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Depression in Women: From PMS to Post-partum Blues


Depression in Women: From PMS to Post-partum Blues Kimberley Guida, MD Pullman Family Medicine Case Presentation Statistics Depression is twice as common in women as ... – PowerPoint PPT presentation

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Title: Depression in Women: From PMS to Post-partum Blues

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

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

  • 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

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
  • Persistent life stressors (i.e. loss of job)
  • Loss of social support system

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

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
  • 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

Treatment For Depression
  • Psychosocial (counseling)- cognitive behavioral
  • 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- SSRIs, tricyclics, others
  • St. Johns wort- some studies suggest a benefit
  • Need a minimum of 2 weeks to see an effect
  • Treatment for minimum of 6 months

SSRIs- 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

Whats 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
  • SSRIs may cause problems with libido and
    difficulty attaining orgasm
  • Other medications may enhance libido- ie
    Wellbutrin, Effexor

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

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

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

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

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

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

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

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

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
  • Societal pressures to be good mother may
    prevent woman from admitting symptoms

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

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

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

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

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
  • Dont hesitate to discuss symptoms with your

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