Post Partum Psychological disorders

Although pregnancy and childbirth are usually joyous times, for some women the experience is followed by significant emotional distress. Approximately 25% of women with previous postpartum mental disease have a recurrence after their next pregnancy. One-third of women with psychiatric illness during the postpartum period have a history of psychiatric disease.

The exact cause of most of the postpartum emotional changes is unknown, although suggested causes include changing hormone levels (as is seen with premenstrual changes), difficulty adjusting to a new lifestyle, and the stresses of parenthood.

Depression after childbirth has largely been divided into three categories:

1. Postpartum Blues
2. Postpartum Depression (ppd)
3. Postpartum Psychosis

Postpartum Blues

This transient state of heightened emotional reactivity can develop in 50-80% of women.

Onset is 2-14 days after childbirth, with peak being at about the 4th day and duration of less than 2 weeks.

Symptoms include:

• Mild insomnia
• Tearfulness
• Fatigue
• Poor concentration
• Depressed affect(emotion)

Treatment:

Blues generally require no intervention. Rest and social support contribute significantly to remission. However, postpartum blues do constitute a significant risk factor for subsequent depression during the postpartum period- in 20%

Postpartum Depression

Any depression developing within 12 months following childbirth is considered to have postpartum onset. About 10-15% of postpartum women suffer from this.

Average duration is 3-14 months

To be diagnosed with ppd, one must exhibit 5 or more of the following symptoms, including one of the first 2, for most of the past 2 weeks:

• Depressed mood- tearfulness, hopelessness, feeling empty inside with or without severe anxiety
• Loss of pleasure in either all or almost all of daily activities
• Appetite and weight changes- usually a decrease in appetite and weight, but sometimes the opposite
• Sleep problems-trouble sleeping even when the baby is sleeping
• Noticeable change in how you walk and talk- restlessness but sometimes sluggishness
• Extreme fatigue or loss of energy
• Feelings of worthlessness or guilt with no reasonable cause
• Difficulty concentrating and making decisions
• Thoughts about death or suicide. Some women with ppd have fleeting, frightening thoughts of harming their babies. These thoughts tend to be fearful thoughts, rather than urges to harm

Treatment consists of :

• Antidepressant pharmacotherapy -The first line agent right now is Selective-serotonin reuptake inhibitors (SSRIs), although caution is necessary in breast feeding mothers.
• Psychotherapy- Cognitive-behavioral therapy and group therapy have had the most significant effects.
• Support groups nationwide

Postpartum Psychosis

This severe condition is most likely to affect women with bipolar disorder or a history of postpartum psychosis. Affects less than 2% of postpartum women

Symptoms, which usually develop during the first 3 postpartum weeks (as soon as 1 to 2 days after childbirth), include:

• 
  Feeling removed from your baby, other people, and your surroundings (depersonalization).
• 
  Disturbed sleep, even when your baby is sleeping.
• 
  Extremely confused and disorganized thinking, increasing your risk of harming yourself, your baby, or another person.
• 
  Drastically changing moods and bizarre behavior.
• 
  Extreme agitation or restlessness.
• 
  Unusual hallucinations*, often involving sight, smell, hearing, or touch.
• 
  Delusional* thinking that isn't based in reality.

Postpartum psychosis is considered an emergency requiring immediate medical treatment (Antipsychotic pharmacotherapy and antidepressants). If you have any psychotic symptoms, seek emergency help immediately. Until you tell your doctor and get treatment, you are at high risk of suddenly harming yourself or your baby.

*A hallucination is a perception of something that is not really there.

A hallucination can involve any of the senses: hearing, sight, smell, taste, or touch.
The most common hallucinations are seeing (visual) and hearing (auditory) things. For example, the person may hear voices or see an object that other people do not see.
Other types of hallucinations include tasting (gustatory), smelling (olfactory), or feeling (tactile) something that is not there.
Treatment for hallucinations depends on the cause.

*Delusions are firmly held but false beliefs. The most common delusion people have is that someone is trying to steal from them.

Technical difficulties

I appologize if my last post on the Reproductive cycle looked kinda weird. On my computer screen it looked fine. It was not until using my sister-in-law's computer that I realized that the words were getting bigger and bigger and wacky different fonts etc. I had to re-do the post and it looks better as of right now. Please let me know if it still looks strange.
Thanks
Dionne

The Female Reproductive Cycle- A Dynamic Monthly Undertaking

E2= estradiol LH=Luteinizing hormone P=progesterone FSH=Follicle Stimulating Hormone

Basically, the reproductive cycle is divided into three phases:

• 
  Menstruation and the follicular phase
• 
  Ovulation
• 
  Luteal phase

These three phases refer to the status of the ovary during the reproductive cycle.

Key Players:

• 
  GnRH-Gonadotropin releasing hormone- is released from the hypothalamus in a pulsatile fashion, stimulating the anterior pituitary gland to secrete LH and FSH accordingly.
  FSH- follicle stimuating hormone- secreted pulsatiley from the anterior pituitary. Stimulates cells in the ovaries called granulosa cells.In charge of developing and maturing follicles in the ovary, one of which will become dominant and detach from the egg during ovulation. The granulosa cells is where estradiol (estrogen) is made.
• 
  LH- Luteinizing hormone- secreted pulsatiley from the anterior pituitary. Stimulates cells in the ovaries called theca cells. The surge of LH at the middle of the cycle is what triggers ovulation. The theca cells surround the granulosa cells. They secrete androgens which serve as precursors for the estradiol production by the granulosa cells.
• 
  Estradiol - Secreted by the ovaries. In the female, estradiol acts as a growth hormone for tissue of the reproductive organs, supporting the lining of the vagina, the cervical glands, the endometrium and the lining of the fallopian tubes. It enhances growth of the myometrium ( the muscle of the uterus). Estradiol appears necessary to maintain oocytes in the ovary. During the menstrual cycle estradiol that is produced by the growing follicle triggers, the hypothalamic-pituitary events that lead to the LH surge, inducing ovulation. In the luteal phase estradiol, in conjunction with progesterone prepares the endometrium for implantation. During pregnancy, estradiol increases due to placental production.
• 
  Progesterone- Secreted by the ovaries. Progesterone is sometimes called the "hormone of pregnancy", and it has many roles relating to the development of the fetus: Progesterone converts the endometrium to its secretory stage to prepare the uterus for implantation. At the same time, progesterone affects the vaginal epithelium (epithelium is a tissue composed of cells that line the cavities and surfaces of structures throughout the body) and cervical mucus, making the mucus thick and impermeable to sperm. If pregnancy does not occur, progesterone levels will decrease, leading, in the human, to menstruation. Normal menstrual bleeding is progesterone withdrawal bleeding. During implantation and gestation, progesterone appears to decrease the maternal immune response to allow for the acceptance of the pregnancy. Progesterone decreases contractility of the uterine smooth muscle In addition progesterone inhibits lactation during pregnancy. The fall in progesterone levels following delivery is one of the triggers for milk production. A drop in progesterone levels is possibly one step that facilitates the onset of labor.

Phase I: Menstruation and the Follicular phase:

The first day of menstrual bleeding is considered day 1 of the menstrual cycle.

• 
  Menstruation marks the beginning of the follicular phase of the cycle.
• 
  The endometrium (innermost lining of the uterus) is sloughed off in response to withdrawal of progesterone
• 
  Development of a new follicle with renewal of the endometrial lining

At the beginning of menstruation, concentrations of estradiol, progesterone and LH reach their lowest point.
This causes the levels of FSH to increase because usually, higher levels of the above hormones, cause the pituitary gland to secrete less FSH.

So: FSH is increased at the beginning of menstruation. This increase begins about 2 days before onset of menstruatiuon and is involved in the maturation of another group of ovarian follicles with selection of a dominant follicle for ovulation in the next cycle. It also stimulates the granulosa cells which surround the individual egg (oocyte) to increase in number and secrete estradiol.

Estradiol begins to rise by day 4.

Stimulates LH receptors on theca cells to increase their secretion of androgen precursors even more, so that the granulosa cells can continue to make more estradiol. This increase in estradiol causes the pituitary gland to secrete less FSH and also tells the pituitary gland to secrete more LH

*** NOTE: as the follicles enlarge, they secrete both androgens and estrogens. However, if the estradiol:androgen ratio is less than 1, the follicle shrinks and never becomes dominant. The dominant follicle is the one that has follicular fluid estradiol:androgen ratio of more than 1

This is why the levels of FSH, estradiol, testosterone and LH, are checked around the 3rd day of the cycle when testing a woman's fertility status.

Phase II: Ovulation:

As the dominant follicle secretes more and more estradiol, there is more stimulation of the pituitary gland to secrete more and more LH.

by Day 11 to 13- LH surge occurs which triggers ovulation within 30-36hrs after that. The oocyte is expelled from the follicle and the follicle is converted into the corpus luteum to facilitate progesterone production during the remainder of the cycle.

*** it is this LH surge that is detected in home ovulation tests
A woman is most fertile within 24-48 hours after this LH surge.

Phase III: Luteal phase:

Characterized by a change in secretion of sex steriod hormones from estradiol predominance to progesterone predominance. Now that there is a lot of LH, that LH stimulates the granulosa cells and theca cells to produce progesterone now, instead of estradiol. Production of progesterone begins about 24hrs before ovulation and rises rapidly thereafter, with max production 3 to4 days after ovulation and is maintained for about 11 days post ovulation. If fertilization and implantation do not occur, progesterone diminshes rapidly, initiating the events leading to the beginning of a new cycle.

**** adequate progesterone is necessary to facilitate implantation of the fertilized oocyte into the endometrium and to sustain pregnancy into the early first trimester

If initial rise in FSH is inadequate and if the LH surge does not achieve max amplitude, an "inadequate luteal phase" can occur, resulting in progesterone production that is inadequate to facilitate implantation of a fertilized oocyte or to sustain pregnancy.

Corpus Luteum

measures about 2.5cm wide and has a characteristic deep yellow color. As it fails, it decreases in volume and loses its yellow color. After a few months, it becomes a white fibrous streak within the ovary and is called the corpus albicans Has a fixed life span of 13-14 days unless pregnancy occurs. If oocyte is fertilized and implants within the endometrium, the early pregnancy begins secreting hCG- human chorionic gonadotropin, which sustains the corpus luteum for another 6-7wks.
*** hCG is the hormone that home pregnancy tests look for

Progesterone causes the pituitary gland to decrease the secretion of both FSH and LH, so, during the luteal phase, both FSH and LH are suppressed to low levels.

As corpus luteum fails and progesterone secretion diminishes, FSH begins to rise to prepare a woman for the next reproductive cycle.

Note, that as all of these changes are occuring in the ovaries, drastic corresponding changes are occuring in the vagina, endometrium and cervix as well. These changes serve to facilitate either menstruation or fertilization and implantation depending on which stage of the cycle it is.

So:

• 
  Menstruation is governed by FSH and estradiol
• 
  Ovulation is governed by LH
• 
  Luteal phase/pregnancy is governed by progesterone

Obstetrics and Gynecology 5th edition, Charles R.B. Beckmann and co-authors.

Topics for conversation

THOUGHTS OPEN FOR DISCUSSION

While we see the practice of breast ironing and wonder how people could be so ignorant or misplace their good intentions the way that they do, I look at our "modern" society and wonder if we are also somewhat misguided in the way that we raise our young women.

So many times I have found the need to encourage women to be candid and open about educating their daughters about their bodies, because it is most often the lack of knowledge about how their bodies work that leads them to end up pregnant or with unwanted STDs etc.

Some things that I have observed are:

-Putting a taboo on female (and male) body parts

using nicknames because either the parent does not feel comfortable with saying the proper names or they don't want to hear their kids call it by its proper name.

-Making girls feel all the pressure about their role in getting pregnant while putting no restraints or restrictions on the activities of our boys

So many young men are completely uneducated about women and their bodies and end up having to rely on what their girlfriends say (about periods, mythical methods of not getting pregnant etc). Also, they are not taught to take ownership of the possibility of impregnation when choosing to have sexual intercourse, instead of leaving that up to the girl to control

-Parents who are not educated enough about how the body works to be able to therefore educate their kids.

This is one of my peeves. I believe that if a parent knows that the subject is over their head then it is their responsibility to read and figure it out before it is time to convey the information to their children. Not knowing is not good enough!

The people of Cameroon were frustrated about the increasing numbers of young women getting pregnant and as a result, failing to pursue an education. They chose to make their girls less attractive to men in hopes that they would be left alone. But:

What about educating the men, encouraging them to take some responsibility in the matter?

What about educating the women about abstinence, methods of birth control (there are free ways to prevent pregnancy)

What about encouraging the women to choose education over short term gratification?

What about looking for resources that will help mothers to still pursue their education?

This is another example of where education/knowledge can bring power. Power to the women over their own bodies and their own lives. Power to the community so that disfigurement does not have to be resorted to, and the female body can be celebrated instead of seen as a detractor or a curse.

How can we better educate our young women?
How can we better prepare them for puberty?
How can we teach them our ideals and morals while not over sheltering them from the realities?

Breast Ironing in Cameroon

In southern Cameroon, the practice of “breast ironing” affects an estimated quarter of the female population, or 4 million women and girls . It is a form of female body mutilation in which household objects such as rocks, spatulas, coconut shells, wooden pestles and unripe bananas are heated over a fire and then used to “iron” flat the breast tissue of pubescent girls.




Scholars and activists who have documented it agree that it is clearly a painful procedure to undergo. The long-term medical complications that can arise from breast ironing are troubling: breast cancer, infections, lesions, and permanent
damage to milk ducts.



The ironing is generally performed by girls’ mothers at the first sign of puberty, but occasionally girls do it to themselves. In sharp contrast to many forms of female body modification, this procedure is carried out specifically to make young women less attractive to men and boys.

Woman using a heated rock

to flatten the young girl's breast

In a country with high pregnancy rates due to lack of sexual
education, many mothers claim that making their daughters’ breasts less attractive to males helps to ensure that their daughters will avoid pregnancy and finish school. Some girls do it to themselves in this effort to secure an education free from male harassment.

Tools used in Breast Ironing

In 2005, representatives from Cameroon's local Aunties' associations formed the National Network of Aunties' Associations (RENATA), whose members themselves have undergone breast ironing. In 2006, the Aunties began a culturally-sensitive campaign to draw public attention to the hidden psychological trauma and other health risks of the practice.
RENATA has produced radio and television spots, and several radio and television journalists have joined in spreading information about breast ironing in local languages. Utilizing images common to Cameroonians, leaflets and calendars outlining the types of objects
used in breast ironing have also been produced. The United Nations Population Fund (UNFPA) concludes that the Aunties' approach utilizing media is transferable to other countries with traditions and contemporary situations not unlike those found in Cameroon. “This approach is a good example of capacity development in that it enables young women at risk of marginalization to connect and support each other, locally and nationwide, and to shape their own futures.”

The question that begs an answer in my mind is an anthropological one. All of central Africa suffers from the same maladies as Cameroon--teen pregnancy, poor education about health, lack of children's rights--but the practice hasn't been adopted elsewhere. Other harmful ceremonial
acts against women have spread throughout sub-Saharan Africa, such as female genital cutting, stoning, and trokosi, but not breast ironing. I don't ask why breast ironing is practiced in Cameroon. On the contrary, why isn't it practiced in neighboring countries? Interesting.

A piece written by Laine Strutton

Pictures imbedded by Dionne Mills

Adams, S. (2007). 'Aunties' for sexual and reproductive health: How
unwed young mothers become advocates, teachers and counsellors in
cameroon. German HIV Practice Collection (Deutsche Gesellschaft Fur
Technische Zusammenarbeit), (July), 35. Retrieved from
http://www.popline.org/docs/1763/319736.html

DeMello, M. (2007). Encyclopedia of body adornment. Westport, CT:
Greenwood Publishing Group.

Sa'ha, Randy Joe. (2006). "Cameroon Girls Battle Breast Ironing." BBC
World New, 23 June, 2006. See:
http://news.bbc.co.uk/2/hi/africa/5107360.stm

United Nation Population Fund (UNFPA). (2006). Breast ironing. New
York: United Nations. Retrieved from
http://www.unfpa.org/16days/documents /pl_breakironing_factsheet.doc

Polycystic Ovarian Syndrome

PCOS, also known as Stein Leventhal syndrome, is an endocrine(hormonal disorder) that affects 5-10% of females, with variation among races and ethnicities.
This syndrome can be diagnosed if at least 2 of the following conditions are present:

- Oligomenorrhea *or amenorrhea *

-hyperandrogenism* and

-polycystic ovaries on ultrasound.

Laboratory testing often reveals mildly elevated serum androgen (such as testosterone etc) levels, an increased ratio of luteinizing hormone to follicle stimulating hormone (LH:FSH), lipid abnormalities and insulin resistance.

PCOS is a constellation of problems. The body's endocrine system is all about checks, balances, and feedback. When one hormone is secreted abnormally, like a domino effect, other systems in the body are negatively affected.




Gonadotropin Releasing hormone (GnRH) is released by the hypothalamus ( ) in a pulsatile manner which causes the release of LH and FSH from the pituitary gland. In PCOS, there is an abnormal release of GnRH, causing LH to be released more than FSH in an erratic fashion. LH stimulates the ovaries to produce androgens (testosterone). Couple this with the lower levels of FSH, whose job is normally to stimulate the ovaries to take those androgens and convert it to the potent form of estrogen called estradiol, you now have a state in which there are too much androgens in the body (hyperandrogenism).

These increased androgens cause the follicles in the ovaries to shrink and also contribute to abnormalities in the lipid metabolism and distribution in the body as well as the development of acne and hursuitism- defined as the presence of coarse, dark, terminal hairs distributed in a male pattern, seen most commonly on the upper lip, chin, sideburns, chest and the midline of the lower abdomen.





Now, even though there is decreased estradiol, fat cells in the periphery of the body can take those androgens and convert them to another form of estrogen called estrone. This constantly feeds back to the hypothalamus and pituitary gland (as opposed to cyclically) and causes problems there. That estrone also continuously stimulates the lining of your uterus, leading to endometrial hyperplasia, which can predisopse you to endometrial cancer and other health problems in the future.

Another problem with PCOS is the issue of insulin resistance. Insulin is the hormone that allows glucose to get into the body's cells. Insulin resistance is defined as a reduced glucose response to a given amount of insulin. The mechanism of this decreased sensitivity to insulin appears to be due to an abnormality in one of the insulin receptors. Both lean and obese women with PCOS are found to be more insulin resistant than non-PCOS counterparts of the same weight.

Insulin resistance has been associated with an increase in several disorders including type 2 diabetes mellitus, hypertension, dyslipidemia*, and cardiovascular disease. Therefore, PCOS is not simply a disorder of short-term consequences such as irregular periods and hirsutism, but also one of long-term heath consequences

Short-term consequences
1. Irregular menses
2. Hirsutism/acne/androgenic alopecia
3. Infertility
4. Obesity
5. Metabolic disturbances
6. Abnormal lipid levels/glucose intolerance

Long-term consequences
1. Diabetes mellitus
2. Cardiovascular disease
3. Endometrial cancer

During a normal menstrual cycle, the various hormones listed go through cycles - rising and falling at certain times. In PCOS however, they tend to remain at a constant level throughout the cycle.

A follicle swells but does not release an egg, so it becomes a cyst. The cells surrounding the cyst release weak levels of testosterone, which the body converts into estrogen ( in the form of estrone). The brain senses the high levels of estrogen present and therefore assumes that the ovaries are functioning normally and a ripe egg is ready to be released. The secretion of FSH is cut back and the LH is sent out. LH usually triggers the ripened egg to break away ready for impregnation, but as there is in fact no egg, the follicle forms a cyst and the process is repeated cycle after cycle and the problem gets worse.

In short - polycystic ovaries are where follicles have matured in the ovaries but are never released due to abnormal hormone balance.
What are the symptoms?

Each woman with PCOS will have varying symptoms and though there is a particular set of dignostic symptoms, each case should be looked at separately.

Some of the symptoms are:
-Acne
-Irregular or absent periods
-Numerous cysts on the ovaries
-Hirsutism
-Obesity
-Infertility or reduced fertility
-Hair loss (androgenic alopecia - similar to male pattern baldness)
-High Blood Pressure
-Elevated Insulin levels, diabetes or insulin resistance.

There are some techniques that your doctor can employ to keep this chronic disease under control. PCOS has been shown to be amenable to ovulation inducing drugs (such as Clomiphene), for patients that want to become pregnant, as well as diabetic medications (such as Metformin).

Since women with PCOS can present with a number of combinations of symptoms, it is important to be patient with your physician since most of these symptoms could be independant or part of many other conditions. However, if you feel as though your symptoms could be explained by PCOS, encourage your doctor to investigate it further and at least attempt to rule it out.

Be an advocate for your health. Knowing is the first step.

* Oligomenorrhea is the medical term for infrequent uterine bleeding episodes with intervals of more than 35 days

*Amenorrhea is the absence of a menstrual period in a woman of reproductive age

*Hyperandrogenism is a medical condition characterized by excessive production and/or secretion of androgens

Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG, "Chapter 17. Polycystic Ovarian Syndrome and Hyperandrogenism" (Chapter). Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG: Williams Gynecology: http://www.accessmedicine.com/content.aspx?aID=3157034.

Pasted from <http://www.accessmedicine.com/citepopup.aspx?aid=3157034&citeType=1>

Tzadik Mor, Purcell Karen, Wheeler James E, "Chapter 40. Benign Disorders of the Ovaries & Oviducts" (Chapter). DeCherney AH, Nathan L: CURRENT Diagnosis & Treatment Obstetrics & Gynecology, 10th Edition: http://www.accessmedicine.com/content.aspx?aID=2389603.

Pasted from <http://www.accessmedicine.com/citepopup.aspx?aid=2389603&citeType=1>