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Perimenopausal Depression

Who?: Women report depressive symptoms during the menopause transition about twice as much as they do prior to the transition. Women who have experienced prior episodes of depression are at greater risk. 

 

What?: During perimenopause, the menstrual cycle becomes irregular. This can co-occur with symptoms including hot flashes, night sweats, vaginal dryness, cognitive shifts, weight gain, and low libido. Menopause occurs 12 months after your final menstrual period. There is a higher risk for depressive symptoms during perimenopause, including low mood, irritability, decreased interest, worthlessness, changes in sleep, energy, and concentration.

 

When?: The early (2-5 years prior to final menstrual period) and late (0-24 months prior to final menstrual period) menopause transition are associated with highest risk for depressive symptoms. The risk increases as you get closer to your final menstrual period. 

 

Why?: Risk factors include prior episodes of depression, anxiety, history of premenstrual depressive symptoms, sleep disturbance, social isolation, and high BMI. The fluctuation of hormones during perimenopause can predispose women to mood changes. 

 

Diagnosis: A diagnostic assessment will include identification of menopause stage, assessment of psychiatric and menopause symptoms, review of previous psychiatric history, and discussion of past and current life stressors. 

 

Treatment: Therapeutic options include lifestyle changes, psychotherapy, and medication management aimed at reducing depressive symptoms, insomnia, and hot flashes/night sweats. 

 
Premenstrual Dysphoric Disorder (PMDD)

Who?: 3-8% of menstruating women

 

What?: Pattern of at least 5 physical, emotional, and behavioral symptoms occurring in most menstrual cycles over the past year. 

 

One or more of the following symptoms must be present:

  1. Marked affective lability (mood swings, increased sensitivity to rejection)

  2. Marked irritability or anger or increased interpersonal conflicts

  3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts

  4. Marked anxiety, tension and/or feelings of being keyed up or on edge 

 

One or more of the following symptoms must additionally be present:

  1. Decreased interest in usual activities

  2. Difficulty in concentration

  3. Lethargy, lack of energy

  4. Change in appetite

  5. Change in sleep patterns

  6. A sense of being overwhelmed or out of control

  7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of bloating, weight gain

 

 

When:? Symptoms begin 1-2 weeks before menstruation and improve within a few days after onset of menses. Symptoms are minimal or absent post-menses.

 

Why?: Increased sensitivity to normal fluctuation of hormones

 

How to diagnose: Track symptoms prospectively for at least 2 menstrual cycles. The Daily Record of Severity of Problems and the Calendar of Premenstrual Experiences can be used for tracking. A full diagnostic psychiatric evaluation is essential to rule out underlying psychiatric disorders, which commonly worsen prior to menses. 

 

Treatment: Non-pharmacologic treatments can include lifestyle modification, psychotherapy, and nutritional supplements. Pharmacologic treatments can include both psychiatric medication and/or hormonal medication. 

 
Traumatic Childbirth

Who?: Nearly half of women describe childbirth as traumatic in some way.

 

What?: Deep distress or psychological disturbance related to childbirth. A medically normal labor and delivery may be experienced as traumatic. 

 

Traumatic childbirth leaves women (and their partners) more vulnerable to postpartum mental health disorders, including anxiety, depression, and post traumatic stress disorder (PTSD). 

 

When?: While mental health symptoms related to a traumatic childbirth can show up right away, it is common to have a delayed presentation of symptoms between 6-12 months postpartum. 

 

Why?: Factors that leave one more vulnerable to birth trauma include a previous mental health history, history of trauma, depression during pregnancy, fear of childbirth, and low social support. Childbirth experiences with a lot of medical intervention, medical complications, physical pain, poor support, and perceived threat to mother or infant increase risk for birth to be experienced as traumatic. Women also describe the experience of childbirth as traumatic when they feel uncared for, powerless, disrespected, or not communicated with. A large mismatch between birth expectations and experience may lead women to appraise their birth experience as traumatic. 

 

Preventative Care: Efforts should be made to identify high risk women during pregnancy. Steps can be taken to prevent traumatization, including early delivery planning that aims to minimize medical interventions and that strategizes around relaxation and pain relief, and to set in place a continuous support system for delivery and early postpartum. Vulnerable women should be evaluated for postpartum depression, anxiety, and PTSD. 

 

Treatment: Treatment for mental health symptoms related to a traumatic childbirth experience can include trauma-focused psychotherapy and/or medication management. The goal of treatment is to reduce symptom burden, and also to facilitate post traumatic growth. 

 

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