Archive for the ‘Women’s Issues’ Category

Women and Stress Disorders Overview

Between puberty and menopause women are twice as likely as men to be anxious or clinically depressed. This vulnerability has been found in multiple countries and ethnic groups and is not just due to socio cultural factors.
Differences in men and women are:
• Frequency of depression and anxiety
• Types of depression and anxiety
• Associated conditions
• Responses to stress
• Types of stress
• Duration and severity of symptoms
• Preferred medications
• Dosages of medications
• Role of hormones
Symptoms in women are especially prominent premenstrually, during pregnancy, post partum and perimenopausal. Dropping levels of estrogen cause symptoms in susceptible women. Menopause has not been found to be a period of increased risk for depression.
The role of hormones (estrogen, progesterone, DHEA, and testosterone)and brain transmitters (serotonin and GABA) have been extensively studied. All of these factors guide the treatment.
More than half of all adults will experience a significant stress disorder in their lifetime. Clinically depressed men and women are very likely to have other concurrent stress disorders. Women most commonly have anxiety and eating disorders. Men are more likely to have alcohol or substance abuse.
Women are three times as likely as men to have seasonal affective disorder. This is a common form of depression referred to as “atypical” because instead of the normal symptoms of depression, loss of appetite, weight decrease, inability to sleep and blunting of normal feelings, in atypical depression they tend to overeat, gain weight, sleep excessively, overreact emotionally, feel rejected, and may have a feeling of “leaden paralysis.” It is as though they have gone into a hibernation state. Since seasonal depression most likely occurs in the winter, there is probably an underlying adaptive mechanism that gets activated.
In general, women are more reactive to stress and are more stressed by problems associated with family and home. Men are more stressed by issues with work and finances. Men are also more likely to respond to stress by taking action, or increasing physical activity. Women tend to seek social support and are more likely to internalize conflict. This can cause women to develop physical symptoms of illness. These include low thyroid, chronic fatigue, irritable bowel, migraine, pain, interstitial cystitis, and fibromyalgia.
Women are more likely than men to seek help for their symptoms, but men are becoming more aware of the effects of stress on functioning and quality of life. There is an old TV ad where a mechanic holds up a can of engine additive for cars and says, “you can pay me now or you can pay me later.” In women as well as men the earlier the recognition of symptoms and the better the patient education and treatment, the less the suffering, long term complications and the higher the quality of life. The goal of complete remission of symptoms and return to full functioning can usually be achieved through collaboration between the patient and the PCP and/or psychiatrist.

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Gender Factors for Depression in Women

? Hormonal – menses, pregnancy, menopause
• Victimization – sexual abuse, assault, harassment in the workplace
• Unresolved loss issues-past abortions, miscarriages, or infertility
• More sensitive to stress and seasonal changes
• Demands of multiple roles
• More likely to have atypical symptoms such as appetite and sleep increases
• Internalizing coping skills

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Premenstrual Dysphoric Disorder (PMDD)

During the childbearing years, 3-5% of women experience physical and psychological symptoms that impair functioning. This is caused primarily by changes in hormone concentrations.
Symptoms of PMDD include the following:
• Depressed mood
• Anxiety
• Lability (sensitive, out of control)
• Irritability
• Decreased interest in usual activities
• Difficulty concentrating
• Marked lack of energy
• Marked change in appetite, or overeating/cravings
• Hypersomnia or insomnia
• Sense of being overwhelmed
• Breast tenderness, headaches
Symptoms must occur during the week before menses and remit a few days after the onset of the menses. Using a symptom tracking chart can aid as a guide for when medication would be beneficial in the cycle. Best meds for PMDD

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Post Partum Depression

10-15% of women experience depression following childbirth. PPD occurs during the first four weeks after delivery, but can emerge as much as 2 years after giving birth. The hormone fluctuations (especially the drop of estrogen and progesterone) is greater than any other time in the life cycle. This causes vulnerability to mood disorders.

Other factors that can lead to PPD are:
• Lack of social and partner support
• Stressful life events
• Previous depression
In addition to the normal symptoms of depression such as sadness, depressed mood, and lost of interest and pleasure, the following symptoms may be present:
• Overconcern for the baby
• Guilt, inadequacy, worthlessness, feeling like a failure as a mother
• Fear of losing control or “going crazy”
• Lack of interest in the baby
• Diminished libido
• Anxiety
• Obsessionality

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Perimenopause and the Roller Coaster Ride

Judith Reichman quotes a patient in her book as saying: “so am I perimenopausal, or has an alien taken over my body?” Perimenopause is a roller coaster ride of hormones. The hormone levels fluctuate erratically because of intermittent ovulation. Estrogen continues to decrease,
Perimenopause occurs in the 40’s to 50’s. The symptoms include changes in periods, hot flashes, night sweats, vaginal dryness, sleep disturbances, concentration problems, libido changes, and mood swings. Perimenopause is the period of transition from regular menstrual cycles to amenorrhea. Therefore, the symptoms which are experienced during the perimenopausal years have a relationship to the changing of the reproductive functioning. Perimenopausal women have a much higher incidence of depression.

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Medications approved for PMDD

SSRI medications approved for PMDD:
Sarafem (Prozac)
However, all of the other SSRI’s, (Paxil, Celexa, Lexapro) and Effexor XR are beneficial. They work by raising serotonin levels in the brain.

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The Hormone Connection


Thyroid – hormone that regulates activity level of every cell in the body. If thyroid is low, brain cell activity is low.

Estrogen – hormone that increases serotonin activity in the brain. If estrogen drops, serotonin activity drops, which can cause depression. Estrogen increases brain cell growth in areas that control mood and memory.

Testosterone – increases libido, and in the brain is converted to estrogen

Serotonin, norepinephrine, GABA and dopamine – brain cell transmitters. They are released by some cells to activate or inhibit adjacent cells. Serotonin regulates temperature, appetite, and sleep. Low serotonin can cause depressed mood and irritability. Norepinephrine increases arousal and activates muscles for fight or flight in an emergency. GABA is the brain’s natural tranquilizer. Dopamine increases to enable the pursuit of pleasure and well being.

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Therapy and Lifestyle Issues

Although medication can be very helpful in treatment of depression in women, it can’t make up for poor health habits. It is important to get 7 hours of good sleep each night, and 30 minutes of vigorous physical activity (preferably on a daily basis). It doesn’t have to be “exercise” it can be work or play. A good sex life has physical as well as emotional benefits.
Family/relationship problems that are not improving may benefit from counseling. Unresolved grief, feelings of helplessness, inability to control addictive behavior, sexual dysfunction, and suicidal thoughts that persist are some of the problems that can benefit from cognitive/behavioral treatment.
Cognitive therapy identifies negative thought patterns and teaches techniques to improve “self-talk.” Behavior therapy helps find better options for counterproductive behavior.

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Women's Issues: Did You Know?

? Depression is twice as common in women as in men
• Lifetime prevalence of depression in women is 21.3% and 12.7% in men
• 75% of depressed women that stop taking antidepressants during pregnancy relapse
• 50-80% of women experience some psychological or physical symptoms premenstrually
• Postpartum depression is more likely to happen in women who lack the support of a partner
• During perimenopause the risk of depression triples
• Depression is the main cause of disability in women
• Women are 3x’s more likely then men to become depressed in response to a stressful event
• 10-15% of mothers become depressed after the birth of a child
• In an unhappy marriage, the woman is 3x’s more likely to be depressed than the man
• Women tend to subordinate their own needs which can lead to depression
• Menopause is a time of decreased depression in women

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Women and Medication

Depression in women is more likely to be associated with anxiety. This is related to imbalances in the serotonin system, or hypersensitivity to changes in serotonin. In general, women do better on SSRI’s, Lexapro, Zoloft, Prozac, Celexa, Paxil and lower doses of Effexor XR. Women with pain, fatigue, or severe melancholic depression do better on antidepressants that also enhance norepinephrine. These include Effexor XR in higher doses, Cymbalta, and Remeron.
Premenstrual depression responds quicker than other forms of depression to medication. For PMDD, there are many advantages to using medication just for the last few days of the menstrual cycle and not during the entire month. The advantages include protection against long term weight gain, sluggishness, and decreased libido.
Rate of onset of medication effect is partly related to how much it gets tied to protein. Only the part not tied to protein crosses into the brain.
Protein binding of antidepressant medications:
Effexor XR-26%
Celexa, Wellbutrin XL, Remeron-80%
Prozac, Paxil, Cymbalta-96%
Since Effexor XR and Lexapro have much lower protein binding, they can be used in lower doses and closer to the time symptoms begin. In women with premenstrual exacerbation(PME), medication is usually taken every day but the dose may be increased premenstrually. Adding estrogen can frequently be helpful. Since oral forms of estradiol significantly increase protein binding this can cause problems with decrease in estradiol, thyroid, and testosterone activity. Non oral forms of estrogen and conjugated forms of estrogen (Premarin, Cenestin) are less likely to increase protein binding.
Alprazolam, by enhancing GABA, helps premenstrual anxiety that is partly due to dropping progesterone. Progesterone increases GABA activity and this effect is lost premenstrually.
Side effects associated with SSRI’s that are short term include:
• Nausea
• Jitteriness
• Headache
• Sluggishness
• Dizziness
• Delayed orgasm

The short-term side effects usually go away in a few days, but if bothersome can be managed by changing the time medication is taken, taking after sex if delayed orgasm, splitting dose to lower peak levels, or decreasing the dose. Some side effects can be blocked with Trazodone. Wellbutrin XL can help with sexual side effects. Ginger is used to help alleviate nausea.
Long term side effects include “poop out,” sluggishness, loss of libido, and weight gain.

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