Issues in Mental and Sexual Health

Educational Objectives

The goal of this program is to improve the evaluation and treatment of women’s mental and sexual disorders. After hearing and assimilating this program, the clinician will be better able to:

Diagnose and treat women suffering from pre-
menstrual syndrome and premenstrual dysphoric disorder.

Identify and treat women with social phobia and generalized anxiety disorder.

Counsel pregnant patients about the risks and benefits of antidepressant medications.

Cite the classifications of sexual dysfunction and identify patients with sexual dysfunction.

Recommend appropriate therapy for women suffering from sexual dysfunction.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and plan­ning committee reported nothing to disclose.

Acknowledgments

Dr. Haller was recorded at Controversies in Women’s Health, sponsored by the University of California, San Francisco, School of Medicine, and held December 4-5, 2008, in San Francisco, CA. Dr. Richards-Bullock was recorded at New Concepts in Women’s Health 2009, sponsored by the University of Miami Miller School of Medicine, and held February 19-21, 2009, in Miami, FL. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Mental Health for Women’s Health

Ellen Haller, MD, Adjunct Professor, Department of Psychiatry; Director, General Adult Psychiatry Residency Training Program; Director, Adult Psychiatry Clinic; Director, WomenCare Mental Health Program, University of California, San Francisco, School of Medicine

Premenstrual Syndrome and Premenstrual
Dysphoric Disorder

Premenstrual Syndrome (PMS): described for centuries; »60% to 80% of women have some PMS symptoms dur­ing menstrual life (»400 menstrual cycles); »30% of women have symptoms affecting quality of life (QOL)

Premenstrual dysphoric disorder (PMDD): experienced by 3% to 5% of women of reproductive age; affective la­bility and physical symptoms; diagnosis requires that symptoms be present for most cycles over course of 12 mo; prospective ratings required for diagnosis; symptoms tracked prospectively using daily symptom diary to assess whether symptoms occurring in late luteal phase of cycle; diagnostic criteria require that symptoms interfere with functioning at work, home, or school

Treatment: healthy diet; decrease in salt, caffeine, and alcohol; discontinuing smoking; exercise (reduces symp­toms); stress management; calcium supplementation  —  data (large multicenter randomized controlled trial) show ³50% improvement in 55% of women with PMS taking 1200 mg of calcium daily (equivalent to 4 TUMS tablets; note, study sponsored by makers of TUMS), compared to placebo (36%); 48% reduction in total symptom scores in women receiving calcium (vs placebo [30%]); calcium relieved emotional and physical symptoms; serotonergic antidepressants  —  continuous or intermittent dosing (antidepressant started on day 14 of menstrual cycle, contin­ued to day 1 of next cycle, then stopped); meta-analysis showed selective serotonin reuptake inhibitors (SSRIs) su­perior to placebo in treating symptoms (different SSRIs and mixture of continuous and intermittent dosing); oral contraceptives (OCs)  —  progesterone alone not helpful and can worsen symptoms; data show decrease in total symptom score over 3 cycles in 47% of women taking drospirenone plus ethinyl estradiol (YAZ), compared to 38% of women in placebo group; »50% response rate among active drug group vs 36% response rate in placebo group; 15% of women in drospirenone plus ethinyl estradiol group dropped out due to side effects (eg, nausea, intermen­strual bleeding) vs 4% dropout rate in placebo group

Nonpathologic Anxiety

Characteristics: most common psychiatric disorder; 2 components; psychic phenomena (worried, mindful and avoidance of danger) and physical phenomena (flight or fight response); anxiety when no real danger exists; devas­tating consequences on QOL; often goes undetected or untreated; prevalence  —31% of women vs 19% of men; so­cial phobia most common anxiety disorder, followed by generalized anxiety disorder (GAD) and lifetime panic disorder

Treatment: rule out medical conditions (eg, hypothyroidism); education and support (many patients unaware that what they are experiencing is anxiety); cognitive behavior therapy (CBT)  —  proven effective; conducted in group setting or individually; usually time-limited; provides tools to cope with thoughts fueling anxiety; medications  —  anxiolytic agents (eg, benzodiazepines) and antidepressants (eg, buspirone) effective for anxiety without depres­sion

Social phobia: exaggerated shyness; excessive fear of humiliation and embarrassment; anxiety, panic, and fear in so­cial situations; recognition that fear excessive; avoidance of social situations, thus impairing functioning and QOL; diagnosis requires that patient experience impaired functioning for ³6 mo; treatment  —  CBT; SSRIs; SSRI discon­tinuation syndrome  — can result from abrupt discontinuation of SSRI; increased anxiety, insomnia and vivid dreams, nausea, dizziness, and electric-like sensations in arms; symptoms not sign of addiction; with exception of fluoxetine (eg, Prozac), taper SSRI when discontinuing

Generalized anxiety disorder: excessive anxiety and constant worry; worry about many things; inability to concen­trate; trouble sleeping; motor tension; significant distress; duration ³6 mo; treatment  —  buspirone (Buspar) useful for patient who has never used benzodiazepine; effective in some; no sedation or addictive potential; takes time to work; safety profile and lack of risk for addiction warrant trial use, even though most experts do not believe buspi­rone effective; clonazepam (Klonopin) once daily or bid can be used safely if patient does not have history of med­ication abuse (tolerance may develop); CBT with focus on catastrophizing thoughts; instruct patient to visualize “STOP” sign when starting to worry or to set aside “worry time” (compartmentalizes worry to specific time of day); progressive muscle relaxation or deep breathing

Medications During Pregnancy

Tricyclic antidepressants (TCAs): all antidepressants cross placenta; much data on safety; no evidence of congeni­tal malformations; nortriptyline and desipramine preferred (slightly better side effect profile, no difference in con­genital effects); potential for neonatal withdrawal symptoms and anticholinergic symptoms (eg, constipation, bladder distention, jitteriness, tachypnea, tachycardia); symptoms resolve within few days

Selective serotonin reuptake inhibitors: fluoxetine  —  »1200 infants in case series; data show minor malformations (defined as no cosmetic or other significant malformation) in 15% of neonates; reported perinatal complications (eg, jitteriness) associated with third trimester; other investigators report no difference vs controls; paroxetine (eg, Paxil)  —  retrospective study showed increased risk for cardiovascular malformation (particularly ventricular septal defects) in neonates exposed to paroxetine; other large studies did not report finding; pregnancy category D; other SSRIs  —  less data; evidence suggests no risk for malformations; atypical antidepressants  —bupropion (eg, Well­butrin); duloxetine (Cymbalta); escitalopram (Lexapro); mirtazapine (Remeron); nefazodone (Serzone; no longer on market); venlafaxine (Effexor); little data in literature; no evidence of congenital malformations

Perinatal effects of SSRIs: medication present in neonate at birth; data show symptoms (eg, jitteriness, agitation) in »30% of neonates exposed in third trimester; resolves within 48 hr; etiology unclear (unclear whether withdrawal from SSRI or serotonergic hyperstimulation); controversial whether medication should be tapered or discontinued in last month before delivery; decision must be individualized; persistent pulmonary hypertension (PPH) in newborn  —  can lead to hypoxemia, requiring ventilation; occurs in 1 to 2 in 1000 births; obesity, diabetes, nonste­roidal anti-inflammatory drugs (NSAIDs) and smoking risk factors; data show use of non-SSRI antidepressants not associated with PPH; no association with hypertension when SSRIs used in early part of pregnancy; significant as­sociation with use of SSRI at 20th week of pregnancy (adjusted odds ratio, 6); study concluded absolute risk <1% of exposed babies; child development after fetal exposure  —prospective study monitoring children £71 mo exposed to TCAs, fluoxetine, and controls; found no differences in development, language, IQ, and temperament; IQ nega­tively associated with duration of maternal depression; considerations in prescribing  —  perform risk-benefit analy­sis for each individual; assess severity of anxiety and/or depression and history of response to treatment; document other exposures; document informed consent

Postpartum Depression (PPD)

Baby blues: transient, nonpathologic; mood lability; usually occurs during first week postpartum; resolves without intervention; seen in 50% to 70% of all pregnant women; risk of developing major depression

Postpartum depression: inability to sleep even when baby asleep important risk factor; 10% to 15% of all pregnant women; tends to occur within first or second month postpartum; screen for risk factors during prenatal care; risk factors  —history of PMDD; conflict in relationship; history of depression or bipolar disorder in primary or first-de­gree relative; personal history of mood disorder before pregnancy; history of PPD (50% risk for PPD with next pregnancy); depression during current pregnancy; postpartum blues; Edinburgh Postnatal Depression Scale used worldwide as screening tool; treatment  —  reassure, educate, and support (Depression After Delivery www.depres­sionafterdelivery.com); interpersonal psychotherapy or CBT; breastfeeding and antidepressants  — all antidepres­sants found in breast milk (low levels); sertraline, paroxetine, and nortriptyline recommended because of level of published data; peak drug concentration in milk »8 hr after last dosing for sertraline (some patients “pump and dump” »8 hr after dosing); conduct individual risk-benefit assessment; document conversation

Postpartum psychosis: acute medical emergency; bipolar disorder (manic depression); »1 in 1000 pregnant women; increased risk for infanticide and suicide; requires hospitalization and polypharmacy

Sexual Dysfunction in the Menopausal Woman

Amanda Richards-Bullock, MD, Associate Professor, Department of Obstetrics and Gynecology, University of Miami Miller School of Medicine,  Miami, FL

General considerations: sildenafil for treatment of male erectile disorder led to recognition of sexual performance disorders in men and women; female sexual dysfunction now recognized (and often treatable) disorder; £43% of American women suffer from sexual dysfunction in lifetime; increased incidence in menopausal women; often ex­plained as normal part of aging, and treatment not indicated; trial looking at use of sildenafil in women terminated prematurely for undisclosed reasons; vardenafil and tadalafil may be beneficial in women; flibanserin currently in phase III trials

Classifications: hypoactive sexual desire disorder (HSDD)  —loss of libido; loss of interest in sexual performance; includes sexual aversion disorder; sexual arousal disorder  —  patient interested in having sexual intercourse, but un­able to lubricate or arouse properly; orgasmic disorder  —  patient has desire and can arouse; orgasm unsatisfactory or nonexistent; sexual pain disorder  —  interest, arousal, and orgasm satisfactory, but pain prevents sexual inter­course; sexual dysfunction considered disorder only if it causes distress or affects relationship

Etiology: primary or secondary (new onset); generalized or situational; organic or psychologic; complex or mixed etiology in most cases; Berman and Berman (experts in field) believe etiology stems from emotional or psychologic problems, physical or medical problems, or combination; lack of hormones  — ovarian failure at time of menopause can lead to clinical depression; can cause lack of desire and performance; patient taking progestin-dominant oral contraceptive (OC) often admits to libido problems when asked; decreased blood flow  —atrophy from lack of hor­mones and aging (increased in patient with coronary disease); intense vasoconstriction from smoking; autoimmune conditions  —  fibrosis itch/scratch scar that interferes with blood supply to genital area; nerve damage  —  can cause lack of sensation; lichen sclerosus — hypertrophic or atrophic (or sclerotic) with lack of vulvar architecture; pain makes intercourse difficult; topical testosterone has little efficacy in restoring vulvar architecture; side effects, par­ticularly clitoromegaly; monitor patient every 6 to 12 mo with vulvoscopy to assess for vulvar intraepithelial changes; lichen planus  —  less common; severe autoimmune inflammatory condition of vulva and vagina; severe discomfort makes intercourse difficult; topical intralesional steroids recommended; endocrine disorders; pelvic floor disorders; vaginismus  —  lack of hormones leads to vaginal dryness and discomfort during sexual intercourse; microtrauma of fourchette can occur, initiating vicious cycle of involuntary spasm of pelvic floor muscles and nar­rowing of vaginal opening; medications (eg, SSRIs, TCAs)

Treatment: individualized or multidisciplinary; identify etiology; refer patient if not comfortable with psychosexual counseling; consider switching medications; advise appropriate lifestyle changes

Hormonal problem: obtain hormone profile (during secretory phase of cycle if patient still cycling); measure total estrogen and sex hormone-binding globulin (often significantly elevated in patient who is overweight or patient taking exogenous estrogen [can bind to other hormones and decrease function]); mood changes, hot flushes, and lack of sleep and libido common in perimenopausal patients with deficient secretory phase progesterone; oral mi­cro-nized progesterone, 100 to 200 mg daily, from day 14 to day 28 of cycle, recommended; transdermal proges­terone cream also may be used; patient deficient in estrogen and progesterone needs replacement; menopausal patient who is overweight may have therapeutic levels of estrogen, symptoms may result from progesterone defi­ciency

Testosterone deficiency: affects desire and libido; treatment indicated only if deficiency established by measuring serum levels; speaker starts by correcting progesterone level; often, correcting deficient progesterone will elevate testosterone levels by bioconversion of progesterone; compounded topical testosterone cream (2 mg/mL); apply £1 mL 2 to 3 times weekly; can be applied to inner thigh (applying directly to labia and clitoris can result in cli­toromegaly); measure serum testosterone after »2 mo of treatment; high levels seen in some patients may be due to differences in absorption; caution patients about side effects (eg, acne, hair growth, deepening of voice); ongo­ing trial looking at transdermal system (ie, patch) that delivers 300 µg/day; consider switching patient from pro­gesterone-dominant OC to estrogen-dominant OC or newer progesterone OC (synthetic progesterone can block estrogen receptors, interfering with lubrication and arousal)

Alternative therapies: vaginal lubricants  —  Astroglide pH-neutral, nonirritating, and not messy; longer lasting than KY Jelly; over-the-counter vasodilator  —  advise patient with atrophy and increased sensitivity to avoid agents containing menthol; compounding pharmacies mix vasodilator and smooth muscle relaxer (eg, L-arginine) in bland cream base; systemic or topical estrogen  —  produces vasodilation by release of nitric oxide in peripheral blood vessels, similar to action of sildenafil

Conclusion: intimacy and companionship central to being; sexual dysfunction can lead to marked psychologic dis­tress, feelings of inadequacy and failure, and disruption of interpersonal relationships and family; clinician should take initiative of asking about sexual function, since many patients do not volunteer information; treatment often possible and always worthwhile

Suggested Reading

Bachmann GA et al: The impact of hormones on menopausal sexuality: a literature review. Menopause 11(:120, 2004; Chambers CD et al: Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med 354:579, 2006; Gjerdingen DK et al: Postpartum depression screening: importance, methods, barriers, and recommendations for practice. J Am Board Fam Med 20:280, 2007; Graziottin A et al: Biological and psychosocial patho­physiology of family sexual dysfunction during the menopausal transition. J Sex Med 2 Suppl 3:133, 2005; Thys-Jacobs S et al: Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Premenstrual Syndrome Study Group. Am J Obstet Gynecol 179:444, 1998; Nulman I et al: Child development following exposure to tricyclic antidepressants or fluoxetine throughout fetal life: a prospective, controlled study. Am J Psychiatry 159:1889, 2002; Rapkin AJ: YAZ in the treatment of premenstrual dysphoric disorder. J Reprod Med 53(9 Suppl):729, 2008; Schwenkhagen A: Hormonal changes in menopause and implications on sexual health. J Sex Med 4 Suppl 3:220, 2007.