June 2010-Postpartum Depression
The American College of Obstetrics and Gynecology has made this month Post Partum Depression Awareness Month. Hardly a day goes by that one does not read about an act of violence committed and then pleaded innocent by way of post partum depression. This article will attempt to define and explain this condition yet leaving defense verdicts to lawyers and jurors. Many new mothers feel sadness, fear, anger and anxiety after having a baby. This is normal but must be distinguished from the “blues” to true post partum depression that affects 10% of new mothers. This condition lasts longer and is more intense than the blues and often requires counseling and treatment.
Many new mothers, after the exhilaration of successfully brought a newborn into the world, are surprised that they feel weak, alone and upset after birth. They do not understand why they feel depressed at this time. They feel depressed, anxious and upset and may cry for no reason, have trouble sleeping and eating, and question themselves about their ability to care for a baby. 70% of mothers have these feelings (the “blues”) and most go away after a few hours or a week. Some think that the profound drop in hormone levels after delivery is the cause but no one cause has been found.
There are women in whom this depression rises to longer time frames of sadness, anxiety and despair that they have trouble coping with daily tasks. They last longer than two weeks, normal function is impaired, she is not able to care for her baby or herself, appetite changes, pleasure is impossible, interest in the baby is lacking, panic attacks occur, she fears harming the baby, she has thoughts of self harm and thoughts of suicide. These symptoms are more common if the mother has had postpartum depression before, has a psychiatric illness or a recent stress. This is a severe mental illness and occurs in 1-3/1,000 births. As stated previously the profound drop in hormone levels after delivery can trigger depression just as hormone drops can trigger premenstrual tension. A decrease in thyroid hormone, common after delivery, can also cause mood swings, nervousness, fatigue, trouble sleeping, and tension. Just the fatigue of delivery and/or cesarean section can be a major reason for depression. Emotional aspects can affect self esteem especially if the pregnancy had been unplanned, the delivery is early, or there is a birth defect that makes adjustment harder. Feelings of loss are common, might lead to depression and can take many forms: loss of freedom by the sense of being trapped and tied down; loss of old identity; loss of slim figure and perception of loss of sex appeal. These factors are amplified if there is a loss of support from partner or family. The role of breast feeding must be taken into account as new mothers who stop or can’t breast feed frequently feel guilty and this leads to depression.
This article would not be complete without addressing some of the myths of motherhood: 1.) motherhood is instinctive: it is not, new mothers need to learn mothering skills that take time and patience and books and pediatric counseling.2.) The perfect baby: this child does not exist. Each baby has a distinct personality –some are easy and some are more difficult to care for. 3.) The perfect mother; for some this is a never ending goal but no mother is perfect and a balance must be struck between household duties, job, and mothering.
So, after delivery get plenty of rest and sleep when the baby sleeps, ask for help from family and friends, take special care of yourself and get out of the house, take a walk, meet with friends. Above all, spend time with your partner and talk out feelings. If the “blues” do not lessen in two weeks call your doctor as this may be a sign of depression. Be sure to be candid if you are afraid of hurting yourself or your baby. You might be referred to specialists to treat the depression through counseling and/or medication. It must be emphasized that a new mother needs to learn how to nurture herself and family and to take time for herself and family do only what is needed and let the rest go. Remember that the “blues” are normal but if they continue after about two weeks it is possible that true postpartum depression has set in and counseling and treatment should be sought.
May 2010-Treatment of Menopause
Last month I wrote of the signs and symptoms of menopause and promised to now write of the treatment. Women are bombarded by information from the television news shows, the print media, internet, and pharmaceutical advertisements as to what is correct and safe treatment during the menopause years. This article will serve as a guideline of what is scientifically proven and acceptable.
It must be remembered that the symptoms of menopause are from estrogen deprivation and to some extent lack of progesterone that is no longer being made by the ovaries. Hormone replacement therapy can be initiated at this time and is usually requested by the patient when hot flashes become intolerable and when mood changes threaten family peace. For women who still have a uterus progesterone must be given along with estrogen to prevent a dangerous buildup of the lining of the uterus that can rarely lead to uterine cancer. There are multiple regimens for how this is accomplished. The two hormones can be taken together in a pill or patch or estrogen taken on some days and progesterone on others. In addition to pills and patches, there are now estrogen creams and vaginal rings and even a spray that is applied to the forearm. The selection is totally the decision of the patient with information from her provider. Vaginal creams and tablets can eliminate vaginal dryness but do not work very well for systemic symptoms. It must be remembered, and I cannot emphasize it enough, that estrogen also prevents bone loss that leads to osteoporosis and the risk of disabling fractures. There has been much said and much worry about the risks of taking estrogen. For women with a uterus progesterone must be added to the estrogen use to prevent the small risk of uterine cancer. However, the use of the added progesterone can increase the risk of breast cancer in roughly one in ten thousand women. The progesterone might also cause bleeding to start again but usually only for a short time. As with all medications, the risks must be weighed against the benefits. For women without a uterus, estrogen alone is all that is necessary and there is no evidence that estrogen in hysterectomized women increases the risk of breast cancer.
There is another class of drugs for women who cannot take estrogens because they may be at risk of breast cancer or who cannot tolerate the side effects of hormone replacement therapy. These drugs are called SERMS (selective estrogen receptor modulators) and one brand is called Evista. They do help prevent bone loss and lower bad cholesterol while not raising good cholesterol. They might help reduce the risk of heart disease. However, they do nothing to prevent or ease the symptoms of hot flashes. I have mentioned in a previous article dedicated to osteoporosis treatment that there are other drugs that can slow down bone loss and even increase bone. These are the well advertised drugs: Boniva, Actonel, Fosamax, Reclast, Forteo, and Myacalcin nasal spray.
Recently, I attended two conferences that focused on nutrition—training that is sorely lacking in most medical schools. A low calorie , low cholesterol balanced diet that avoids sugars and flours, is high in calcium from sources such as broccoli, kale, salmon, and 2% dairy products is essential. We now recommend supplemental calcium of 1200 mgs a day in divided doses. Some of these preparations contain vitamin D. Without vitamin D, calcium cannot be absorbed. Milk provides vitamin D and vitamin D supplements of 1,000 mg daily can be taken also. Exercise, especially weight bearing exercise 30 minutes a day five days a week or two days of 45 minutes can not only reduce the waist line but increase muscle tone, lower cholesterol, and increase bone density.
Lastly, remember that menopause is a natural event that should not prevent enjoying life. A good diet and regular exercise are essential. Regular doctor visits that include pap smears, cholesterol screening, mammograms, colorectal cancer screening, glucose testing and flu vaccines are now an essential part of the wellness that leads to empowerment.
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