Mass General Hospital

Harvard Medical School

Specialty Areas

PMS and PMDD

Many women in their reproductive years experience transient physical and emotional changes around the time of their period. Premenstrual syndrome, or PMS, typically refers to a general pattern of physical, emotional, and behavioral symptoms occurring 1-2 weeks before menses and remitting with the onset of menses. Premenstrual dysphoric disorder (PMDD) is a more severe form of PMS affecting 3-8% of women in their reproductive years. The most common symptom is irritability; however, many women also report depressed mood, anxiety, or mood swings. For patients with mild physical and emotional symptoms of PMS, various lifestyle modifications and nutritional supplements may be helpful. Pharmacologic treatment for more severe PMS and PMDD include selective serotonin reuptake inhibitors (SSRIs), hormonal interventions such as oral contraceptives (OCPs) and gonadotropin-releasing hormone (GnRH) agonists.

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Psychiatric Disorders During Pregnancy

Although pregnancy has typically been considered a time of emotional well being, recent studies suggest that up to 20% of women suffer from mood or anxiety disorders during pregnancy. Particularly vulnerable are those women with histories of psychiatric illness who discontinue psychotropic medications during pregnancy. Information regarding the risks of prenatal exposure to psychotropic medications is still incomplete, so clinicians face certain challenges when making recommendations regarding the treatment of psychiatric disorders during pregnancy. Decisions regarding the initiation or maintenance of treatment during pregnancy must reflect an understanding of the risks associated with fetal exposure to a particular medication, but must also take into consideration the risks associated with untreated psychiatric illness in the mother. Psychiatric illness in the mother is not a benign event and may cause significant morbidity for both the mother and her child; thus, discontinuing or withholding medication during pregnancy is not always the safest option.

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Breastfeeding and Psychiatric Medication

The nutritional, immunologic and psychological benefits of breastfeeding have been well documented. Given the prevalence of psychiatric illness during the postpartum period, a significant number of women may require pharmacologic treatment while nursing. Appropriate concern is raised, however, regarding the safety of psychotropic drug use in women who choose to breastfeed while using these medications. Current research indicates that, while all medications are secreted into the breast milk, the incidence of adverse events in nursing infants appears to be relatively low. It is felt that certain agents may be used safely by mothers who are planning to breastfeed.

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Postpartum Psychiatric Disorders

Postpartum psychiatric illness is typically divided into three categories: (1) postpartum blues, (2) postpartum depression, and (3) postpartum psychosis. While the blues affects many women shortly after delivery, this type of mood disturbance is mild, transient, and typically does not affect a woman’s ability to function. In contrast, postpartum depression is a more severe and pervasive mood episode usually emerging over the first two to three postpartum months. Postpartum psychosis is the most severe form of postpartum psychiatric illness. It is a rare event that occurs in approximately 1 to 2 per 1000 women after childbirth. While effective non-pharmacologic and pharmacologic treatments are available, many women with these disorders to not receive adequate treatment.

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Fertility and Mental Health

Infertility is perceived as a problem across virtually all cultures and societies and affects an estimated 10%-15% of couples of reproductive age. Infertility has been associated with a spectrum of emotional consequences including anger, depression, anxiety, marital problems, sexual dysfunction, and social isolation. There is also concern that depression itself may affect fertility. In light of data suggesting that psychological symptoms may interfere with fertility, success of infertility treatment, and the ability to tolerate ongoing treatment, interest in addressing these issues during infertility treatment has grown.

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Menopausal Symptoms

The menopausal transition is typically marked by the presence of vasomotor symptoms such as hot flushes and night sweats (hot flushes that occur with perspiration causing nocturnal awakenings). Other symptoms commonly observed during the menopausal transition include depression, anxiety, insomnia, memory problems, and sexual dysfunction. Hormone therapy has been the treatment of choice to alleviate physical symptoms associated with the menopausal transition and to help in preventing the clinical consequences of an estrogen-deficient state, including osteoporosis and cardiovascular disease; however, recent results form large, prospective studies have questioned the safety of long-term hormonal therapy, as well as its efficacy to prevent cardiovascular diseases. Thus, other treatment options, including antidepressants, are being considered to provide relief for menopausal symptoms.

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