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PSYCHIATRY AND

REPRODUCTIVE MEDICINE

A.J. TANRA
BAG. PSIKIATRI, FK-UNHAS
MAKASSAR, 2013.
Psychiatry and Reproductive
Medicine
The fields of psychiatry and reproductive medicine are to
elaborate the multiple mechanisms by which psyche and
soma interact to determine a woman's gynecological
and psychological function .
This fields addresses such events, including menstrual
cycling, abortion, pregnancy, postpartum,infertility,
menopause, and sterilization.
This section illustrates how reproductive processes
interact with psychosocial events and aims ultimately
to improve the approach to both gynecologic and
psychiatric treatments.
Brain & Mind
Biology & Psychology
Hypothalamus & Gonads
Psychological effects & Reporductive function
Reproductive hormonal changes & Psychological
well being
Somatopsychic & Psychosomatic illness
e.g Menstrual cycle :Hipothalamic,psychogenic,
idiopathic Amenorrhea Psychosomatic
illness
Harmonious working relation
Premenstural syndrome(PMS)or tension
(PMT), dysphoric disorder(PDD)
Syndrome Related Menstural, chronic,cyclical,
physical and emotional symtoms occuring in luteal
phase of mestural cycle.
Symptoms: breast tenderness,fatique,cramping,
bloating,irratable,aggresisive,depression, inability
consentrate, food craving,lethargy,change of libido
Etiology: unknown, hormonal/NT abnormality.
DD: 50% are found in prezises diagnosis, 5%
mimically as anxiety & depression,hypothyroidsm,
dysmenorhoe, postpartum depression, polycystic
ovary disease, endometreousis.
Premenstrual Mood Disorders
While over 50% of menstruating women report mild
irritability or depression prior to their periods, between 5%
and 8 % suffer from the more serious mood changes of
Premenstrual Dysphoric Disorder (PMDD). These women
are usually seen by their Ob/Gyn first. PMDD is a risk
factor for both prenatal depression and perimenopausal
depression. PMMD can have a significant impact on social
and occupational functioning. Lifestyle modification and
cognitive-behavioral therapy are helpful in reducing some
of the symptoms, but there is now a large body of
evidence also supporting the use of serotonergic
antidepressants for the treatment of PMDD. It is important
to keep in mind that premenstrual mood changes may not
be PMS or PMDD, but may represent cyclical worsening
of an underlying mood disorder. The symptoms must be
evaluated prospectively in order to make the proper
diagnosis and insure proper treatment.
Management:
Conservative , diet of low salt, lipid,caffeine, sugar,
diminished or cessasion of smoke, alcohol, aerobic
If unsatisfied, interference with antidepressant,
diuretic.
Prementural dysphoric disorder:
Severe form of PMS, depression, anxiety, emotional
unstable, retarded activity
Psychologically healthy women often find pregnancy a
means of self-realization a creative act gratifying a
fundamental need.
to diminish self-doubts about femininity or to
reassure themselves that they can function as women
in the most basic sense. Women's unconscious fears
and fantasies during early pregnancy often center on
the idea of fusion with their own mothers.

When preexisting conflict gives rise to problems of


identity, self-esteem, and guilt, the disturbance may
be severe and may manifest through regression;
extreme dependence on a physician, mate, or parent;
diffuse anger; impulsive behavior; or depression
Trimester I :
Hormonal changes, irritable,
emotional fluctuated
Trimester II :
Foetus movement, clearly
gender, cultural believing
(anxiety & depression)
Trimester III :
Higher estrogen, libido
down,uninterested physical
changesinclude sexual desire,
emotional highest
Abortion
some studies have sho
wn a correlation betwe
en abortion and clinical
depression, anxiety, sui
cidal behaviors,or adve
rse effects on women's
sexual functions for a
small number of women
these correlations may
be explained by preexis
ting social circumstance
s and emotional health
Abortion
Induced abortion is the planned termination of a pregnancy.
About 1.3 million abortions are performed in the United States
each year, 246 abortions for every 1,000 live births. Over the
last decade, the number of abortions has declined by about 15
percent.
Family planning experts believe that more sex education and
greater availability of contraceptive devices keep the number of
abortions down.
In Western countries, most women who obtain abortions are
young, unmarried, and primiparous;
In emerging countries, abortion is most common among
married women with two or more children.
Of abortions, 60 percent are performed before 8 weeks of
gestation, 88 percent are performed before 13 weeks, and 4.1
percent between 16 and 20 weeks, with 1.4 percent occurring
after 21 weeks.
Pseudocyesis
Pseudocyesis (false pregnancy) is the development of the
classic symptoms of pregnancy amenorrhea, nausea, breast
enlargement and pigmentation, abdominal distention, and
labor pain in a nonpregnant woman. Pseudocyesis
demonstrates the ability of the psyche to dominate the soma,
probably via central input at the level of the hypothalamus.
Predisposing psychological processes are thought to include a
pathological wish for, and fear of, pregnancy; ambivalence or
conflict regarding gender, sexuality, or childbearing; and a grief
reaction to loss following a miscarriage, tubal ligation, or
hysterectomy. The patient may have a true somatic delusion
that is not subject to reality testing, but often a negative
pregnancy test result or pelvic ultrasound scan leads to
resolution. Psychotherapy is recommended during or after a
presentation of pseudocyesis to evaluate and treat the
underlying psychological dysfunction.
Mrs S, aged 16, thought she had become pregnant
after her first coital experience, which occurred without
contraception. Shortly after she read about the signs
and symptoms of pregnancy, her menses stopped.
She related that she felt tingling in her breasts, which
she believed were enlarged. She also reported
nausea and vomiting in the morning, which was
observed by her mother. On examination, the uterus
was enlarged, breasts were developed with dark
areola and contained milk, and a pigmented line was
observed from the umbilicus to the pubis. The
abdomen was not enlarged, but she believed she felt
fetal movement. A pregnancy test had negative results
and the patient was so informed; however, she could
not be dissuaded of her belief that she was pregnant.
She entered psychotherapy, and within 2 months her
menses returned and she accepted the fact that she
was not pregnant
Hyperemesis Gravidarum
Hyperemesis gravidarum is differentiated from
morning sickness in that vomiting is chronic,
persistent, and frequent, leading to ketosis,
acidosis, weight loss, and dehydration. The
prognosis is excellent for both mother and fetus
with prompt treatment. Most women can be
treated as outpatients, with changing to smaller
meals, discontinuing iron supplements, and
avoiding certain foods. In severe cases,
hospitalization may be necessary. Although the
cause is unknown, a psychological component
may exist. Women with histories of anorexia
nervosa or bulimia nervosa may be at risk.
Hyperemesis Gravidarum :
Frequently chronic persistent vomiting,
lowest body weigh,&dehidration.
Etiology :
Unknown , endocrine disturbances, anorexia
nervosa, bulimia nervosa , hormonal
changes.
Terapi :
Counseling,physical correction, low dose
psychotropic (CPZ 25 mg).
Baby blues
Most of these women report symptoms
consistent with baby blues, a transient mood
disturbance characterized by mood lability,
sadness, dysphoria, subjective confusion, and
tearfulness. These feelings, which may last
several days, have been ascribed to rapid
changes in women's hormonal levels, the
stress of childbirth, and the awareness of the
increased responsibility that motherhood
brings. No professional treatment is required
other than education and support for the new
mother
Post partum blue :
normal mood, 50%-80% birthed, emotional
disturbances(dysphoria, irritable ,tearness),3-10 days
post partum, E/ dramatical hormonal changes
(estradiol & progesteron), stress in partu, responsible
burdening.
Postpartum depression is characterized by a
depressed mood, excessive anxiety, insomnia, and
change in weight. The onset is generally within 12
weeks after delivery.

postpartum depression:
10-15% birthed,depression, attempt suicide,
melancholia, Neurosthenia, insomnia, duration
6-9 months ,
Therapy : Antidepresant ( SSRI)
(floxetine) 25mg/day.
Postpartum Psychosis= puerperal psychosis
The syndrome is often characterized by the
mother's depression, delusions, and thoughts
of harming either herself or her infant. Such
ideation of suicide or infanticide must be
carefully monitored; although rare, some
mothers have acted on these ideas. Most
available data suggest a close relation between
postpartum psychosis and mood disorders,
particularly bipolar disorder and major
depressive disorder
Pospartum psikotik :
0,1% birthed, 90% mood disorders, 40%
mania, delirium, confusion, agitation,
insomnia, depersonalitation, hallusination,
delusion, onset acute 2 weeks after partus ,
durasion 2-3 months, .
R/ low dose antepsychotic (haloperidol 0,5
mg (3 x 1/day)
Therapy: (in pregnancy )
regulairrly pregnancy examination to prevent
phisical diseases & mentak disorder.
Low dose of psychotropic (congenital,
teratogenic, withdrawal syndrome)
Psychoteraphy supportive (counseling).
Perimenopause and Menopause
In the United States more than 1.3 million women are expected to
reach menopause every year. Menopause is reached when a
woman has stopped menstruating for one full year. The transition to
menopause, also known as perimenopause, represents the
passage from a womans reproductive life to non-reproductive life.
During perimenopause woman will experience irregular menstrual
periods and may have hot flashes and night sweats, all of which
reflect the large fluctuations in hormone levels during the transition.
Women who are surgically menopausal (e.g. following removal of
the ovaries), are at increased risk for depression compared to
naturally menopausal women. During the menopausal transition,
there is an increased risk for developing depression, even among
women with no prior history. On the other hand, a history of
depression increases the risk for an earlier menopausal transition.
The dynamic interaction between depression and the
perimenopause, including the roles of hormonal fluctuations, hot
flashes, night sweats, and sleep disturbances, is an area of current
research. While hormonal changes undoubtedly play a role in the
development of mood symptoms, hormonal therapies are not
necessarily the most appropriate treatments. Consideration must be
given to standard psychiatric treatment modalities such as
antidepressants and other medications.
Menopause
Menopause, the cessation of ovulation,
generally occurs between 47 and 53 years of
age. The hypoestrogenism that follows can
lead to hot flashes, sleep disturbances, vaginal
atrophy and dryness, and cognitive and
affective disturbances. Women are at increased
risk for osteoporosis, dementia, and
cardiovascular disease. Depression at
menopause has been attributed to the empty
nest syndrome.Many women, however, report
an enhanced sense of well-being and enjoy
opportunities to pursue goals postponed
because of child rearing.
Infertile
Depression had a significant relation with cause
of infertility, duration of infertility, educational
level, and job of women. Anxiety had a
significant relationship with duration of infertility
and educational level, but not with cause of
infertility, or job. Findings showed that anxiety
and depression were most common after 4-6
years of infertility and especially severe
depression could be found in those who had
infertility for 7-9 years
the infertile women exhibited
significantly higher psychopathology
in all HADS parameters in the form
of tension, hostility, anxiety,
depression, self-blame and suicidal
ideation
They affected the personality and
social behavior of the male partner
and caused anxiety, but led to
depression in the female partner
Psychiatric impact mainly through effect
on sexuality: Male impotence ,sperm quality
Female-hormonal, vaganismus
The present study delivers the strongest
evidence to date that distress due to infertility is
a significant risk factor for a decrease in sperm
quality.
A study of 10 depressed and 13 normal
women indicated that depression is
associated with abnormal regulation of
luteinizing hormone . Activation of the
hypothalamic-pituitary-adrenal axis can
profoundly inhibit reproductive function.
This inhibition of reproductive function
can be at many levels, ranging from
inhibition of hypothalamic GnRH to
possible direct actions on the ovary and
endometrium in a manner that could
prevent pregnancy. Furthermore, stress
and depression alters immune function
and specific cytokines , which in turn
could adversely affect reproductive
function
Psychological stress may affect
the outcome of IVF treatment
since state anxiety levels among
those who did not achieve
pregnancy were slightly higher
than among those who became
pregnant.
Intervention of the mental health team
could be seen as a way to lower dropout
rates, but also as interference in this
possibly self-protective process. The
patient's mental health should indeed be
considered an integral component of
infertility care. Whether this leads to higher
rates of treatment success, prevention of
long-term depression, or lower dropout
rates needs and deserves further
exploration.
More attention to the psychological
repercussions of infertility treatment could
lead to a more personalized approach to
optimize patient satisfaction. The
availability of a multidisciplinary team that
holistically integrates medical and mental
health during the treatment period, which
extends the period of regular appearances in
the clinic, would be the first step
Psychiatric treatment of infertility for women and couples
undergoing assisted reproduction
Up to 15% of all couples are unable to conceive after one year
of unprotected intercourse. Infertility is probably caused by
male factors in about 50% of cases. In addition to the usual
known female causes of infertility, eating disorders, depression
and anxiety may be associated with a decline in ovarian
function and may therefore also contribute to difficulties with
conception. The difficult and demanding aspects of infertility
involve the daily monitoring of reproductive-related bodily
functions and can have a negative impact on spontaneity and
intimacy. For women with preexisting psychiatric disorders,
infertility often produces negative mood changes and may
precipitate relapses and recurrences. A psychiatric evaluation
may be helpful to address the mental health needs of women
dealing with the challenges of infertility and also enhance her
ability to move forward with fertility treatments. Psychiatric
treatment options include psychotherapy (both individual and
couples therapy), and sometime judiciously chosen psychiatric
medications.
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