After delivery, women experience a dramatic drop in estrogen hormone levels. Many have hypothesized that this decline in estrogen levels may precipitate postpartum depression (PPD) in susceptible individuals, and several studies have explored the use of estrogen for the treatment of depression after delivery.

In a double blind, placebo-controlled study including 61 women with PPD, Gregoire and colleagues demonstrated that transdermal estrogen therapy may be beneficial. Although this study was small and was confounded by the inclusion of patients who were simultaneously treated with antidepressant medications, it is the first to demonstrate that estrogen alone or when used in conjunction with an antidepressant may be useful in women with PPD.

More recently, Ahokas and colleagues have shown that estrogen was effective in women with PPD who had low estrogen levels. In this open trial, 23 women with PPD were treated with sulingual estradiol. Within two weeks of treatment, 19 of the 23 women experienced a remission of their depressive symptoms. It is unclear if these findings can be generalized to all women with PPD, as most of the women had very low estrogen levels. (In 16 of the 23 participants, estrogen concentrations were even lower than the threshold value for gonadal failure.)

Although these studies suggest a role for estrogen in the treatment of women with postpartum depression, hormonal treatments remain experimental. Estrogen delivered in the acute postpartum period is not without risk and has been associated with changes in breast milk production, as well as an increased risk of significant thrombo-embolic events, including stroke and deep vein thrombosis.

Antidepressants are safe, well tolerated and highly effective and remain the first choice for women with PPD. Estrogen augmentation is typically reserved for cases where there is evidence of estrogen deficiency or when the depression appears particularly refractory to treatment.

Ruta Nonacs, MD PhD

Gregoire AJP, Kumar R, Everitt B, et al. Transdermal oestrogen for treatment of severe postnatal depression. Lancet 1996; 347: 930-933.

Ahokas A. Kaukoranta J. Wahlbeck K. Aito M. Estrogen deficiency in severe postpartum depression: successful treatment with sublingual physiologic 17beta-estradiol: a preliminary study. Journal of Clinical Psychiatry 2001; 62: 332-336.

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