en mujeres en edad reproductiva
1: Postgrad Med 2002 Sep;112(3):45-50; quiz 2
Depression in women of reproductive age.
Considerations in selecting safe, effective therapy.
Young SA, Campbell N, Harper A.
Department of Neuropsychiatry and Behavioral
Science, University of South Carolina School of Medicine, 3555 Harden St
Extension, Columbia, SC 29203, USA. email@example.com
The understanding of biologic and psychologic
underpinnings of depression in women of reproductive age continues to grow.
Overall, the news is good. Increased knowledge, safer treatments, and
early identification have combined to reduce the morbidity of depression
in this population. Many treatments appear to be safe and well tolerated
by mother and infant alike. No matter how safe the treatment, however, a
poor perinatal outcome will prompt both physician and patient to second-guess
the intervention. Women who are pregnant or breast-feeding and have a
history of depression or are currently experiencing symptoms need to be
educated about the risks and benefits of treatment and nontreatment.
Whenever possible, another family member should be involved in this
discussion. Ultimately, the decision to medicate or not comes down to
whether the risk of treatment outweighs the risk of no treatment.
Untreated depression is not without its own risks and morbidity.
Psychotherapy remains an important tool that can be used independent of or
in addition to medication. It is especially helpful for the many women who
refuse any and all medications when they are pregnant or breast-feeding.
2: J Clin Psychiatry 2002 Apr;63(4):284-7
The impact of reproductive events on the
course of bipolar disorder in women.
Freeman MP, Smith KW, Freeman SA, McElroy SL,
Kmetz GE, Wright R, Keck PE Jr.
Department of Psychiatry, University of Arizona
College of Medicine, Tucson 85724-5002, USA. firstname.lastname@example.org
BACKGROUND: Little is known about the impact of
female reproductive hormones on the course of bipolar disorder. This study
was designed to assess the influence of reproductive events and hormonal
therapies on the course of bipolar disorder in women. METHOD: Fifty women
with DSM-IV bipolar disorder completed a structured clinical interview to
assess the impact of reproductive events on the course of their illness.
RESULTS: The onset of bipolar disorder occurred before menarche in 32% (N
= 16) of women; 18% (N = 9) experienced the onset within 1 year of
menarche. Most women did not receive an accurate diagnosis of nor
treatment for bipolar disorder until after they had children, and
therefore the majority were not treated with mood stabilizers during or
immediately after pregnancies. Of women with children, 20 (67%) of 30
experienced a postpartum mood episode. Of the women who had postpartum
episodes after delivery of a first child, all had episodes after
subsequent pregnancies. Having a postpartum mood episode after a first
pregnancy significantly increased the risk of a postpartum episode after
subsequent deliveries (p = .02). Postpartum episodes were almost
exclusively depressive. Increased depressive symptoms during pregnancy
were significantly associated with postpartum mood episodes (p = .01).
Women who were not using hormone replacement therapy (HRT) were
significantly more likely than those who were using HRT to report
worsening of symptoms during perimenopause/menopause (p = .02). CONCLUSION:
These data suggest that hormonal fluctuations are associated with
increased risk of affective dysregulation and mood episodes in women with
3: J Clin Psychiatry 2002;63 Suppl 7:9-15
Epidemiology of depression throughout the
female life cycle.
Burt VK, Stein K.
University of California School of Medicine, Los
Women are at an increased risk for first onset
of major depression from early adolescence until their mid-50s and have a
lifetime rate of major depression 1.7 to 2.7 times greater than that for
men. There is accumulating evidence that certain reproductive-related
hormonal changes place women at increased risk for depression. For example,
puberty marks the beginning of increased risk for depression in women.
Most women report physical or emotional symptoms premenstrually, with some
severe enough to be diagnosed as premenstrual dysphoric disorder. While
pregnancy does not increase the risk for depression, women with past
histories of depression are at risk for recurrent episodes or relapse if
antidepressant medications are discontinued. Hormonal changes during the
postpartum period also increase the incidence of depression. Similarly,
women transitioning through perimenopause, particularly those with past
psychiatric histories, report depressive symptoms. Prophylaxis and
treatment to minimize severity in cases of recurrence are discussed in the
article, using reproductive transitional events as markers.
4: J Clin Psychiatry 2001;62 Suppl 24:11-7
The evaluation and management of depression
in women across the life span.
Department of Psychiatry, Medical College of
Virginia, Virginia Commonwealth University, Richmond 23298-0710, USA.
Depression is more common in women than in men,
particularly during the childbearing years. Women may present with
different depressive symptoms than men and may respond differently to
antidepressant treatment. In addition, depression in women can surface in
association with specific points in the reproductive cycle, such as during
the premenstrual period, during pregnancy and the postpartum period, and
during the perimenopausal years. Antidepressant medications may be used
effectively at all stages in a woman's life. In the case of premenstrual
dysphoric disorder, serotonergic agents have demonstrated efficacy in both
full-cycle and luteal-phase dosing strategies. For depressed women who are
pregnant or breastfeeding, the limited safety data available on
antidepressants suggest minimal danger to the fetus or infant, and the
risks and benefits to both mother and child must be weighed against the
risks of untreated illness. Treatment of depression in middle-aged and
elderly women should take into account the possible influence of both
menopausal status and hormone replacement therapy on antidepressant
response. This article will focus on special considerations in the
evaluation and management of depression in women across the life span.
5: Obstet Gynecol 2001 Sep;98(3):391-7
Sleep quality, estradiol levels, and
behavioral factors in late reproductive age women.
Hollander LE, Freeman EW, Sammel MD, Berlin JA,
Grisso JA, Battistini M.
Department of Obstetrics and Gynecology,
University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
19104-4283, USA. email@example.com
OBJECTIVE: To estimate the prevalence of
perceived poor sleep in women aged 35-49 years and to correlate sleep
quality with levels of gonadal steroids and predictors of poor sleep.
METHODS: A cohort of 218 black and 218 white women aged 35-47 years at
enrollment (aged 37-49 at final follow-up) with regular menstrual cycles
was identified through random digit dialing for a longitudinal study of
ovarian aging correlates. Data obtained at four assessment periods,
including enrollment, over a 2-year interval were collected between days 1
and 6 (mean = 3.9) of the menstrual cycle. The primary outcome measure was
subjects' rating of sleep quality at each assessment period. Associations
of sleep quality with hormone levels (estradiol, follicle-stimulating
hormone, luteinizing hormone, testosterone, and dehydroepiandrosterone
sulfate) and other clinical, behavioral, and demographic variables were
examined in bivariable and multivariable analyses. RESULTS: Approximately
17% of subjects reported poor sleep at each assessment period. Significant
independent associations with poor sleep included greater incidence of hot
flashes (odds ratio [OR] 1.52; 95% confidence interval [CI] 1.08, 2.12, P
=.02), higher anxiety levels (OR 1.03; 95% CI 1.00, 1.06, P =.04), higher
depression levels (OR 1.05; 95% CI 1.02, 1.07, P <.001), greater
caffeine consumption (OR 1.25; 95% CI 1.04, 1.49, P =.02), and lower
estradiol levels in women aged 45-49 (OR 0.53; 95% CI 0.34, 0.84, P
=.006), after adjustment for current use of sleep medications. CONCLUSION:
Both hormonal and behavioral factors were associated with sleep quality.
Estradiol levels are an important factor in poor sleep reported by women
in the 45-49 age group. Further evaluation of estrogen treatment for poor
sleep of women 45 years and older is warranted.
6: Can J Psychiatry 2001 Jun;46 Suppl 1:63S-76S
Clinical guidelines for the treatment of
depressive disorders. VI. Special populations.
Thorpe L, Whitney DK, Kutcher SP, Kennedy SH;
CANMAT Depression Work Group.
Department of Psychiatry, University of
Saskatchewan, Regina, Saskatchewan.
BACKGROUND: The Canadian Psychiatric Association
and the Canadian Network for Mood and Anxiety Treatments partnered to
produce clinical guidelines for psychiatrists for the treatment of
depressive disorders. METHODS: A standard guidelines development process
was followed. Relevant literature was identified using a computerized
Medline search supplemented by review of bibliographies. Operational
criteria were used to rate the quality of scientific evidence, and the
line of treatment recommendations included consensus clinical opinion.
This section, "Special Populations," is 1 of 7 articles that
were drafted and reviewed by clinicians. Revised drafts underwent national
and international expert peer review. RESULTS: This section reports on the
prevalence, course, and outcome of depression for specific populations.
Psychological, pharmacologic, and other biological treatment options for
these populations--children and adolescents, the elderly, women at times
of increased risk within the reproductive cycle, and specific
ethnocultural groups--are critically evaluated. CONCLUSIONS: Major
depressive disorder (MDD) is prevalent across the lifespan. In general,
clinical presentations are more similar than different across age, sex,
and cultural divides. Although less evidence is available for the efficacy
of treatments in these subpopulations than in mid-life patients,
comparable rates of response for pharmacotherapies, electroconvulsive
therapy (ECT), and, in some cases, evidence-based psychotherapies have
7: Arch Gen Psychiatry
Efficacy of estradiol for the treatment of
depressive disorders in perimenopausal women: a double-blind, randomized,
Soares CN, Almeida OP, Joffe H, Cohen LS.
Perinatal and Reproductive Psychiatry Clinical
Research Program, Massachusetts General Hospital, Harvard Medical School,
15 Parkman St, WACC 812, Boston, MA 02114, USA. firstname.lastname@example.org
BACKGROUND: Results of previous studies suggest
that estrogen improves somatic and mild depressive symptoms experienced by
perimenopausal women. This study investigated the efficacy of 17beta-estradiol
for the treatment of clinically significant depressive disorders in
endocrinologically confirmed perimenopausal women. METHODS: Perimenopausal
women (aged 40-55 years, with irregular menstrual periods and serum
concentrations of follicle-stimulating hormone >25 IU/L), meeting
criteria for major depressive disorder, dysthymic disorder, or minor
depressive disorder, according to DSM-IV, were randomized to receive
transdermal patches of 17beta-estradiol (100 microgram) or placebo in a
12-week, double-blind, placebo-controlled study. A 4-week washout period
followed the 12-week treatment phase. Outcome measures were the Montgomery-Asberg
Depression Rating Scale and Blatt-Kupperman Menopausal Index scores.
RESULTS: Fifty women were enrolled in the study; 26 met DSM-IV criteria
for major depressive disorder, 11 for dysthymic disorder, and 13 for minor
depressive disorder. Remission of depression was observed in 17 (68%)
women treated with 17beta-estradiol compared with 5 (20%) in the placebo
group (P =.001). Subjects responded similarly to estradiol treatment,
regardless of DSM-IV diagnosis. Patients treated with estradiol sustained
antidepressant benefit of treatment after the 4-week washout period,
although somatic complaints increased in frequency and intensity.
Treatment was well tolerated and adverse events were rare in both groups.
CONCLUSION: Transdermal estradiol replacement is an effective treatment of
depression for perimenopausal women.
8: J Clin Psychiatry 2001 Feb;62(2):82-6
Prevention of recurrent postpartum depression:
a randomized clinical trial.
Wisner KL, Perel JM, Peindl KS, Hanusa BH,
Findling RL, Rapport D.
Department of Reproductive Biology, Case Western
Reserve University School of Medicine, Cleveland, Ohio 44106, USA. email@example.com
BACKGROUND: Women who
have suffered one episode of postpartum-onset major depression (PPMD)
comprise a high-risk group for subsequent episodes. We conducted a double-blind,
randomized clinical trial to test the efficacy of nortriptyline in the
prevention of recurrent PPMD. METHOD: Nondepressed women who had at least
one past episode of PPMD (Research Diagnostic Criteria) were recruited
during pregnancy. Subjects were randomly assigned to nortriptyline or
placebo. Treatment began immediately postpartum. Each subject was assessed
for 20 sequential weeks with the Hamilton Rating Scale for Depression and
Research Diagnostic Criteria for recurrence of major depression. RESULTS:
No difference was found in the rate of recurrence in women treated with
nortriptyline compared with those treated with placebo. Of 26 subjects who
took nortriptyline preventively, 6 (0.23, 95% exact confidence interval
[CI] = 0.09 to 0.44) suffered recurrences. Of 25 subjects who took
placebo, 6 (0.24, 95% exact CI = 0.09 to 0.45) suffered recurrence (Fisher
exact p = 1.00). CONCLUSION: Nortriptyline did not confer additional
preventive efficacy beyond that of placebo. The rate of recurrence of PPMD
(one fourth of women) was unacceptably high.
9: Arch Gen Psychiatry
Gonadal hormones, reproductive age, and women
State University of New York at Buffalo, SUNY
Clinical Center, BB-170, 462 Grider St, Buffalo, NY 14215, USA.
10: Arch Gen Psychiatry
Alteration in the hypothalamic-pituitary-ovarian
axis in depressed women.
Young EA, Midgley AR, Carlson NE, Brown MB.
Mental Health Research Institute, 205 Zina
Pitcher Place, Ann Arbor, MI 48109, USA.
BACKGROUND: Stress and corticotropin-releasing
hormone inhibit the reproductive axis. We hypothesized that reproductive
axis hormone secretion, particularly luteinizing hormone secretion, is
inhibited in women with depression, similar to what has been observed to
be caused by stress in numerous species. METHODS: Blood samples were
collected every 10 minutes for 12 hours in 25 untreated premenopausal
women with depression and 25 nondepressed women who were matched by age
and menstrual cycle day. Samples were assayed for luteinizing hormone,
follicle-stimulating hormone, estradiol, and progesterone. RESULTS: The
mean plasma estradiol level was 30% lower in the follicular phase in women
with depression than in their matched controls: 191 + 136 vs 261 + 169
pmol/L (52 + 37 vs 71 + 46 pg/mL). The half-life of luteinizing hormone
was significantly shorter in women with depression than in their matched
controls during both the follicular (22% shorter) and luteal (15% shorter)
phases. CONCLUSIONS: The blood levels of reproductive hormones were mostly
normal in women with depression, but the blood level of estradiol was
significantly lower. Estradiol is known to affect a number of
neurotransmitter systems in the brain.
11: Am J Psychiatry 2000 Jun;157(6):924-30
Effects of gonadal steroids in women with a
history of postpartum depression.
Bloch M, Schmidt PJ, Danaceau M, Murphy J,
Nieman L, Rubinow DR.
Behavioral Endocrinology Branch, NIMH, NIH,
Bethesda, MD 20892-1276, USA.
OBJECTIVE: Endocrine factors are purported to
play a role in the etiology of postpartum depression, but direct evidence
for this role is lacking. The authors investigated the possible role of
changes in gonadal steroid levels in postpartum depression by simulating
two hormonal conditions related to pregnancy and parturition in euthymic
women with and without a history of postpartum depression. METHOD: The
supraphysiologic gonadal steroid levels of pregnancy and withdrawal from
these high levels to a hypogonadal state were simulated by inducing
hypogonadism in euthymic women-eight with and eight without a history of
postpartum depression-with the gonadotropin-releasing hormone agonist
leuprolide acetate, adding back supraphysiologic doses of estradiol and
progesterone for 8 weeks, and then withdrawing both steroids under double-blind
conditions. Outcome measures were daily symptom self-ratings and
standardized subjective and objective cross-sectional mood rating scales.
RESULTS: Five of the eight women with a history of postpartum depression
(62.5%) and none of the eight women in the comparison group developed
significant mood symptoms during the withdrawal period. Analysis of
variance with repeated measures of daily and cross-sectional ratings of
mood showed significant phase-by-group effects. These effects reflected
significant increases in depressive symptoms in women with a history of
postpartum depression but not in the comparison group after hormone
withdrawal (and during the end of the hormone replacement phase), compared
with baseline. CONCLUSIONS: The data provide direct evidence in support of
the involvement of the reproductive hormones estrogen and progesterone in
the development of postpartum depression in a subgroup of women. Further,
they suggest that women with a history of postpartum depression are
differentially sensitive to mood-destabilizing effects of gonadal steroids.
12: Obstet Gynecol 2000 Jan;95(1):55-60
Ethnic differences in depressive
symptomatology among young women.
Rickert VI, Wiemann CM, Berenson AB.
Department of Obstetrics & Gynecology, The
University of Texas Medical Branch at Galveston, USA. firstname.lastname@example.org
OBJECTIVE: To examine
racial and ethnic differences in moderate to severe depressive symptoms
among young women seeking reproductive health care. METHODS: Nine hundred
four white, black, or Hispanic women between 14 and 26 years of age
completed an anonymous questionnaire that assessed demographic and
reproductive characteristics; recent substance use, including binge
drinking; sexual behaviors; occurrence of assault; and depressive symptoms.
Logistic regression analysis was used to develop adjusted odds ratios (OR)
and 95% confidence intervals for correlates of depressive symptomatology
for each racial or ethnic group. RESULTS: Twenty-one percent (68 of 321)
of whites, 28% (88 of 316) of blacks, and 29% (77 of 267) of Hispanics
reported moderate to severe depressive symptoms. White females with
moderate to severe depressive symptoms were more likely to report sexual
assault (OR = 3.1); being a high school dropout (OR = 2.6); unemployment
(OR = 2.4); two or more episodes of binge drinking (OR = 2.1); and having
a mother with less than a high school education (OR = 2.4). Black females
with depressive symptoms were more likely to report smoking one to nine
cigarettes per day (OR = 3.5); sexual assault (OR = 3.2); and unemployment
(OR = 2.1). Hispanic females with depressive symptoms were more likely to
report adolescent age (OR = 3.5); physical assault (OR = 3.2); and smoking
one or more cigarettes per day (OR = 2.4). CONCLUSION: Twenty to 25% of
young women, regardless of race or ethnicity, have moderate to severe
depressive symptoms, and behavioral markers vary according to ethnicity.