00:00:17
Speaker 1: Pushkin.
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Speaker 2: This show is not a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes. Please consult your healthcare professional with any medical questions. Also in this show, we use women as shorthand for people with XX chromosomes. We understand sex and gender are more complex and acknowledge the experiences we describe reach beyond that word.
00:00:55
Speaker 1: There are pivotal moments in a woman's life, pregnancy, postpartum, perimenopause that can quietly and sometimes dramatically reshape our mental health. Yet for decades, the intersection of reproductive health, health and psychiatric care has been underfunded, under researched, and often ignored. That's where the field of reproductive psychiatry comes in. It's a specialized discipline focused on how hormonal changes across a woman's life influence her emotional and psychologic well being, and it's a field that is finally getting the attention it deserves. Doctor Rudo Nonas has spent her career at the forefront of women's mental health. She's a psychiatrist at Massachusetts General Hospital and a faculty member at Harvard Medical School. She's also an editor in chief of the Perinatal Information Resource Center at mass General Center for Women's Mental Health, one of the most respected resources in the world for clinicians and patients navigating psychiatric care during the reproductive years. I had so many questions for doctor Nonas, but first I wanted to hear about her professional journey to this important work. How did you choose this as your life's work and what was your path to reproductive psychiatry.
00:02:23
Speaker 3: I was really taken by the fact that there were so many women that I was seeing that had really lousy or no information on the use of medications to treat their disorders. And this was specifically during pregnancy, but I was also practicing around the time of the Women's Health Initiative when there was a lot of questions about the use of menopausal hormone therapy and a lot of women were suddenly coming off their treatments, so there was a lot of depression and anxiety that was emerging in that setting. These were high functioning women who were incredibly vulnerable due to the lack of information, and it was really remarkable and satisfying how much of a difference you could make just by supplying accurate And.
00:03:12
Speaker 1: Why do women come to see you and what are you specifically advising them on.
00:03:17
Speaker 3: There's a couple of reasons women will come to see me or other reproductive psychiatrists, and probably the most common is that they are considering pregnancy and might be taking some type of medication for the treatment of depression or anxiety or bipolar disorder, and they want to know what's safe to use during pregnancy. We also treat a lot of women with postpartum mood and anxiety disorders. And the other big population that we see are menopausal women who have had mood and anxiety disorders as they transition into the menopause. And we're not usually the first person they come to. They often will see a couple of other treaters, whether it's their PCP or another general psychiatrists who maybe doesn't know what the best treatments for these disorders are. It's a big niche, but it is a specialty field.
00:04:11
Speaker 1: I'd like to jump into PMS because so many women suffer from PMS and PMDD. Can you tell us a little bit about what PMS is and what PMDD is and explain the difference between the two and for our listeners, PMDD is pre menstrual dysphoric disorder.
00:04:31
Speaker 3: So PMS, or pre menstrual syndrome or pre menstrual symptoms are the symptoms women will experience during the luteal phase of their menstrual cycle, and that's the two weeks before they get their period. And for most women, these are physical symptoms that can be cramping, bloating, headache, but for a subset of women, there will be more mood and anxiety symptoms that occur during this phase, and if those symptoms are very severe and cause disruption of functioning, that women may have pre menstrual dysphoric disorders. So there's some core symptoms that go along with that, market irritability, a lot of mood swayings. Some women have just more depression sadness, others have more anxiety or feeling out of control. But those symptoms occur during the last couple of weeks of the cycle and then they disappear when women get their period. And about eighty percent of women have some pre menstrual symptoms, but only three to five percent have what is classic pre menstrual dysphoric disorder PMDD, and there's a lot of people in between. So there's women who maybe don't meet all of the criteria of PMDD, but they have clear mood symptoms that occur during the pre menstrual phase. So about twenty percent of women will have something that merits some type of intervention, although it might not be specifically PMDD.
00:06:03
Speaker 1: And will you talk about mood symptoms or mood issues? Is it anxiety, irritability, depression, what are you referring to or is it a common nation of all of them?
00:06:12
Speaker 3: It's often all of the above. But I think what's really interesting about some of these hormonally mediated disorders, especially PMDD, is that irritability is such a market symptom, and it often presents within the context of social relationships, so it's not usually a deterred professionally, but it can cause a lot of conflict in the relationships at home. You know, depression occurs, but it's more manageable, perhaps than irritability. And also mood swings, so a lot of people use the term very generally, but when I ask a woman about mood swings, it's so determined by outside events. They're very sensitive to either interpersonal relationships or things going on in their environment. So it feels kind of like you don't have any sort of stable platform. If things are going good, you feel okay, But as soon as things take it down toward your mood really deteriorates.
00:07:09
Speaker 1: Is it normal from women in the luteal phase to feel a little more reactive or is this not a normal thing.
00:07:18
Speaker 3: That's a great question, but it's also a matter of degree. And I think if you or a woman sees that these symptoms are interfering, then it's worth mentioning. But I think many of us will have mood shifts during the course of the menstrual cycle. And also there are things that influence mood which are sleep. So sometimes if sleep gets disrupted because of the menstrual cycle, or there's a lot of pain and physical discomfort, that can have a negative impact on mood, But it might not be reaching an issue where it's causing problems with relationships or other elements of functioning.
00:07:58
Speaker 1: Sleep in the luteal phase or in the second half of the menstrual cycle disrupted.
00:08:03
Speaker 3: Usually it can go both ways. Some women sleep more and some women have a problem sleeping. I don't think that there's a lot of consistency there in terms of PMS and PMDD. Is it usually the two weeks before the period, or one week before the period, or ten days, So it definitely has to occur before the period starts. But there are some women who have a couple days of symptoms, and in very severe cases, some women might know as soon as they ovulate that there's a shift in mood, so that could be like two weeks of symptoms. And in terms of when they stop, some women stop a couple days into the cycle, and other women can tell that they're going to get their period that day they start to feel better and they know their period's going to come later on in the day because their symptoms start to lighten.
00:08:54
Speaker 1: Oh that's interesting, So the symptoms start to lighten before they actually bleed you actually have the period. Are women being screened do you find by their general practitioners or their gynecologists for PMS and PMDD. Do you find that that's on their radar screen?
00:09:09
Speaker 3: I don't think people are typically screened for it. Maybe within a GYN setting, but I think there are so many things to screen for that they probably get a general depression screen. But I don't know if people are regularly asking, you know, do you have any mood changes that are associated with a menstrual cycle. And similarly, you know, we're not screening for perimenopausal depression either, so those seem very nuanced and perhaps neglected in a general setting.
00:09:40
Speaker 1: You talk about a general depression screening score tool, does one exist for PMS and PMDD, like for postpartum depression or for depression not.
00:09:50
Speaker 3: In the same way. I think there's some short tools that can be used, but they're not terrific. So the gold standard is really daily tracking, where you're measuring these symptoms on a daily basis and correlating them with when your period starts and ends. There are some online apps that help track your symptoms, and I think those can be really helpful because they generate sort of a layout of your symptoms that you can bring to your doctor and say, look, you know, my symptoms get better as soon as I have my period, and then after I ovulate they get worse. So I think that documentation that can be helpful. But I think again, as in many of these cases, women often have to educate and advocate for themselves.
00:10:36
Speaker 1: So we often hear that PMS and PMDD get worse at midlife or in the perimenopausal transition. Is that true or is that just kind of perimenopausal mood shifts and changes. On top of PMS mood changes.
00:10:50
Speaker 3: There's a couple of different patterns we see Occasionally. I see women who have their first onset of premenstual symptoms as they're transitioning into the perimenopause, so they haven't really had any basomotor symptoms, but suddenly their periods are maybe a little bit changed in cyclicity, but they're having man I need more mood symptoms, and the mood symptoms seem to be correlated with their cycles. The other patterns we see is that maybe women with a history of a moot or anxiety disorder notice that their symptoms are getting worse pre menstrally as they age. So normally their symptoms were fairly well controlled with whatever they were doing, whether it was therapy or medications, and now they're seeing this bump up in pre menstrual symptoms. So I think as the hormodal shifts become more dramatic, so can the pre menstrual symptoms. And just to summarize, you can have new onset of pre menstrual symptoms or dysphoric disorder as well as exacerbation of an existing problem.
00:11:57
Speaker 1: Yeah, it's interesting because you'll see patients sometimes it will come to us saying, my SSR has been working for years and all of a sudden it's not working and people are flipping around the SSRIs and it's like it's kind of maybe perimenopause, right, So I always tell people when something's not working any more, look at your hormones. Also, are there any other ages where PMS and PMDD are worse? We talked about midlife that we hear many many women complain saying that my PMS is worse. Any other times in a woman's life where we see worsening a PMS or PMDD.
00:12:27
Speaker 3: PMS and PMDD often appear later than people think, so women who are younger can have anovulatory cycles and might not have the full blown PMS PMDD when they start menstruating, but it can emerge during the twenties. And then the other time where we see it is sometimes postpartum, So women who have had their hormone functioning suppressed because they've been pregnant or nursing can have pre menstrual symptoms as they transition back into regular cycles, and so you can have postpart of depression that looks like PMS or PMDD.
00:13:07
Speaker 1: What is the connection between PMDD postpartum depression and significant mood issues or fluctuations at the time of perimenopause. Are women who have PMDD postpartum depression more risk of having mood issues at perimenopause.
00:13:26
Speaker 3: So there's a group of women, it seems, that are more vulnerable to the hormonal fluctuations that take place either during the menstrual cycle, during pregnancy, in the postpartum or at the time of transitioning into the perimenopause. And so some women with PMDD do well during pregnancy but are at increased risk of postpartum depression, and that same group of women are also at increased risk of perimenopausal depression as well. It's not an absolute one to one, so we definitely see women who have PMDD who do fine at other times. But it does seem that there's probably some genetic underpinnings of this increased sensitivity, and I think with that group of women you also see at least this is what I see clinically, is that there's a family history, so it really suggests that there's some genetic vulnerability to hormonal changes.
00:14:22
Speaker 1: One topic in terms of women's hormonal health and where it intersects with their mood that we haven't spoken about is PMOS or polyendocrine metabolic obarian syndrome. I still can't say that we just recently changed the name from PCOS, which was so much easier to say. Do women with PMOS have more mood disorders and elevated androgen levels with like such as dagas and testosterone related to mood disruption at all?
00:14:54
Speaker 3: So if you look at all women with PMOS or what used to be called PCOS, there is a higher risk of both major depression and bipolar disorder. Interestingly, you know that said I think whatever fits into this PMOS category is on a spectrum, and there are so many different flavors of this disorder that I don't know who's more vulnerable and who's not. But I would say, if there's evidence, one should screen regularly for mood and anxiety disorders. And I don't think treatment for a psychiatric disorder makes the endocrine symptoms better, but treating the endocrine symptoms makes the mood and anxiety symptoms better, so it's worth looking at the whole package.
00:15:47
Speaker 1: When should a woman seek medical help or support? When should she really reach out to say something's really wrong here.
00:15:55
Speaker 3: The short answer is, if you feel like there's a problem, you know, don't suffer alone. Talk to someone, but to give some guidelines around it. Because I think women are great at sort of tolerating a lot of symptoms and not asking for help. I would say that if you feel your symptom are causing you to avoid situations, like you know it's going to be a bad time, and you're not going to do something because the symptoms might interfere with your enjoyment or might make it difficult to interact with others. I think if you also find that there's an increased irritability, sensitivity to your partner, your kids, that you know, when you are two weeks ahead of it, you're like, why did I get so bent out of shape about that one particular issue like dribbling coffee onto the counter. Those would be some signs that maybe it's time to ask for help. Also, I think pretty dramatic changes in sleep. If you're having a really hard time sleeping, that's a good sign that there's something going on that deserves some attention.
00:17:02
Speaker 1: Coming up. Doctor Nonax explains how the hormonal shifts during perimenopause can trigger a worsen anxiety and deprise. Plus we discussed options for treatment for women with pre existing psychiatric conditions.
00:17:30
Speaker 2: Let's talk a.
00:17:31
Speaker 1: Little bit about just mental health and psychiatric issues at midlife. You know, there was recently in recent means a few years ago, right, some publications that people finally began to publish on depression can get worse at midlife, or bipolar issues or psychoses can get worse at midlife. Can you tell us a little bit about that For women who have diagnosed psychiatric issues before midlife and as they enter midlife, what should they be cautious about.
00:18:03
Speaker 3: Yeah, that's a great question that doesn't get enough attention. It's really sort of the menopausal transition where you have so many things that come together, including hormonal changes which can lead to physical symptoms which can lead to sleep deprivation. So I think all of these things can contribute to increased vulnerability to mood and anxiety disorders. And so the most common presentation would be either new onset of depressive symptoms or worsening of depressive symptoms. And with women, when I say depression, depression often comes along with anxiety and sometimes anxiety can be the leading edge of depression. So women might find themselves sort of worrying about things, not being able to sleep, and then eventually it morphs into more of a depressive picture where they're really not enjoying themselves. They feel defeated, they feel like they can't get out of this hole. And I think if you push on anybody hard enough, they can suffer from depression. There's a lot of stresses that go on with a perimenopause. You also have women, especially now in midlife, they're juggling caring for younger kids as well as caring for aging parents, as well as managing really the demands of a career at the height of those demands. So there's a lot of things that contribute. I think it can be really hard to disentangle the mix. And I think the other interesting thing is that you can see cognitive changes and mood changes even way before you start to see changes in the menstrual cycle. I think it's important to educate women about that and to say, you know, if you're not feeling so well, it might be perimenopause. And I think that's a new tack in terms of addressing midlife women. I think a lot of times these symptoms are ignored or underestimated, but they really can last a long time, and they can have significant impact on women. The other thing, a lot of women tolerate motor symptoms, irritability, sleep, disturbance, and I say, oh, it's just the perimenopause, but I think that can cause significant decreases in quality of life and can lead to mood and anxiety disorders. So even if you're not depressed, really attending to those uncomfortable symptoms is important. They might last only a couple of months, but they could last for a really long time and have a profound impact on one's life. For people who've listened to the show before, you may be familiar with my story that at forty three, I had just had a child a couple of years before at forty one, and it was really the perfect storm with perimenopause, anxiety, postpartum issues which actually turned into severe depression. But was able to function during the week.
00:20:57
Speaker 1: I was able to pull myself together, see my patients, operate at the top of my game, but then over the weekend.
00:21:04
Speaker 2: I would just totally crash.
00:21:05
Speaker 1: Covers would go over my head. I wouldn't get out of bed all week and long, and I'd just be there and it was so confusing, because was it postpartum issues? Was it PMS that's now turning into PMDD I'd always had some PMS? Or was a perimenopause? And I suppose it was probably a perfect storm of kind of all of them. But how do you begin to sort through this? I mean, it's very complicated, right.
00:21:28
Speaker 3: I think I start by saying, we're not exactly sure what the driving factors are. It could be you know this, it could be hormonal changes, it could be new onset of depression. There's a lot of stigma associated with mood and anxiety disorders, so sometimes it's helpful for a patient to think of this as a hormonal change. And on the other hand, I think if you put it too squarely in the perimenopause group, women feel that they can only take hormones to treat the symptoms, and the truth is there's really a wide array of treatments that can be used to target the symptoms. So I think what we're trying to do is sort of find out what the most distressing symptoms are. And often I'll start with sleep and try to get some good night sleep in there and see how does that impact mood, how does that impact functioning? And if depression remains, then we'll think about an antidepressant. I think how this particular scenario might be managed depends on whether you see a gyn, a PCP, or a psychiatrist, So there might be different agents that or medications that people are more comfortable with. It is challenging, and I think we have to be upfront with our patients and say, you know, it's not so clear, but many of the treatments overlap, and we'll treat all of those symptoms or some of those symptoms, and let's get you better and then we'll figure out what happened a little bit down the road and clean up your regimen.
00:23:05
Speaker 1: So how do you use estrogen and progesterone in your practice at the time of the perimenoposal tree position?
00:23:12
Speaker 3: So typically I do not prescribe them, but if I see a patient where I feel like the vasomotor symptoms and sleep disturbance seem to be the primary symptom, I might have them go back to their gy to talk about the use of hormone therapy. Many of the patients I see cannot take hormone therapy for whatever reason or don't want to, and we will try to treat depression and anxiety with antidepressants, typically the s SRIS and the s NRIs. You can also use other medications like gabapentin to treat vasomotor symptoms and sleep disturbance. So we'll try to treat the symptoms if someone isn't eligible for treatment with estrogen. If they are eligible for treatment with estrogen and we get some improvement with depression or anxiety, but they're still having vasomotor symptoms, or they're having a lot of depressionsmptoms that don't seem to resolve, then again I might have them go back to their gyn to consider if they're eligible for estrogen treatment.
00:24:21
Speaker 1: We see a lot of women who do have worsening of PMS at perimenopause. Right, just looking at PMS or maybe anxiety depression also, right, is that better treated with progesterone or estrogen or combination of both hormones?
00:24:37
Speaker 2: Is it more like.
00:24:38
Speaker 1: A GABBA related progesterone allopregnant alone issue or estrogen issue.
00:24:45
Speaker 3: Despite studying this for the long time, I'm really puzzled by how progesterone works. And it's various metabolites. So there is a medication that has been used for postpartum depression. The first one was rexan alone, the second one was zoranolone, and they're both derivatives of allopregnanolone, which is a metabolite of progesterone, and they seem to help with both mood and anxiety. But clinically we also know that when we give some progestins to women, whether they're synthetic or natural, they can cause depression. So I think it's something about the mix of metabolites that affect that affect mood and anxiety, whether it comes from perimenopause or pre menstrual symptoms. I think estrogen is more of a positive event. It is easier to use estrogen because it tends to be mood protective, mood stabilizing, not with all women, but with most women. But if women have a uterus, you need to use the progestines alongside, which I think can complicate the picture. So I've definitely seen women who do well on the estrogen and then you add some progestin to the mix and things deteriorate.
00:26:05
Speaker 1: Outside of midlife perimenopausal transitions, how do you treat PMDD and how do you help women who are refractory to standard treatments.
00:26:16
Speaker 3: There are some women who are refractory to standard treatments. Fortunately it's not that common, but we do see a lot of them because at our program, we see a lot of them because they've been referred from other outside treats. The first line treatment if you see a psychiatrist for PMDD, would be serotonin reactake inhibitor, and we typically use those every day of the month. Some women use it only during the luteal phase or the last two weeks of the cycle, but that would be our first stab at treatment. There are some women who use oral contraceptives to manage pre menstrual symptoms, and that sometimes works great. Sometimes it doesn't work. I think with oral contraceptives you have sort of a steady low level of estrogen, but during the placebo week you can have some symptoms because you're removing thatgen. So sometimes women don't tolerate those oral contraceptives. If those two treatments don't work, we try to figure out sort of what are the residual symptoms, is their sleep disturbance, anxiety, and then we might use some add on medications, and those add on medications would be nothing novel. There would be the medications we commonly use to treat depression or anxiety that's refractory to treatment. So sometimes the benzodiazepines, which are like clonipin or adavan, can be helpful. We also use some of the newer atypical antipsychotic medications like arapiprosol or abilify, which is advertised, so we're treating some of those residual symptoms. If that doesn't work, we will often go back to sort of shutting down the whole axis and use medications like lupron that just turn off the menstrual cycles, and that can be helpful, but unfortunately that's like menopause. You can have the problems associated with menopause, like hot flashes, and you can have cognitive problems. If it's a young woman, you can have bone loss. That treatment might be more effective, however, in someone who is about to go into the perimenopause, so it's not such a big deal if they go into menopause a year earlier, but you don't want to use that type of treatment in a younger woman.
00:28:45
Speaker 1: So let's go through the treatments and drill down on them just a little bit. Birth control pills. What's your favorite level of estrogen that you recommend in a birth control pill? Your favorite progestin that you recommend? Is there one that you recommend over another? Skip placebos pill pack to pill pack to stabilize the hormone levels. Can you get a little bit more specific for us with this.
00:29:06
Speaker 3: We always want to use the lowest dose possible because that decreases the risk of side effect, especially in younger women. I don't get into the doses. I usually leave that to the experts, but what I do recommend is using a monophasic preparation, so it's a single level of estrogen and a single level of progesterone, and I recommend using it continuously, so skipping the placebo weeks and going from pilt back to pilt back, and eventually someone has to have a period, but at least you can do it on your own schedule. There is some data to suggest that certain progesterones progestines are better for PMDD than others, and that would be drisperinone, which was originally marketed as part of yaz Or Yasmin and it's now included in a bunch of other types of oral contraceptives that are now generic, and I can't keep track of the names because they keep coming up with new ones, but those would be my initial approaches. And in older women, we might use a transdermal estrogen because I think there's lower risk of side effects, and you know, you can limit the amount of progesterone they're exposed to by using it only intermittently for.
00:30:26
Speaker 1: The uterus SSRIs. What's your favorite SSRI for PMS PMDD in younger women, And what's your favorite SSRI or pick your medication at the time of perimenopause for somebody who is experiencing mood disorders.
00:30:45
Speaker 3: So my favorite one is if a woman has a history of depression and she's taken one of those and has done well, that's what I put at the top of my list. Whether it's soloft or effects or whatever it is. If it worked for them, we go for that. If they have no history of using it, I tend to use kind of the middle of the road SSRIs, which have not too much sedation, not too much at devation, and are easy to use because you can hit the right dose on the first try. And those would be cytalopram and s cytalopram so Selexa and lexapro, and also fluoxetine prozac. I use those pretty much at any age. I think sexual side effects are a big deal in this patient population, so that can occur with any of the SSRIs. I also don't tend to use peroxetine a lot because it's the one that's most associated with weight gain and sexual side effects. It works for some people, but it has a pretty hefty side effect burden.
00:31:52
Speaker 1: Do you layer in well buttrin at all to help with the sexual side effects?
00:31:57
Speaker 3: Sometimes I do so well. Bututrin on its own isn't a good treatment for PMDD or pre menstrual symptoms, but it can be a little bit more activating. Sometimes it can help reduce sexual side effects, and sometimes it can help sort of older women who have some cognitive dulling. It can be a little bit activating and can help with concentration.
00:32:20
Speaker 1: Let's talk about shutting down the HPO axis with lupron and just having an individual having stable hormone levels or low estrogen levels. How effective is that is that?
00:32:32
Speaker 2: Does it?
00:32:32
Speaker 1: Do you find that that really works for women who are a refractory to other maneuvers.
00:32:40
Speaker 3: So yes, if someone has pure PMDD, it works. What we often find is that when you shut down the hormonal access, they continue to have symptoms. So is that a hormonal mood disorder or just a mood disorder? And sometimes the answer to that question can be very helpful because maybe we're sort of looking at all these treatments for PMDD, but what they really have is bipolar disorder or major depression that we need to treat more effectively. So it can be helpful with regard to treatment, but it can also be helpful with regard to diagnosis.
00:33:18
Speaker 1: Do add back estrogen for these women just to give them a stable level of estrogen, or add back estrogen plus progesterone if they tolerated.
00:33:26
Speaker 3: So, the original studies suppressed the HPO access with prime and then they tried to add back estrogen and women had recurrent mood symptoms. There was a follow up study which said that yes, they have recurrent mood symptoms, but if you're patient and have them on the estrogen at a low dose for a couple of cycles, these mood symptoms eventually vanish or become more manageable. So I think that would be from a medical standpoint, the best option because you're reducing the risk of estrogen withdrawal in a younger patient population. I do think the women who end up on these medications like lupron for PMDD have the worst symptoms and severe depression or mood dysregulation, and they don't love the estrogen add Back.
00:34:24
Speaker 1: Still to come. Doctor Nonax walks us through lifestyle choices to support women during their most productive and fruitful years. Back in a minute, Where does lifestyle fit into this? My favorite maneuver for my neurotransmitters is exercise and fitness and weightlifting. Everybody knows I think from this podcast now that I'm a big weightlifter and a big fan of movement and exercise, especially for mood. Where does that fit in with how you treat women in terms of nutrition and exercise.
00:35:05
Speaker 3: I think in addition to these options, or especially with women with pre menstrual symptoms, I think lifestyle modifications are really important and essential. There's good data for aerobic exercise. There's also some data about switching from simple carbohydrates to more complex carbohydrates that can be helpful. There's some data on using calcium and magnesium supplements. That can be helpful. I think avoiding alcohol, avoiding excessive caffeine or variable levels of caffeine can be really helpful. And sleep high gene is really like my number one important for whatever mood or anxiety disorder is just getting good sleep, and enough sleep can really do wonders. I probably should have mentioned all of those things upfront, but they're very important and hard. Aerobic exercise to the level you have to do it to get some of the mood benefits is a lot of work and a lot of time, and unfortunately we don't prioritize it.
00:36:12
Speaker 1: Talk to me a little bit about supplement support, vitext or any of herbal supplement recommendations at all that have any data behind them that you recommend.
00:36:20
Speaker 3: There's a little bit so chaste ferry does have evidence that it decreases the risk of pre menstrual symptoms in general. A lot of the studies on the supplements were done with women with milder symptoms and not necessarily PMDD, and Saint John's wart works a little bit like SSRI's. I don't think it's been studied extensively in PMDD, but that might be another sort of supplement to option but we also have to say with the supplements, they have medication interactions, they have side effects. It's not like all natural is all better or risk free.
00:37:00
Speaker 1: If a woman thinks that she is experiencing PMS and not really getting attention or PMDD, what are the best questions to ask her provider so that her provider recognizes or she helps her provider recognize what's going on so that she can start to move to get some treatment and some help. What should she review with her provider.
00:37:21
Speaker 3: I think the first thing to do as the patient is to be a scientist and to collect data. So I think daily charting of symptoms can be really helpful because you can demonstrate that there's changes in your mood depending on where you are in the cycle. And I think you can bring that information to your doctor and talk about you know, I think these symptoms are increasing during this phase, they have an impact on my functioning and what can we do about them? And if your primary care provider doesn't listen to you, there are obgins, you know, there are reproductive psychiatrists, but I think psychiatrists in general are better at talking about mood and anxieties symptoms and understanding how negative their impact can be on ones functioning and quality of life.
00:38:18
Speaker 1: Can you walk us through when a woman has PMS which is severe or PMDD. We've talked about the different treatments, but what is like your algorithm for treatment? What should she expect in terms of treatment options to be recommended to her, kind of in a layered manner or in a stepwise manner.
00:38:38
Speaker 3: There's a bifurcated treatment option tree. If you have a younger woman who's sexually active and who's interested in having some sort of contraception, it might be helpful to go down the oral contraceptive route. If you have a woman who doesn't want to take hormonal treatments or doesn't need contraception, you would go down the treatment route with SSRIs and SNRIs. That would be the first step.
00:39:11
Speaker 1: And then the periman apausal woman who just says everything is worse at perimenopause.
00:39:18
Speaker 3: I think it would be a similar bifurcated treatment option. If there were a lot of symptoms, both physical and psychiatric, I would probably start with hormone replacement if that was an option for them. The good thing about hormone replacement is it treats all of the symptoms.
00:39:39
Speaker 1: I love that you say this.
00:39:40
Speaker 2: I'm just glad you said this.
00:39:42
Speaker 3: You know, if it's just mood and anxiety or just PMS emerging in that, then you could go down SSRIs and SNRIZ. You know, there are a lot of women who don't want to take hormones. But I don't think we should cross it off the list if there are no medical contraindications, because it does address a lot of those symptoms during that transition. One of the things I do worry about is the current recommendations suggests limited timeframe, and this would require your feedback. What's going to happen to those women when we have to take away the estrogen and replacement therapy or are we going to put them in a worse position or will they have crossed through the perimenopause and will feel much better.
00:40:26
Speaker 1: I think we're moving past that. Actually, I think we're realizing with our transdermal preparations now. I think one of our big concerns was stroke risk as we age, and with our transdermal preparations now we know that if you keep the level of what we're dosing at reasonable, the stroke risk is not elevated. So I think kind of the newer recommendations are to stay on as long as you can unless you have obviously an estrogen dependent malignancy or have a medical issue that is a contraindication. But which actually leads me into my next question for women who have perimenopausal mood issues that once they transition through menopause, do all the mood issues go away or do they come back. I mean, I think you're alluding to that they'd have the potential to come back if they stop former and support and it's helpful to them.
00:41:12
Speaker 3: I think we don't fully know the answer to that question. If you look at epidemiologic studies, there's higher rates of depression and anxiety during the perimenopause, but their rates are still a little bit elevated during the postmenopause, so not everything goes away during the postmenopause. Estrogen makes people feel better physically. It's neuroprotective. So I'm sure you know, even if you had low stable estrogen levels that it has some benefit for people. And there's a reason that women were put on estrogen replacement and stayed on it till they died. It makes them feel good.
00:41:53
Speaker 1: Not to personalize everything, but for me it was my mother, who actually very astutely said twenty years ago, I think it's probably your estrogen and you should just take an estrogen patch and try it. And I did, and I actually you know, stopped, you know, sleeping all weekend and you know, came out from underneath the cover. It was so fascinating. Actually, no psychiatrists said it, no doctor said it. And I had trained in all the best institutions and I didn't think of that.
00:42:19
Speaker 3: I do hope we can have more of these cross disciplinary discussions and really centers where you have people who are facile and discussing hormone replacement therapy as well as anti depressants, so that you don't have to go to three different treats to find a solution to your problems.
00:42:46
Speaker 1: My conversation with doctor Nonas is an important reminder that women's mental health during hormonal transitions doesn't fit neatly into a single specialty. It takes a multi pronged approach, which includes doctors like doctor Nonas, who bring expertise, care, and compassion to how we care for women throughout their lives. If you're struggling with feeling overwhelmed, anxious, or down, remember that tracking your symptoms and sharing with your doctor might be a good place to start. A few things to note for PMS and PMDD, the approach splits along a simple line. Younger sexually active women interested in contraception often start with oral contraceptives, while those who don't need or want hormonal birth control typically start with a low dose SSRI. Regardless of your situation, it's important to address whatever symptoms you're having when they start interfering with your daily activities or your emotional wellbeing, or both. Also, when symptoms are primarily mood and anxiety related with fewer physical complaints, consider asking your doctor about the use of antidepressants, which have proven to be effective. The stakes can be higher when physical and psychiatric symptoms appear together. A strong first option for treatment for women and midlife is hormone support or MHT, since it generally treats all of the symptoms rather than just mood issues alone. And remember, if you're not getting the support that you require from your primary care doctor, seek additional help and consider seeing a board certified reproductive psychiatrist. Your mental health and well being matter. Decoding Women's health is a production of Pushkin Industries and the Atria Health and Research Institute. This episode was produced by Kalalia. It was edited by Amy Gaines McQuaid, mastering by Sarah Bugaire. Our associate producer is Sonia Gerwit. Our executive producer is Alexander Garaton. Our theme song was composed by Hannas Brown. Concept and cre active development by Shaban O'Connor. Special thanks to Vicky Merrick, Alan Tish, David Saltzman, doctor David Dodick, Sarah Nix, Jacob Goldstein, Leah Rose, Jordan McMillan, Morgan Ratner, Owen Miller, Eric Sandler, and Greta Cohne. I'm doctor Elizabeth Pointer. Thanks for listening and until next time.
Speaker 1: Pushkin.
00:00:24
Speaker 2: This show is not a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes. Please consult your healthcare professional with any medical questions. Also in this show, we use women as shorthand for people with XX chromosomes. We understand sex and gender are more complex and acknowledge the experiences we describe reach beyond that word.
00:00:55
Speaker 1: There are pivotal moments in a woman's life, pregnancy, postpartum, perimenopause that can quietly and sometimes dramatically reshape our mental health. Yet for decades, the intersection of reproductive health, health and psychiatric care has been underfunded, under researched, and often ignored. That's where the field of reproductive psychiatry comes in. It's a specialized discipline focused on how hormonal changes across a woman's life influence her emotional and psychologic well being, and it's a field that is finally getting the attention it deserves. Doctor Rudo Nonas has spent her career at the forefront of women's mental health. She's a psychiatrist at Massachusetts General Hospital and a faculty member at Harvard Medical School. She's also an editor in chief of the Perinatal Information Resource Center at mass General Center for Women's Mental Health, one of the most respected resources in the world for clinicians and patients navigating psychiatric care during the reproductive years. I had so many questions for doctor Nonas, but first I wanted to hear about her professional journey to this important work. How did you choose this as your life's work and what was your path to reproductive psychiatry.
00:02:23
Speaker 3: I was really taken by the fact that there were so many women that I was seeing that had really lousy or no information on the use of medications to treat their disorders. And this was specifically during pregnancy, but I was also practicing around the time of the Women's Health Initiative when there was a lot of questions about the use of menopausal hormone therapy and a lot of women were suddenly coming off their treatments, so there was a lot of depression and anxiety that was emerging in that setting. These were high functioning women who were incredibly vulnerable due to the lack of information, and it was really remarkable and satisfying how much of a difference you could make just by supplying accurate And.
00:03:12
Speaker 1: Why do women come to see you and what are you specifically advising them on.
00:03:17
Speaker 3: There's a couple of reasons women will come to see me or other reproductive psychiatrists, and probably the most common is that they are considering pregnancy and might be taking some type of medication for the treatment of depression or anxiety or bipolar disorder, and they want to know what's safe to use during pregnancy. We also treat a lot of women with postpartum mood and anxiety disorders. And the other big population that we see are menopausal women who have had mood and anxiety disorders as they transition into the menopause. And we're not usually the first person they come to. They often will see a couple of other treaters, whether it's their PCP or another general psychiatrists who maybe doesn't know what the best treatments for these disorders are. It's a big niche, but it is a specialty field.
00:04:11
Speaker 1: I'd like to jump into PMS because so many women suffer from PMS and PMDD. Can you tell us a little bit about what PMS is and what PMDD is and explain the difference between the two and for our listeners, PMDD is pre menstrual dysphoric disorder.
00:04:31
Speaker 3: So PMS, or pre menstrual syndrome or pre menstrual symptoms are the symptoms women will experience during the luteal phase of their menstrual cycle, and that's the two weeks before they get their period. And for most women, these are physical symptoms that can be cramping, bloating, headache, but for a subset of women, there will be more mood and anxiety symptoms that occur during this phase, and if those symptoms are very severe and cause disruption of functioning, that women may have pre menstrual dysphoric disorders. So there's some core symptoms that go along with that, market irritability, a lot of mood swayings. Some women have just more depression sadness, others have more anxiety or feeling out of control. But those symptoms occur during the last couple of weeks of the cycle and then they disappear when women get their period. And about eighty percent of women have some pre menstrual symptoms, but only three to five percent have what is classic pre menstrual dysphoric disorder PMDD, and there's a lot of people in between. So there's women who maybe don't meet all of the criteria of PMDD, but they have clear mood symptoms that occur during the pre menstrual phase. So about twenty percent of women will have something that merits some type of intervention, although it might not be specifically PMDD.
00:06:03
Speaker 1: And will you talk about mood symptoms or mood issues? Is it anxiety, irritability, depression, what are you referring to or is it a common nation of all of them?
00:06:12
Speaker 3: It's often all of the above. But I think what's really interesting about some of these hormonally mediated disorders, especially PMDD, is that irritability is such a market symptom, and it often presents within the context of social relationships, so it's not usually a deterred professionally, but it can cause a lot of conflict in the relationships at home. You know, depression occurs, but it's more manageable, perhaps than irritability. And also mood swings, so a lot of people use the term very generally, but when I ask a woman about mood swings, it's so determined by outside events. They're very sensitive to either interpersonal relationships or things going on in their environment. So it feels kind of like you don't have any sort of stable platform. If things are going good, you feel okay, But as soon as things take it down toward your mood really deteriorates.
00:07:09
Speaker 1: Is it normal from women in the luteal phase to feel a little more reactive or is this not a normal thing.
00:07:18
Speaker 3: That's a great question, but it's also a matter of degree. And I think if you or a woman sees that these symptoms are interfering, then it's worth mentioning. But I think many of us will have mood shifts during the course of the menstrual cycle. And also there are things that influence mood which are sleep. So sometimes if sleep gets disrupted because of the menstrual cycle, or there's a lot of pain and physical discomfort, that can have a negative impact on mood, But it might not be reaching an issue where it's causing problems with relationships or other elements of functioning.
00:07:58
Speaker 1: Sleep in the luteal phase or in the second half of the menstrual cycle disrupted.
00:08:03
Speaker 3: Usually it can go both ways. Some women sleep more and some women have a problem sleeping. I don't think that there's a lot of consistency there in terms of PMS and PMDD. Is it usually the two weeks before the period, or one week before the period, or ten days, So it definitely has to occur before the period starts. But there are some women who have a couple days of symptoms, and in very severe cases, some women might know as soon as they ovulate that there's a shift in mood, so that could be like two weeks of symptoms. And in terms of when they stop, some women stop a couple days into the cycle, and other women can tell that they're going to get their period that day they start to feel better and they know their period's going to come later on in the day because their symptoms start to lighten.
00:08:54
Speaker 1: Oh that's interesting, So the symptoms start to lighten before they actually bleed you actually have the period. Are women being screened do you find by their general practitioners or their gynecologists for PMS and PMDD. Do you find that that's on their radar screen?
00:09:09
Speaker 3: I don't think people are typically screened for it. Maybe within a GYN setting, but I think there are so many things to screen for that they probably get a general depression screen. But I don't know if people are regularly asking, you know, do you have any mood changes that are associated with a menstrual cycle. And similarly, you know, we're not screening for perimenopausal depression either, so those seem very nuanced and perhaps neglected in a general setting.
00:09:40
Speaker 1: You talk about a general depression screening score tool, does one exist for PMS and PMDD, like for postpartum depression or for depression not.
00:09:50
Speaker 3: In the same way. I think there's some short tools that can be used, but they're not terrific. So the gold standard is really daily tracking, where you're measuring these symptoms on a daily basis and correlating them with when your period starts and ends. There are some online apps that help track your symptoms, and I think those can be really helpful because they generate sort of a layout of your symptoms that you can bring to your doctor and say, look, you know, my symptoms get better as soon as I have my period, and then after I ovulate they get worse. So I think that documentation that can be helpful. But I think again, as in many of these cases, women often have to educate and advocate for themselves.
00:10:36
Speaker 1: So we often hear that PMS and PMDD get worse at midlife or in the perimenopausal transition. Is that true or is that just kind of perimenopausal mood shifts and changes. On top of PMS mood changes.
00:10:50
Speaker 3: There's a couple of different patterns we see Occasionally. I see women who have their first onset of premenstual symptoms as they're transitioning into the perimenopause, so they haven't really had any basomotor symptoms, but suddenly their periods are maybe a little bit changed in cyclicity, but they're having man I need more mood symptoms, and the mood symptoms seem to be correlated with their cycles. The other patterns we see is that maybe women with a history of a moot or anxiety disorder notice that their symptoms are getting worse pre menstrally as they age. So normally their symptoms were fairly well controlled with whatever they were doing, whether it was therapy or medications, and now they're seeing this bump up in pre menstrual symptoms. So I think as the hormodal shifts become more dramatic, so can the pre menstrual symptoms. And just to summarize, you can have new onset of pre menstrual symptoms or dysphoric disorder as well as exacerbation of an existing problem.
00:11:57
Speaker 1: Yeah, it's interesting because you'll see patients sometimes it will come to us saying, my SSR has been working for years and all of a sudden it's not working and people are flipping around the SSRIs and it's like it's kind of maybe perimenopause, right, So I always tell people when something's not working any more, look at your hormones. Also, are there any other ages where PMS and PMDD are worse? We talked about midlife that we hear many many women complain saying that my PMS is worse. Any other times in a woman's life where we see worsening a PMS or PMDD.
00:12:27
Speaker 3: PMS and PMDD often appear later than people think, so women who are younger can have anovulatory cycles and might not have the full blown PMS PMDD when they start menstruating, but it can emerge during the twenties. And then the other time where we see it is sometimes postpartum, So women who have had their hormone functioning suppressed because they've been pregnant or nursing can have pre menstrual symptoms as they transition back into regular cycles, and so you can have postpart of depression that looks like PMS or PMDD.
00:13:07
Speaker 1: What is the connection between PMDD postpartum depression and significant mood issues or fluctuations at the time of perimenopause. Are women who have PMDD postpartum depression more risk of having mood issues at perimenopause.
00:13:26
Speaker 3: So there's a group of women, it seems, that are more vulnerable to the hormonal fluctuations that take place either during the menstrual cycle, during pregnancy, in the postpartum or at the time of transitioning into the perimenopause. And so some women with PMDD do well during pregnancy but are at increased risk of postpartum depression, and that same group of women are also at increased risk of perimenopausal depression as well. It's not an absolute one to one, so we definitely see women who have PMDD who do fine at other times. But it does seem that there's probably some genetic underpinnings of this increased sensitivity, and I think with that group of women you also see at least this is what I see clinically, is that there's a family history, so it really suggests that there's some genetic vulnerability to hormonal changes.
00:14:22
Speaker 1: One topic in terms of women's hormonal health and where it intersects with their mood that we haven't spoken about is PMOS or polyendocrine metabolic obarian syndrome. I still can't say that we just recently changed the name from PCOS, which was so much easier to say. Do women with PMOS have more mood disorders and elevated androgen levels with like such as dagas and testosterone related to mood disruption at all?
00:14:54
Speaker 3: So if you look at all women with PMOS or what used to be called PCOS, there is a higher risk of both major depression and bipolar disorder. Interestingly, you know that said I think whatever fits into this PMOS category is on a spectrum, and there are so many different flavors of this disorder that I don't know who's more vulnerable and who's not. But I would say, if there's evidence, one should screen regularly for mood and anxiety disorders. And I don't think treatment for a psychiatric disorder makes the endocrine symptoms better, but treating the endocrine symptoms makes the mood and anxiety symptoms better, so it's worth looking at the whole package.
00:15:47
Speaker 1: When should a woman seek medical help or support? When should she really reach out to say something's really wrong here.
00:15:55
Speaker 3: The short answer is, if you feel like there's a problem, you know, don't suffer alone. Talk to someone, but to give some guidelines around it. Because I think women are great at sort of tolerating a lot of symptoms and not asking for help. I would say that if you feel your symptom are causing you to avoid situations, like you know it's going to be a bad time, and you're not going to do something because the symptoms might interfere with your enjoyment or might make it difficult to interact with others. I think if you also find that there's an increased irritability, sensitivity to your partner, your kids, that you know, when you are two weeks ahead of it, you're like, why did I get so bent out of shape about that one particular issue like dribbling coffee onto the counter. Those would be some signs that maybe it's time to ask for help. Also, I think pretty dramatic changes in sleep. If you're having a really hard time sleeping, that's a good sign that there's something going on that deserves some attention.
00:17:02
Speaker 1: Coming up. Doctor Nonax explains how the hormonal shifts during perimenopause can trigger a worsen anxiety and deprise. Plus we discussed options for treatment for women with pre existing psychiatric conditions.
00:17:30
Speaker 2: Let's talk a.
00:17:31
Speaker 1: Little bit about just mental health and psychiatric issues at midlife. You know, there was recently in recent means a few years ago, right, some publications that people finally began to publish on depression can get worse at midlife, or bipolar issues or psychoses can get worse at midlife. Can you tell us a little bit about that For women who have diagnosed psychiatric issues before midlife and as they enter midlife, what should they be cautious about.
00:18:03
Speaker 3: Yeah, that's a great question that doesn't get enough attention. It's really sort of the menopausal transition where you have so many things that come together, including hormonal changes which can lead to physical symptoms which can lead to sleep deprivation. So I think all of these things can contribute to increased vulnerability to mood and anxiety disorders. And so the most common presentation would be either new onset of depressive symptoms or worsening of depressive symptoms. And with women, when I say depression, depression often comes along with anxiety and sometimes anxiety can be the leading edge of depression. So women might find themselves sort of worrying about things, not being able to sleep, and then eventually it morphs into more of a depressive picture where they're really not enjoying themselves. They feel defeated, they feel like they can't get out of this hole. And I think if you push on anybody hard enough, they can suffer from depression. There's a lot of stresses that go on with a perimenopause. You also have women, especially now in midlife, they're juggling caring for younger kids as well as caring for aging parents, as well as managing really the demands of a career at the height of those demands. So there's a lot of things that contribute. I think it can be really hard to disentangle the mix. And I think the other interesting thing is that you can see cognitive changes and mood changes even way before you start to see changes in the menstrual cycle. I think it's important to educate women about that and to say, you know, if you're not feeling so well, it might be perimenopause. And I think that's a new tack in terms of addressing midlife women. I think a lot of times these symptoms are ignored or underestimated, but they really can last a long time, and they can have significant impact on women. The other thing, a lot of women tolerate motor symptoms, irritability, sleep, disturbance, and I say, oh, it's just the perimenopause, but I think that can cause significant decreases in quality of life and can lead to mood and anxiety disorders. So even if you're not depressed, really attending to those uncomfortable symptoms is important. They might last only a couple of months, but they could last for a really long time and have a profound impact on one's life. For people who've listened to the show before, you may be familiar with my story that at forty three, I had just had a child a couple of years before at forty one, and it was really the perfect storm with perimenopause, anxiety, postpartum issues which actually turned into severe depression. But was able to function during the week.
00:20:57
Speaker 1: I was able to pull myself together, see my patients, operate at the top of my game, but then over the weekend.
00:21:04
Speaker 2: I would just totally crash.
00:21:05
Speaker 1: Covers would go over my head. I wouldn't get out of bed all week and long, and I'd just be there and it was so confusing, because was it postpartum issues? Was it PMS that's now turning into PMDD I'd always had some PMS? Or was a perimenopause? And I suppose it was probably a perfect storm of kind of all of them. But how do you begin to sort through this? I mean, it's very complicated, right.
00:21:28
Speaker 3: I think I start by saying, we're not exactly sure what the driving factors are. It could be you know this, it could be hormonal changes, it could be new onset of depression. There's a lot of stigma associated with mood and anxiety disorders, so sometimes it's helpful for a patient to think of this as a hormonal change. And on the other hand, I think if you put it too squarely in the perimenopause group, women feel that they can only take hormones to treat the symptoms, and the truth is there's really a wide array of treatments that can be used to target the symptoms. So I think what we're trying to do is sort of find out what the most distressing symptoms are. And often I'll start with sleep and try to get some good night sleep in there and see how does that impact mood, how does that impact functioning? And if depression remains, then we'll think about an antidepressant. I think how this particular scenario might be managed depends on whether you see a gyn, a PCP, or a psychiatrist, So there might be different agents that or medications that people are more comfortable with. It is challenging, and I think we have to be upfront with our patients and say, you know, it's not so clear, but many of the treatments overlap, and we'll treat all of those symptoms or some of those symptoms, and let's get you better and then we'll figure out what happened a little bit down the road and clean up your regimen.
00:23:05
Speaker 1: So how do you use estrogen and progesterone in your practice at the time of the perimenoposal tree position?
00:23:12
Speaker 3: So typically I do not prescribe them, but if I see a patient where I feel like the vasomotor symptoms and sleep disturbance seem to be the primary symptom, I might have them go back to their gy to talk about the use of hormone therapy. Many of the patients I see cannot take hormone therapy for whatever reason or don't want to, and we will try to treat depression and anxiety with antidepressants, typically the s SRIS and the s NRIs. You can also use other medications like gabapentin to treat vasomotor symptoms and sleep disturbance. So we'll try to treat the symptoms if someone isn't eligible for treatment with estrogen. If they are eligible for treatment with estrogen and we get some improvement with depression or anxiety, but they're still having vasomotor symptoms, or they're having a lot of depressionsmptoms that don't seem to resolve, then again I might have them go back to their gyn to consider if they're eligible for estrogen treatment.
00:24:21
Speaker 1: We see a lot of women who do have worsening of PMS at perimenopause. Right, just looking at PMS or maybe anxiety depression also, right, is that better treated with progesterone or estrogen or combination of both hormones?
00:24:37
Speaker 2: Is it more like.
00:24:38
Speaker 1: A GABBA related progesterone allopregnant alone issue or estrogen issue.
00:24:45
Speaker 3: Despite studying this for the long time, I'm really puzzled by how progesterone works. And it's various metabolites. So there is a medication that has been used for postpartum depression. The first one was rexan alone, the second one was zoranolone, and they're both derivatives of allopregnanolone, which is a metabolite of progesterone, and they seem to help with both mood and anxiety. But clinically we also know that when we give some progestins to women, whether they're synthetic or natural, they can cause depression. So I think it's something about the mix of metabolites that affect that affect mood and anxiety, whether it comes from perimenopause or pre menstrual symptoms. I think estrogen is more of a positive event. It is easier to use estrogen because it tends to be mood protective, mood stabilizing, not with all women, but with most women. But if women have a uterus, you need to use the progestines alongside, which I think can complicate the picture. So I've definitely seen women who do well on the estrogen and then you add some progestin to the mix and things deteriorate.
00:26:05
Speaker 1: Outside of midlife perimenopausal transitions, how do you treat PMDD and how do you help women who are refractory to standard treatments.
00:26:16
Speaker 3: There are some women who are refractory to standard treatments. Fortunately it's not that common, but we do see a lot of them because at our program, we see a lot of them because they've been referred from other outside treats. The first line treatment if you see a psychiatrist for PMDD, would be serotonin reactake inhibitor, and we typically use those every day of the month. Some women use it only during the luteal phase or the last two weeks of the cycle, but that would be our first stab at treatment. There are some women who use oral contraceptives to manage pre menstrual symptoms, and that sometimes works great. Sometimes it doesn't work. I think with oral contraceptives you have sort of a steady low level of estrogen, but during the placebo week you can have some symptoms because you're removing thatgen. So sometimes women don't tolerate those oral contraceptives. If those two treatments don't work, we try to figure out sort of what are the residual symptoms, is their sleep disturbance, anxiety, and then we might use some add on medications, and those add on medications would be nothing novel. There would be the medications we commonly use to treat depression or anxiety that's refractory to treatment. So sometimes the benzodiazepines, which are like clonipin or adavan, can be helpful. We also use some of the newer atypical antipsychotic medications like arapiprosol or abilify, which is advertised, so we're treating some of those residual symptoms. If that doesn't work, we will often go back to sort of shutting down the whole axis and use medications like lupron that just turn off the menstrual cycles, and that can be helpful, but unfortunately that's like menopause. You can have the problems associated with menopause, like hot flashes, and you can have cognitive problems. If it's a young woman, you can have bone loss. That treatment might be more effective, however, in someone who is about to go into the perimenopause, so it's not such a big deal if they go into menopause a year earlier, but you don't want to use that type of treatment in a younger woman.
00:28:45
Speaker 1: So let's go through the treatments and drill down on them just a little bit. Birth control pills. What's your favorite level of estrogen that you recommend in a birth control pill? Your favorite progestin that you recommend? Is there one that you recommend over another? Skip placebos pill pack to pill pack to stabilize the hormone levels. Can you get a little bit more specific for us with this.
00:29:06
Speaker 3: We always want to use the lowest dose possible because that decreases the risk of side effect, especially in younger women. I don't get into the doses. I usually leave that to the experts, but what I do recommend is using a monophasic preparation, so it's a single level of estrogen and a single level of progesterone, and I recommend using it continuously, so skipping the placebo weeks and going from pilt back to pilt back, and eventually someone has to have a period, but at least you can do it on your own schedule. There is some data to suggest that certain progesterones progestines are better for PMDD than others, and that would be drisperinone, which was originally marketed as part of yaz Or Yasmin and it's now included in a bunch of other types of oral contraceptives that are now generic, and I can't keep track of the names because they keep coming up with new ones, but those would be my initial approaches. And in older women, we might use a transdermal estrogen because I think there's lower risk of side effects, and you know, you can limit the amount of progesterone they're exposed to by using it only intermittently for.
00:30:26
Speaker 1: The uterus SSRIs. What's your favorite SSRI for PMS PMDD in younger women, And what's your favorite SSRI or pick your medication at the time of perimenopause for somebody who is experiencing mood disorders.
00:30:45
Speaker 3: So my favorite one is if a woman has a history of depression and she's taken one of those and has done well, that's what I put at the top of my list. Whether it's soloft or effects or whatever it is. If it worked for them, we go for that. If they have no history of using it, I tend to use kind of the middle of the road SSRIs, which have not too much sedation, not too much at devation, and are easy to use because you can hit the right dose on the first try. And those would be cytalopram and s cytalopram so Selexa and lexapro, and also fluoxetine prozac. I use those pretty much at any age. I think sexual side effects are a big deal in this patient population, so that can occur with any of the SSRIs. I also don't tend to use peroxetine a lot because it's the one that's most associated with weight gain and sexual side effects. It works for some people, but it has a pretty hefty side effect burden.
00:31:52
Speaker 1: Do you layer in well buttrin at all to help with the sexual side effects?
00:31:57
Speaker 3: Sometimes I do so well. Bututrin on its own isn't a good treatment for PMDD or pre menstrual symptoms, but it can be a little bit more activating. Sometimes it can help reduce sexual side effects, and sometimes it can help sort of older women who have some cognitive dulling. It can be a little bit activating and can help with concentration.
00:32:20
Speaker 1: Let's talk about shutting down the HPO axis with lupron and just having an individual having stable hormone levels or low estrogen levels. How effective is that is that?
00:32:32
Speaker 2: Does it?
00:32:32
Speaker 1: Do you find that that really works for women who are a refractory to other maneuvers.
00:32:40
Speaker 3: So yes, if someone has pure PMDD, it works. What we often find is that when you shut down the hormonal access, they continue to have symptoms. So is that a hormonal mood disorder or just a mood disorder? And sometimes the answer to that question can be very helpful because maybe we're sort of looking at all these treatments for PMDD, but what they really have is bipolar disorder or major depression that we need to treat more effectively. So it can be helpful with regard to treatment, but it can also be helpful with regard to diagnosis.
00:33:18
Speaker 1: Do add back estrogen for these women just to give them a stable level of estrogen, or add back estrogen plus progesterone if they tolerated.
00:33:26
Speaker 3: So, the original studies suppressed the HPO access with prime and then they tried to add back estrogen and women had recurrent mood symptoms. There was a follow up study which said that yes, they have recurrent mood symptoms, but if you're patient and have them on the estrogen at a low dose for a couple of cycles, these mood symptoms eventually vanish or become more manageable. So I think that would be from a medical standpoint, the best option because you're reducing the risk of estrogen withdrawal in a younger patient population. I do think the women who end up on these medications like lupron for PMDD have the worst symptoms and severe depression or mood dysregulation, and they don't love the estrogen add Back.
00:34:24
Speaker 1: Still to come. Doctor Nonax walks us through lifestyle choices to support women during their most productive and fruitful years. Back in a minute, Where does lifestyle fit into this? My favorite maneuver for my neurotransmitters is exercise and fitness and weightlifting. Everybody knows I think from this podcast now that I'm a big weightlifter and a big fan of movement and exercise, especially for mood. Where does that fit in with how you treat women in terms of nutrition and exercise.
00:35:05
Speaker 3: I think in addition to these options, or especially with women with pre menstrual symptoms, I think lifestyle modifications are really important and essential. There's good data for aerobic exercise. There's also some data about switching from simple carbohydrates to more complex carbohydrates that can be helpful. There's some data on using calcium and magnesium supplements. That can be helpful. I think avoiding alcohol, avoiding excessive caffeine or variable levels of caffeine can be really helpful. And sleep high gene is really like my number one important for whatever mood or anxiety disorder is just getting good sleep, and enough sleep can really do wonders. I probably should have mentioned all of those things upfront, but they're very important and hard. Aerobic exercise to the level you have to do it to get some of the mood benefits is a lot of work and a lot of time, and unfortunately we don't prioritize it.
00:36:12
Speaker 1: Talk to me a little bit about supplement support, vitext or any of herbal supplement recommendations at all that have any data behind them that you recommend.
00:36:20
Speaker 3: There's a little bit so chaste ferry does have evidence that it decreases the risk of pre menstrual symptoms in general. A lot of the studies on the supplements were done with women with milder symptoms and not necessarily PMDD, and Saint John's wart works a little bit like SSRI's. I don't think it's been studied extensively in PMDD, but that might be another sort of supplement to option but we also have to say with the supplements, they have medication interactions, they have side effects. It's not like all natural is all better or risk free.
00:37:00
Speaker 1: If a woman thinks that she is experiencing PMS and not really getting attention or PMDD, what are the best questions to ask her provider so that her provider recognizes or she helps her provider recognize what's going on so that she can start to move to get some treatment and some help. What should she review with her provider.
00:37:21
Speaker 3: I think the first thing to do as the patient is to be a scientist and to collect data. So I think daily charting of symptoms can be really helpful because you can demonstrate that there's changes in your mood depending on where you are in the cycle. And I think you can bring that information to your doctor and talk about you know, I think these symptoms are increasing during this phase, they have an impact on my functioning and what can we do about them? And if your primary care provider doesn't listen to you, there are obgins, you know, there are reproductive psychiatrists, but I think psychiatrists in general are better at talking about mood and anxieties symptoms and understanding how negative their impact can be on ones functioning and quality of life.
00:38:18
Speaker 1: Can you walk us through when a woman has PMS which is severe or PMDD. We've talked about the different treatments, but what is like your algorithm for treatment? What should she expect in terms of treatment options to be recommended to her, kind of in a layered manner or in a stepwise manner.
00:38:38
Speaker 3: There's a bifurcated treatment option tree. If you have a younger woman who's sexually active and who's interested in having some sort of contraception, it might be helpful to go down the oral contraceptive route. If you have a woman who doesn't want to take hormonal treatments or doesn't need contraception, you would go down the treatment route with SSRIs and SNRIs. That would be the first step.
00:39:11
Speaker 1: And then the periman apausal woman who just says everything is worse at perimenopause.
00:39:18
Speaker 3: I think it would be a similar bifurcated treatment option. If there were a lot of symptoms, both physical and psychiatric, I would probably start with hormone replacement if that was an option for them. The good thing about hormone replacement is it treats all of the symptoms.
00:39:39
Speaker 1: I love that you say this.
00:39:40
Speaker 2: I'm just glad you said this.
00:39:42
Speaker 3: You know, if it's just mood and anxiety or just PMS emerging in that, then you could go down SSRIs and SNRIZ. You know, there are a lot of women who don't want to take hormones. But I don't think we should cross it off the list if there are no medical contraindications, because it does address a lot of those symptoms during that transition. One of the things I do worry about is the current recommendations suggests limited timeframe, and this would require your feedback. What's going to happen to those women when we have to take away the estrogen and replacement therapy or are we going to put them in a worse position or will they have crossed through the perimenopause and will feel much better.
00:40:26
Speaker 1: I think we're moving past that. Actually, I think we're realizing with our transdermal preparations now. I think one of our big concerns was stroke risk as we age, and with our transdermal preparations now we know that if you keep the level of what we're dosing at reasonable, the stroke risk is not elevated. So I think kind of the newer recommendations are to stay on as long as you can unless you have obviously an estrogen dependent malignancy or have a medical issue that is a contraindication. But which actually leads me into my next question for women who have perimenopausal mood issues that once they transition through menopause, do all the mood issues go away or do they come back. I mean, I think you're alluding to that they'd have the potential to come back if they stop former and support and it's helpful to them.
00:41:12
Speaker 3: I think we don't fully know the answer to that question. If you look at epidemiologic studies, there's higher rates of depression and anxiety during the perimenopause, but their rates are still a little bit elevated during the postmenopause, so not everything goes away during the postmenopause. Estrogen makes people feel better physically. It's neuroprotective. So I'm sure you know, even if you had low stable estrogen levels that it has some benefit for people. And there's a reason that women were put on estrogen replacement and stayed on it till they died. It makes them feel good.
00:41:53
Speaker 1: Not to personalize everything, but for me it was my mother, who actually very astutely said twenty years ago, I think it's probably your estrogen and you should just take an estrogen patch and try it. And I did, and I actually you know, stopped, you know, sleeping all weekend and you know, came out from underneath the cover. It was so fascinating. Actually, no psychiatrists said it, no doctor said it. And I had trained in all the best institutions and I didn't think of that.
00:42:19
Speaker 3: I do hope we can have more of these cross disciplinary discussions and really centers where you have people who are facile and discussing hormone replacement therapy as well as anti depressants, so that you don't have to go to three different treats to find a solution to your problems.
00:42:46
Speaker 1: My conversation with doctor Nonas is an important reminder that women's mental health during hormonal transitions doesn't fit neatly into a single specialty. It takes a multi pronged approach, which includes doctors like doctor Nonas, who bring expertise, care, and compassion to how we care for women throughout their lives. If you're struggling with feeling overwhelmed, anxious, or down, remember that tracking your symptoms and sharing with your doctor might be a good place to start. A few things to note for PMS and PMDD, the approach splits along a simple line. Younger sexually active women interested in contraception often start with oral contraceptives, while those who don't need or want hormonal birth control typically start with a low dose SSRI. Regardless of your situation, it's important to address whatever symptoms you're having when they start interfering with your daily activities or your emotional wellbeing, or both. Also, when symptoms are primarily mood and anxiety related with fewer physical complaints, consider asking your doctor about the use of antidepressants, which have proven to be effective. The stakes can be higher when physical and psychiatric symptoms appear together. A strong first option for treatment for women and midlife is hormone support or MHT, since it generally treats all of the symptoms rather than just mood issues alone. And remember, if you're not getting the support that you require from your primary care doctor, seek additional help and consider seeing a board certified reproductive psychiatrist. Your mental health and well being matter. Decoding Women's health is a production of Pushkin Industries and the Atria Health and Research Institute. This episode was produced by Kalalia. It was edited by Amy Gaines McQuaid, mastering by Sarah Bugaire. Our associate producer is Sonia Gerwit. Our executive producer is Alexander Garaton. Our theme song was composed by Hannas Brown. Concept and cre active development by Shaban O'Connor. Special thanks to Vicky Merrick, Alan Tish, David Saltzman, doctor David Dodick, Sarah Nix, Jacob Goldstein, Leah Rose, Jordan McMillan, Morgan Ratner, Owen Miller, Eric Sandler, and Greta Cohne. I'm doctor Elizabeth Pointer. Thanks for listening and until next time.
