
Alter chemical balance in the body to enhance mood (norepinephrine, serotonin levels)
Many different types- SSRI’s, tricyclics, others
St. John’s wort- some studies suggest a benefit
Need a minimum of 2 weeks to see an effect
Treatment for minimum of 6 months

8. SSRI’s- Often the First Choice
Selective serotonin reuptake inhibitors- allow more serotonin to be available in the body, enhancing mood
Examples: Prozac, Paxil, Zoloft, Luvox, Celexa
Once daily dosing
Side effects: nausea, headaches, nervousness, insomnia/fatigue, sexual dysfunction, weight gain with prolonged use

9. What’s That About Sexual Dysfunction?
Up to 70% of depressed patients experience a loss of sexual interest
If we treat the underlying depression, the libido often improves
SSRI’s may cause problems with libido and difficulty attaining orgasm
Other medications may enhance libido- ie Wellbutrin, Effexor

10. Premenstrual Dysphoric Disorder
Mood and anxiety symptoms that occur only during the premenstrual period, or worsen significantly during that time
Can be very debilitating, with a negative impact on the quality of life and relationships
Symptoms usually disappear within a few days after the period starts
There are 11 identified symptoms, of which 5 must be present

11. Symptoms of PMDD Depressed mood Feelings of personal rejection
Decreased interest in usual activities
Fatigue, no energy
Marked appetite changes/cravings
Insomnia or increased sleep
Anxiety- feeling “on edge”
Irritability, anger
Feeling overwhelmed
Difficulty concentrating
Physical symptoms- breast tenderness, headaches, “bloated”, muscle pain

12. Cause of PMDD?
Unknown, but felt by many researchers to result from an abnormal response to normal cycle of hormonal changes in the body
Likely a combination of genetic, environmental, and behavioral factors
Women with PMDD have greater risk of future depression during pregnancy, post-partum period, and perimenopause

13. Treatment For PMDD
Choice of treatment is aimed at the most troubling symptoms
Lifestyle modification
Dietary approach
Vitamin supplementation
Medications
Cognitive/behavioral approach

14. Lifestyle/diet Modification
Women who engage in moderate aerobic exercise 3 times weekly have fewer premenstrual symptoms than sedentary women
Low-fat, vegetarian diet has been shown to decrease duration and intensity of menstrual pain
Women with a high caffeine intake have more premenstrual irritability symptoms
Excess of simple carbohydrates (sugar) is associated with mood disturbances

15. Vitamin Supplementation
Controversial- data is conflicting
Vitamin B6 100mg/day
Magnesium 400 mg/day
Manganese 6 mg/day
Vitamin E 400 iu/day
Calcium 1000 mg/day

16. Medications for PMDD Anti-inflammatories- effective for pain relief
Oral contraceptives- suppress ovulation
Diuretics– when salt restriction not helpful in reducing significant fluid retention
SSRI’s are often first choice- daily versus premenstrual week only

17. Cognitive Behavioral Therapy
Attempts to reduce negative feelings in the premenstrual period
Improve feelings of self-esteem and problem solving skills
Relaxation therapy may also be helpful

18. Post-partum Depression
1 of 10 women experience post-partum depression, but the condition is under-diagnosed
May have significant impact on both mother and child
Societal pressures to be “good mother” may prevent woman from admitting symptoms

19. “Baby Blues” Occurs in 70-85% of women
Onset within the first few days after delivery
Resolves by 2 weeks
Symptoms include: mild depression, irritability, tearfulness, fatigue, anxiety
May have increased risk of post-partum major depression later on

20. Post-partum Major Depression
Symptoms of depression that last longer than 2 weeks
Usually begins 2-3 weeks after delivery
May last up to one year
High risk of recurrence in future pregnancies

21. Post Partum Psychosis Rare disorder (Andrea Yates?)- 0.2% women
Onset within the first month after delivery
Symptoms include mania, agitation, expansive or irritable mood, avoidance of the infant
May have delusions or hallucinations that involve the infant- possessed by demon, etc.
This is a medical emergency- needs hospitalization

22. Treatment for Post Partum Depression
Same as for major depression
SSRI’s work well
All antidepressants are to some degree, excreted in the breast milk, but usually undetectable levels in the infant’s blood
Avoid Prozac due to long half life- may accumulate in the infant

23. To Summarize…. Depression is very common in women
May be more likely around times of hormonal flux- premenstrual, post-partum, perimenopause
There is effective treatment available
Don’t hesitate to discuss symptoms with your doctor

24. This Presentation Is Available Online At:
Thank You