An add-back regimen of estrogen-progestin in addition to gonadotropin-releasing hormone agonist has been reported. If replicated, it may have potential for an effective, long-term treatment for premenstrual syndrome.
From The American College of Obstetricians and Gynecologists. Committee opinion. Washington, DC: ACOG, 1995, with permission.
There is no convincing evidence that induced abortion causes clinical depression or any other negative psychiatric sequelae. Studies purporting to demonstrate negative sequelae fail to take into account the circumstances under which women conceive unintended pregnancies and elect to terminate them—abuse, abandonment, poverty, rape, and incest—or the circumstances in which they occur—familial pressure or disapproval, the presence of clinic demonstrators (70).
The incidence of depression in women during their reproductive years is approximately 10%. The incidence of depression does not decrease during pregnancy; most postpartum depression is a continuation of antepartum depression (71–73). Although there are some cross-cultural variations under study, postpartum depression is found around the globe (74). Risk factors include social isolation, lack of social supports, history of depression, and past or present victimization (75). It is important to remember that women without risk factors may become depressed. Postpartum depression must be distinguished from the transitory, self-limited, and very common “baby blues,” which are associated with changes in hormone levels and are better characterized as mood intensity and lability rather than depression. Mild depression can be managed with psychotherapy (76). Moderate to severe cases often require antidepressant medications (77). Electroconvulsive treatment acts rapidly and effectively, appears to be safe during and after pregnancy, and can be a life-saving option for the most severe cases (78). Treatment with artificial light may alleviate milder symptoms (79). Although no agent can be declared perfectly safe for use during pregnancy and lactation, older SSRI agents are well studied, yielding little or no evidence of adverse effects on the fetus or nursing infant (80–82). These agents are used in the treatment of obsessive-compulsive disorder (83).
Medication should not be stopped arbitrarily, nor should breastfeeding be prohibited. The withdrawal of antidepressant medication during pregnancy is very likely to result in postpartum depression; both antenatal and postnatal depression have demonstrable, long-term ill effects for mother and child (84–91). There is concern about withdrawal syndromes in neonates whose mothers took SSRIs (92). These concerns arise from anecdotal reports and do not include data about the number of births from which the reports emerged, nor about confounding variables. Some observers recommended that pregnant women be withdrawn from SSRIs some days or weeks before delivery. However, delivery dates are often uncertain; maternal withdrawal might subject the fetus, rather than the newborn, to withdrawal symptoms; and the likelihood of postpartum depression, with its effects on both mother and infant, would be greatly increased. Researchers are exploring ways to prevent postpartum depression, but thus far nothing has proved effective (93,94).
Sertraline appears to be the safest medication for pregnant and lactating women, and paroxetine is the cause of most concern. If treatment is begun during pregnancy or lactation sertraline is the reasonable choice. Switching a patient successfully treated with another antidepressant to sertraline is not indicated. The fetus would be exposed to a second medication, and the patient may not respond as well to sertraline as to the currently effective antidepressant (80–82).
Hysterectomy Studies of the relationship between hysterectomy and mental illnesses are contradictory (95,96). Probably the determining factors in psychiatric outcomes are the reason for the procedure and the context, whether the patient loses valued fertility as a result, including the reactions of significant others and cultural beliefs about the importance of an intact uterus (97).