12 Psychiatry of menstruation and pregnancy

Introduction

Psychiatric disorders are more common in women. Genetic, social and cultural theories have been put forward to explain these findings. Table 12.1 shows psychiatric disorders for which the prevalence is different between men and women. The lifetime risk of developing bipolar mood disorder or schizophrenia is, however, equal in males and females.

Table 12.1 Psychiatric disorders more common in men or women

More common in men	More common in women
Alcoholism (eight times)	Senile dementia
Mental retardation	Dysthymia
Criminal behaviour, especially violence	Unipolar psychotic depression
Completed suicide	Anxiety and phobic disorders
	Dissociative (conversion) disorders
	Anorexia nervosa (nine times)
	Bulimia nervosa
	Deliberate self-harm

Premenstrual syndrome (PMS) (late luteal-phase dysphoric disorder)

PMS consists of emotional, physical and behavioural symptoms, which occur regularly during the second half of each menstrual cycle (i.e. between ovulation and menstruation), subside during menstruation and are completely absent between menstruation and ovulation.

Epidemiology

Most women experience some premenstrual symptoms, but of these only 20–40% consider them severe enough to seek medical help. For about 6% these symptoms are considered incapacitating. The syndrome does not improve with age or parity. Although PMS is found more often in those with other psychiatric disorders, it may be that these sensitize such women to the additional premenstrual changes.

Clinical features

Over 150 symptoms of PMS have been described. Among the most common are psychological symptoms such as tension, irritability, depression, fatigue and poor concentration. Physical symptoms are shown in Figure 12.1.

Figure 12.1 • Physical symptoms of premenstrual tension.

During the premenstrual period there is an increase in parasuicidal acts, suicide, accidents, violent crimes, shoplifting and poor academic performance. Migraine and skin disorders worsen during this period. Mothers are also more likely to take their children to see their GP. Mental hospital admissions are increased premenstrually, suggesting that PMS exacerbates pre-existing psychiatric disorder.

Investigations and diagnosis

Diagnosis depends predominantly on confirming the timing of symptoms in relation to menstruation, i.e. symptoms begin in mid-cycle, they increase in number and severity to maximum intensity the day before the onset of menstruation, and this is followed by rapid and complete resolution of symptoms. The woman should be advised to keep a diary for at least two months of daily ratings of common menstrual cycle symptoms, using a standard symptom record chart (Figure 12.2) to help confirm the diagnosis.

Figure 12.2 • Symptom record diary for diagnosis of PMS.

(a) The diary consists of 30 such sheets. (b) Results of questionnaire illustrate that a great majority of women do notice some change in physical and psychological functioning premenstrually.

Differential diagnosis

There is at least a seven-day symptom-free phase after menstruation in PMS. This distinguishes PMS from merely premenstrual exacerbation of other psychiatric disorders, such as depressive disorder or panic disorder and physical disorders. In dysmenorrhoea (painful menstruation), the symptoms occur with menstruation, whereas in premenstrual syndrome the symptoms are worst premenstrually.

Aetiology

The exact cause of PMS is unknown and different factors may be important in the development of different symptoms. Genetic factors have been suggested, as there is an increased incidence in monozygotic compared to dizygotic twins. Psychological factors may also have a role. A correlation of PMS with neuroticism has been suggested.

Physiological factors have also been suggested. Luteal-phase changes in hormones are likely to be important, for example a relative deficiency of progesterone, or a rise in oestrogen levels. Alterations in the renin–angiotensin system resulting in excessive aldosterone secretion and fluid retention, pyridoxine deficiency and alterations in monoamine neurotransmitters with increased monoamine activity have also been suggested.

Management

For many no medical treatment is required, other than information giving, explanation of the development of symptoms and reassurance, including supportive psychotherapy. For those more severely affected, target symptoms should be identified and treated, for example with analgesics if the predominant symptoms are headache or pain, or evening primrose oil or danazol for cyclical breast pain.

Pyridoxine (vitamin B₆) may provide some benefit.

Where contraception is also required, the oral contraceptive pill, particularly a low-dose combination, may help.

Pregnancy

Recurrent miscarriages and infertility may be associated with neurotic or mood disorders, particularly given the importance attached to the fertility of women in society and its importance in a woman’s identity of herself. Women who have become pregnant are less likely to develop psychiatric disorder, commit suicide or be admitted to a psychiatric hospital than at other times. This is in spite of pregnancy being a major life event. Theories as to why this may be so include increasing levels of progesterone during pregnancy, which may be sedative and mildly euphoric, increasing tolerance levels, and the psychology of having something ‘good’ inside, which may subsequently contrast with the reality of having to look after a child.

However, up to two-thirds of pregnant women have some psychological symptoms, especially in the first and third trimesters, particularly anxiety but also irritability, lability of mood and depression. Excessive worries may develop about possible deformities in the child, stillbirth, and of pain and splitting open at delivery. Up to 10% of women do, however, become clinically depressed, particularly in the first trimester, and the risk is increased in those with a previous history of depression, abortion, unwanted pregnancy and marital conflict. Counselling, supportive psychotherapy and, on occasion, marital therapy may be required.

Hyperemesis gravidarum (bad morning sickness) is said to be more common and severe among those who are immature or whose pregnancy is unplanned, or who are denying pregnancy.

Postpartum psychiatric disorders

The postpartum period is a time of increased psychiatric disorder: in some studies an increase of up to 18 times has been found (Figures 12.3 and 12.4). Psychiatric disorders termed postpartum are usually taken to include those with an onset up to about 12 weeks following delivery, although other definitions vary from an onset of six weeks to up to one year post delivery. Psychoses are referred to as postpartum when onset is from six weeks up to one year post delivery. Psychoses in which onset is after six weeks have also been referred to as lactational psychoses. Clearly, the longer the period from delivery to onset, the less likely there is to be a direct relationship between the two. In the past, puerperal or lactational psychoses were seen as a specific, unitary psychiatric disorder. Nowadays, they are seen as a group of psychiatric illnesses, such as depressive disorder or schizophrenia, which can occur at other times. They are not classified separately in ICD-10 or DSM-IV-TR.