Most women experience some degree of sleep disturbance during pregnancy, and for a significant number of women sleep disruption may be quite severe. There are many different causes for sleep disturbance during pregnancy, and choosing the appropriate intervention relies on an accurate diagnosis of the problem.
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.
Oral contraceptives are commonly prescribed for the treatment of premenstrual symptoms and premenstrual dysphoric disorder (PMDD); however, the evidence supporting the use of oral contraceptives in this setting is limited. While most studies have shown that oral contraceptives are not effective for the treatment of premenstrual symptoms, there is preliminary evidence that a new oral contraceptive pill, Yaz, which contains low-dose estrogen and a novel progestin called drospirenone, may alleviate the symptoms of PMDD.
Estrogen was first approved by the FDA for the treatment of menopausal symptoms in 1942, and for many decades estrogen replacement therapy had been widely prescribed for peri- and post-menopausal women. In 2002, however, data from the Women’s Health Initiative (WHI) suggested that hormonal therapy may be associated with an increased risk of breast cancer and cardiovascular disease. These findings have led to a dramatic decrease in the use of hormone replacement therapy (HRT), with many women abruptly discontinuing its use.
Polycystic ovarian syndrome (PCOS) occurs in 4-7% of women and is characterized by irregular menstrual cycles and hyperandrogenism (facial hair, acne, male-pattern hair loss, acne, or elevated male hormone levels). The majority of women with PCOS also suffer from obesity and insulin resistance. PCOS has been associated with a spectrum of health problems including infertility, diabetes, and possibly heart disease and endometrial cancer. Recently there has been concern that women with bipolar disorder who are treated with the mood stabilizer valproate (VPA; brand name Depakote or Depakene), may be at higher risk for PCOS, although the data have been somewhat conflicting.
Peri- and post-menopausal women frequently complain of insomnia or poor sleep quality. Sleep disturbance is often attributed to nocturnal hot flashes; however, a recent study from researchers at Wayne State University School of Medicine suggests that about half of these women may have a primary sleep disorder.
While earlier observational studies suggested that postmenopausal hormone treatment may improve cognitive functioning in women, studies from the Women's Health Initiative have shown that estrogen replacement therapy started in postmenopausal women (65 years or older) did not enhance cognitive functioning nor did it decrease the risk of dementia.
While it appears that many women with eating disorders may experience a remission of their symptoms during pregnancy, a new study from researchers at the University of North Carolina, Chapel Hill and the University of Oslo, Norway suggests that binge eating disorder may be triggered during pregnancy.
While there have been concerns regarding the reproductive safety of psychotropic medications, it must be recognized that withholding or withdrawing pharmacologic treatment for depression or anxiety during pregnancy may not always be the safest option. Untreated psychiatric illness in the mother cannot be considered a benign event, and a number of studies have indicated that depression during pregnancy may negatively affect pregnancy outcomes (reviewed in Bonari 2004).
Depression is common during pregnancy, affecting 10% to 15% of women. While psychotherapy is an attractive option for the treatment of depression during pregnancy, all women do not respond to this intervention and many require pharmacotherapy. Thus far, no antidepressants have yet been approved by the FDA for use during pregnancy. Although data accumulated over the past 30 years suggest that certain medications, including the serotonin reuptake inhibitors (SSRIs), may be used safely during pregnancy, several new studies have raised concerns regarding the use of these medications during pregnancy.
