Depression disrupts daily life and affects thoughts, feelings, behavior, and relationships that have a significant impact on mental, emotional, social, professional, and physical well-being.  Women are twice as likely as men to have depression.  Clinical depression is common among reproductive age women 25-45 and the leading cause of disability in women in the U.S.  This can account for $30-50 billion in lost productivity or medical costs. 

Perinatal depression refers to depression that occurs during pregnancy and postpartum up to one year after delivery.  14%-23% of women experience depression during pregnancy and 5%-25% of women will have postpartum depression.  It is essential that perinatal depression be treated as it can lead to sporadic prenatal care, inadequate nutrition, poor fetal growth, preterm delivery, preeclampsia, low birth weight, self-medication with tobacco, alcohol, or drugs, increased risk of postpartum depression, inability to care for self or child, lack of mother-infant bonding,  and in extreme cases may lead to suicide or infanticide.  Studies have shown that untreated maternal depression negatively affects an infant’s cognitive, neurologic, and motor skill development and can also impact older children’s mental health and behavior.

Symptoms of depression include:

• Sadness
• Trouble sleeping - Insomnia or increased sleeping
• Feelings of guilt, worthlessness, or hopelessness
• Lack of motivation or interest
• Decreased energy
• Changes in appetite with weight loss or gain
• Difficulty concentrating
• Psychomotor retardation or agitation
• Thoughts of death or suicide
• Anxiety, worry, and fear
• Physical  manifestations of body aches, digestive problems, fatigue, or  sexual dysfunction

Treatment options for depression in pregnancy include:

• Therapy
  • Psychotherapy
  • Cognitive Behavioral Therapy
  • Support Groups
  • Family, friends, church, community
  • Antidepressants
    • Tricyclic Antidepressant (TCA)
      • Elavil (amitriptyline)
      • Pamelor (nortriptyline)
      • Tofranil (imipramine)
      • Sinequan (doxepin)
    • Selective Serotonin Reuptake Inhibitor (SSRI)
      • Prozac (fluoxetine)
      • Zoloft (sertraline)
      • Paxil (paroxetine)
      • Celexa (citalopram)
      • Lexapro (escitalopram)
    • Monamine Oxidase Inhibitor (MAO)
      • Nardil (phenelazine)
      • Parnate (tranylcypromine)
    • Alternatives
      • Wellbutrin (bupropion) – also good for smoking cessation
      • Effexor (venlafaxine) - SNRI
      • Cymbalta (Duloxetine) - SNRI
  • Alternative Therapy (still being studied/investigated)
    • Exercise – yoga
    • Massage
    • Light therapy
    • Acupuncture
    • Omega 3
    • Calcium
    • Herbs
      • St John’s Wart (very little known about the effect on the fetus)
    • Electroconvulsive Therapy (ECT) – safe in pregnancy
    • Transcranial magnetic stimulation

As many as 1 in 4 pregnant women may suffer from depression, and about 1 in 8 receives treatment with antidepressants.  If a pregnant woman was previously on antidepressants then it is not advisable to stop abruptly as she may experience nausea, vomiting, fatigue, anxiety, and irritability.  Additionally, a 2006 study in Journal of American Medical Association (JAMA) found that  68% of women who discontinued their antidepressants in pregnancy experienced a relapse of their depression. 

Many antidepressants and drugs have been used for many years without any obvious signs of serious risk to the baby.  There are some potential concerns, side effects, and risks associated with the anti-depressant medications.  However, studies have had small sample sizes, conflicting data, and lack of consistency with findings. 

MAOIs are not typically recommended as they can limit fetal growth and aggravate maternal high blood pressure.  There appears to be a small potential risk of fetal malformation with antidepressants, but not higher than the average overall risk of malformations in the general pregnancy population which is 1-3%.  Previously, there were concerns for limb defects with TCAs, but these results have not been reproduced in future studies.  TCAs are considered safe, but blood levels may need to be monitored during treatment.  SSRIs may be associated with low birth weight, preterm birth, and miscarriage.  Of all the SSRIs, Paxil is a category D and not recommended in pregnancy due to initial studies showing possible cardiac defects of the fetus when taken in the first trimester of pregnancy.  15-30% of babies whose mothers took SSRIs late in pregnancy may experience withdrawal  symptoms with irritability, jittery behavior, weak crying, hypoglycemia, seizures, temperature instability, and tachypnea.  These symptoms typically resolve within two weeks.  The remaining SSRIs are considered safe, but there have been some inconsistent findings of cardiac septal defects (“holes in the heart”) which typically occur in less than 1% of babies and resolve spontaneously without treatment, omphaloceles,  and neural tube defects.  There have been no studies showing any neurobehavioral , IQ, or language problems.   There has inconsistently been an increased relative risk of persistent pulmonary hypertension of the newborn (PPHN).  

PPHN is a condition which causes an elevation in the pressure of the pulmonary artery causing a patent ductus arteriosis and right to left shunting of blood through the heart which results in hypoxia  (lack of oxygen) to the baby and results in respiratory distress.  Most cases are treatable and 10% of cases can be fatal.   Risk factors for PPHN can include meconium aspiration, maternal obesity, smoking, diabetes, or maternal use of non-steroidal anti-inflammatory drugs (NSAIDs).  It can normally occur in 1-2/1000 infants.  Based upon 6 studies from the past 15 years, for those pregnant women taking SSRI medication there can be no association to a 6-fold increased risk of PPHN.  Most recently a study published in British Medical Journal (BMJ) on January 12, 2012 reveals that SSRI treatment in pregnancy may double the risk of PPHN as their findings from 1.6 million infants revealed an incidence of 3/1000 rather than the normal 1.2/1000.  Although, the risk may be two-fold in this study, it is still clearly extremely low.

The FDA recently made a safety announcement regarding SSRI and PPHN on December 14, 2011:

FDA has reviewed the additional new study results and has concluded that, given

the conflicting results from different studies, it is premature to reach any conclusion

about a possible link between SSRI use in pregnancy and PPHN . . . At this time, FDA advises health care professionals not to alter their current clinical practice of treating depression

during pregnancy.

The FDA had not evaluated the recent BMJ study which was published a few weeks later.  However, it is unlikely the findings would have changed their recommendation as it was another conflicting result.

This poses the question as to whether it is worse to have depression during pregnancy or take medication for it?  As outlined at the beginning of this discussion, untreated depression in pregnancy can lead to multiple maternal, obstetrical, and neonatal problems.  As for the antidepressant options, no drug is 100% safe, but most are considered  safe and effective for treatment and may be necessary depending upon the severity of maternal depression.  Additionally, in some cases the duration of treatment can be targeted to not start until after embryogenesis is complete at 8-10 weeks and discontinued in the third trimester before delivery to reduce risks of withdrawal and PPHN.  However, if there is severe maternal depression this would not be advisable as it increases the risk of postpartum depression.

Postpartum blues encompasses mood symptoms such as crying, anxiety, trouble sleeping, feeling sad or doubt, and being overwhelmed that may occur immediately postpartum, but subside within two weeks without treatment.  70-80% of women will have some “baby blues”.  Postpartum depression is depression and anxiety symptoms that occur anytime postpartum up to 1 year after delivery and interfere with daily functioning.  The condition may occur from an imbalance or adjustment of hormones, body changes, lack of sleep, feeling overwhelmed as a mother, lack of support or socialization, loss of freedom/identity, genetic predisposition, and breastfeeding problems.  The same treatment options can be used during the postpartum period and most antidepressants are considered safe during breastfeeding.  Antidepressant exposure through the breast milk is significantly less than transplacental exposure and is not associated with significant risks to full-term and healthy infants.

The risks and benefits of taking an antidepressant during pregnancy must be weighed carefully.  Ultimately, it is best to treat each patient individually, case by case to determine the best course of action and treatment.  Whenever possible, multidisciplinary management involving the obstetrician, mental health clinician, primary care provider, and pediatrician is helpful to facilitate and coordinate care.  It is essential that we screen and treat perinatal depression and stabilize maternal mental health for the overall well-being of mom and baby.  

optimawomenshealthcare.com
 

By Monique Fox, MD

Don’t  Forget To Do Your Monthly And Yearly Clinical Breast Exam
In Addition to Your Yearly Mammogram

So many of my patients casually mention to me that they do not do their monthly breast exam because they get a yearly mammogram and think that they are covered.  While yearly screening with mammography is the only test shown to decrease mortality, the combination of a yearly screening mammogram , monthly self breast exam and yearly clinical breast exam is the best combination for early detection of cancer.

Breast Cancer Detection

• Breast screening that included both a clinical exam and a mammogram was 95% effective at detecting breast cancer.
• Screening using mammography alone was 89% effective at detecting breast cancer.
• 20% of breast cancers are found by the patient’s physician on clinical exams.
• 10% of breast cancers are found by the patients on monthly self breast exams .

Clinical Breast Exam

• A clinical breast exam (CBE) is an exam of your breasts by a health expert such as a doctor, nurse practitioner, nurse, or physician assistant.
• For this exam, you undress from the waist up.
• The examiner will first look at your breasts for changes in size or shape. Then, using the pads of the fingers, she or he will gently feel your breasts for lumps. The area under both arms will also be checked.
• This is a good time to learn how to do breast self-exam if you don't already know how.

Breast Awareness and Breast Self-Exam

• Women should be aware of how their breasts normally look and feel and report any changes to a doctor right away. Finding a change does not mean that you have cancer.
• By being aware of how your own breasts look and feel, you are likely to notice any changes that might take place. You can also choose to use a step-by-step approach to checking your breasts on a set schedule. The best time to do breast self-examination (BSE) is when your breasts are not tender or swollen. If you find any changes, see a doctor right away.
• Women with breast implants can also do BSE. It may help to have the surgeon help you feel the edges of the implant so that you know where they are. It may be that the implants push out the breast tissue and actually make it easier to examine.

Commonly Accepted Recommendations For Early Breast Cancer Detection

• Women age 40 and older should have a screening mammogram every year.
• Women with increased risk factors should start regular mammography before the age of 40.
• Between the ages of 20 and 39, women should have a clinical breast examination by a health professional every 3 years. After age 40, women should have a breast exam by a health professional every year.
• Women age 20 or older should perform a breast self-examination (BSE) every month. By doing the exam regularly, you get to know how your breasts normally feel and you can more readily detect any signs or symptoms.

*Remember:  No one knows your body like you do, and you have the best chance of spotting changes early on!

Dr. Monique Fox is a breast radiologist at The Trio Breast Center at Parker Adventist Hospital.  For more information visit parkerhospital.org/mammogram.

By Vandna Jerath, MD

• Pregnant women are more prone to severe illness and pregnancy complications from the flu.
• Physiologic changes and an altered immune system in pregnancy make pregnant women high-risk candidates for the flu.
• In pregnancy, the flu can cause dehydration, pneumonia, acute respiratory distress syndrome (ARDS), miscarriage, preterm labor, or preterm delivery and birth.
• In 2009, pregnant women accounted for only 1% of the population, but 6% of H1N1 related deaths.
• ACOG (American College of Obstetricians and Gynecologists) recommends that ALL pregnant women receive the flu shot.
• Influenza vaccination is the best way to prevent the flu – it can reduce your risk of catching the flu by 70-90% and decrease your risk of hospitalization or death by 50-80%. 
• Vaccination during pregnancy protects both the mother and her infant (up to 6 months of age).
• Influenza vaccine is SAFE as it has been given to millions of pregnant women and has not demonstrated harm to women or their infants.
• The flu shot can be given to pregnant women in ANY trimester.
• Pregnant women should receive the inactivated vaccine (killed virus) or flu shot, but NOT the nasal spray vaccine (live attenuated virus) which is contraindicated.
• Postpartum women – especially within two weeks after pregnancy or pregnancy loss – should also receive the flu vaccine and may receive either the shot or nasal spray.
• Women who are breastfeeding are encouraged to receive either type of vaccine and can pass antibodies via the breast milk to their infants that may provide passive immunity.  This is one of the best ways to protect infants under 6 months of age, who are too young to be vaccinated.
• If preferred, a thimerosal free version of the flu shot is available.
• Women with an egg allergy or who are actively ill with a fever should not get the flu shot.
• Influenza vaccination is an essential part of prenatal care and recommended for all pregnant, breastfeeding, or postpartum women.
• Please talk to your doctor about getting your flu shot.

Premenstrual Syndrome (PMS) is defined by the American College of Obstetricians and Gynecologists (ACOG) as “the cyclic occurrence of symptoms that are of sufficient severity to interfere with some aspects of life and that appear with consistent and predictable relationship to the menses.”  Typically, PMS is a syndrome with physical, emotional and/or psychological manifestations.  Symptoms occur after ovulation and are most significant 5-7 days before the menses and subside within 4 days after the onset of menses. 

PMS can affect women of any reproductive age, but is most common between age 25-45.  75 - 85% of women will have at least one symptom or some form of PMS.   Many women will find their symptoms tolerable, but 20-30% will have clinically significant PMS with moderate to severe symptoms that have an adverse affect on their life.  3-5% of women will have debilitating PMS with a disruption of daily, social, and work activities and a significant impairment of their lifestyle.  These women have a severe variant known as PMDD – Premenstrual Dysphoric Disorder. 

Risk factors and the cause of PMS or PMDD are still unknown and research continues, but symptoms are thought to occur due to an imbalance or alteration of cyclic physiologic hormones and brain chemicals known as neurotransmitters, particularly an insufficient amount of serotonin.

Symptoms include an affective or mood component and/or a somatic or physical component: 

Emotional/Mood Symptoms

• Crying
• Angry outbursts or mood swings
• Depressed mood
• Anxiety
• Irritability
• Social withdrawal
• Poor concentration

Physical Symptoms

• Breast tenderness
• Bloating
• Constipation
• Weight gain
• Swelling
• Acne
• Headache
• Fatigue
• Sleep disturbances – insomnia or hypersomnia
• Appetite changes/food cravings

PMS can mimic several medical conditions including hypothyroidism, irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, migraines, and depression/mood disorders.  The best way to diagnose PMS is to keep a comprehensive menstrual diary outlining symptoms for 2-3 cycles.  If symptoms typically occur after ovulation, before menses, and resolve after menses, they are consistent with PMS.  A variety of menstrual diaries can be found on the internet or most smart phones will have a useful app for charting. 

There is no “cure” for PMS, but there are multiple options to reduce PMS symptoms.  Treatment regimens include lifestyle modifications, alternative therapies, and medications:

Lifestyle Modifications

• Stress reduction and support
• Relaxation
• Aerobic exercise – release endorphins which improve mood
• Healthy diet –
  • Smaller and frequent meals
  • Reduce sugar and fat intake
  • Increase complex carbohydrates (whole grains, fruits, vegetables)
  • Calcium rich foods
  • B vitamins – thiamine and riboflavin (spinach, fortified cereal, dried beans, red meat)
• Reduction in caffeine, salt, and alcohol
• Quit smoking

Alternative/Natural Therapies

• Vitamins
  • Calcium - 1200 mg daily
  • B6 – 50-100mg daily (doses over 100mg can cause peripheral neuropathy)
  • Magnesium – 400mg daily
  • Vit E – 400 IU daily
• Herbs – not FDA approved or regulated and may react with other prescription medications; may still require further investigation
  • Chasteberry
  • Gingko Biloba
  • Black Cohosh
  • Raspberry Leaf
  • St John’s Wart (may reduce efficacy of OCPs)
  • Kava Kava
  • Primrose Oil – not particularly helpful
• Massage Therapy
• Yoga
• Acupuncture
• Psychotherapy – cognitive behavioral therapy
• Light therapy – being researched

Medications

• Analgesics or NSAIDs
  • Ibuprofen (Motrin, Advil)
  • Naproxen (Aleve, Anaprox)
  • Mefenamic Acid (Ponstel)
• Oral Contraceptives (OCP’s)
  • Drosperinone (Yaz, Yasmin, Safryl, BeYaz, Ocella)
• Diuretics
  • Spironolactone (Aldactone)
• Ovarian Suppression
  • Danacrine (Danazol)
  • GnRH analogs – gonadotropin releasing hormone (Lupron) – cannot be given for more than 6 months and may lead to menopausal symptoms and osteoporosis
• Antidepressants /Anxiolytics
  • SSRI – selective serotonin reuptake inhibitors
    • Fluoxetine (Prozac, Sarafem)
    • Paroxetine (Paxil)
    • Sertraline (Zoloft)
    • Citalopram  (Celexa)
    • Venlafaxine (Effexor)
    • Duloxetine (Cymbalta)
    • Benzodiazepine
      • Alprazolam (Xanax) – increased risk for addiction
• Other
  • PH80 – pherine intranasal spray in clinical trials now
  • Bilateral Salpingoopherectomy – removal of ovaries, extreme measure

PMS is definitely a woman’s monthly madness and many women live in silent suffering.  But, with proper recognition, communication, and understanding between the patient and doctor, there are many options that can improve quality of life. 

www.optimawomenshealthcare.com