In this month’s edition of Medication Talk, we discuss issues around medication that are specific to women with Dr. Alicia Murray. Dr. Murray is a board certified Addiction Psychiatrist and General Psychiatrist. She did her training at St Lukes-Roosevelt Hospital (New York Presbyterian Hospital) and her post doctoral fellowship and clinical addiction medicine fellowship at New York Presbyterian Hospital and Columbia University. She currently has a private practice in Westchester County and Manhattan where she specializes in the treatment of addictive disorders and Dual Diagnosis disorders. To find out more about Dr. Murray, you can visit her website at http://www.draliciamurray.com/.
What research is there on the escalation of mental health symptoms around the menstrual cycle and what kinds of things can women discuss with their doctors to help with this?
It is unclear exactly what the biological mechanism that causes Premenstrual dysphoric disorder (PMDD) symptoms is. However there are many suggestions that several key neurochemicals and hormones are thought to play a role in causing PMDD.
For decades Progesterone has thought to be the root cause of premenstrual symptoms. Progesterone is secreted by the lining of the uterus called the corpus luteum in the luteal phase of the menstrual cycle. The luteal phase is the phase of the menstrual cycle after one ovulates, approximately 14 days after the first day of a woman’s menses but can be different for many women. We know that progesterone is involved with these symptoms because studies show that women who do not ovulate, do not in fact have premenstrual symptoms. When progesterone is administered exogenously these women will then do in fact develop PMS. The role of progesterone is not clear cut in causing or exacerbating affective symptoms although some data shows that the metabolites of progesterone may be the culprit of the physical and affective symptoms throughout the cycle.
Another chemical likely involved is the neurotransmitter GABA. GABA helps to regulate stress and anxiety as well as other neurologic functions. Metabolites of progesterone activate the GABA A receptor to play an important role in causing and modulating PMS and PMDD symptoms. ( this is the same receptor in which benzodiazepines and alcohol bind)
Another neurotransmitter that significantly impacts symptoms of PMDD and PMS is serotonin. Serotonin modulates mood, appetite, arousal and the sleep wake cycle. Studies show that serotonin production and destruction is also altered during the luteal phase of the menstrual cycle in women with PMS. This is likely due to decreased platelet uptake of serotonin and decreased blood serotonin levels. Estrogen and Progesterone have been found to also augment serotonin levels which makes it a likely additional cause of mood symptoms and anxiety during the cycle and pregnancy. SSRI’s, oral contraceptive pills, nutritional supplementation like calcium, healthy diet and exercise are all found to be helpful in treatment PMDD.
Some women report mood changes during their cycle and/or during pregnancy. Does estrogen and progesterone have an effect on medications?
During pregnancy, when endogenous progesterone and estrogen rise dramatically, psychiatric symptoms (like mood disorders, anxiety, depression, mania) can increase. Women can also sometimes report relapse of otherwise stable psychiatric symptoms. This may be due to many variables.
During pregnancy, women’s total blood volume increases which changes the way that medications are distributed throughout the body. Also increased emotional distress around the transition to motherhood and anxiety about delivery can also play a role in mood changes.
That said, few medications are affected in regards to drug clearance however it is important to be aware of the medications that are. For example, lamictal is a mood stabilizer that is very useful for depression, bipolar depression and other mood related disorders. Increasing levels of estradiol increase the clearance of Lamictal. Women commonly need up to a 50% increase in their dose during pregnancy.
This is also true when women are on oral contraceptives. Oral contraceptives technically “trick” your body into being pregnant so you do not conceive. Women on certain oral contraceptives may need to increase their dose as well. It is important to talk with both your treating psychiatrist and treating obstetrician to find out if this is necessary for you.
What medications are OK for women to use when they are pregnant and are there any medications that they should stop for the duration of the pregnancy?
Interesting question: More and more pregnant women are taking medications each year. Medication use has surged to 9 out of 10 pregnant women according to Mass General Studies. Many women need to take medications during pregnancy to manage their health conditions and in many cases, stopping medications during pregnancy may be more harmful than taking medications. Unfortunately, fewer than 10% of medications actually have enough information to determine their safety in pregnancy. This is why it is so very important for patients who are thinking about pregnancy and or become pregnant to discuss with their treating doctors and their obstetrician which medications are safe during pregnancy and what the risk to benefit ratio is. Each pregnancy is different and may require different treatment.
Medications are graded in categories according to their safety profile in pregnancy.
- Category A: includes the safest drugs to take during pregnancy with no known adverse reactions.
- Category B: includes drugs in which no risks have been found in humans.
- Category C: are drugs in which not enough research or data has been developed to determine if these drugs are safe.
- Category D: Includes drugs in which adverse reactions have been found in humans.
- Category X: avoid in pregnancy.
Many doctors will prescribe medications in Categories A, B and C. There also may be times in which a Category D medication is prescribed based on the risk benefit ratio.
Can a woman take an anti-depressant while she’s pregnant?
There are many different anti-anxiety medications and antidepressants on the market, some of which may pose some risk to a developing fetus. It is important to discuss with your doctors which type of medication may be most helpful and of the least risk. Many antidepressants are safe during pregnancy and are very valuable in maintaining maternal well-being and bonding with the infant. Sometimes the safety profile of medications is evaluated on a case to case basis.
For example, I personally struggled with multiple miscarriages until I was diagnosed with a rare clotting disorder. I was prescribed daily aspirin and daily heparin to allow the embryo to develop. Both of these medications would not be recommended in pregnancy however in my clinical case these medications were essential maintaining a healthy pregnancy. I was also highly anxious about losing the pregnancy while pregnant and was prescribed Zoloft (sertraline) throughout the pregnancy. This allowed me to enjoy pregnancy and kept my heart rate low and mood stable. As with all medications, there are risks, but, in my case, the benefits of being less anxious outweighed the infrequent rare side effects of sertraline during pregnancy. All cases are different and should be discussed at length with your provider.
A website I really like and direct my patients to is the http://www.cdc.gov/pregnancy/meds/treatingfortwo/. A lot of information including current research on medications in pregnancy are available on this link and most recent safety profile for commonly prescribed medications is on this site.