Vol 4 n° 2 - Cerebral aspects of reproductive endocrinology
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Several forms of depression are unique to women because of their apparent association with changes in gonadal hor- mones, which in turn modulate neuroregulatory systems associated with mood and behavior. This review examines the evaluation and treatment of depression that occurs premenstrually, postpartum, or in the perimenopause on the basis of current literature. The serotonergic antide- pressants consistently show efficacy for severe premen- strual syndromes (PMSs) and premenstrual dysphoric dis- order (PMDD), and are the first-line treatment for these disorders.  The  use  of  antidepressants  for  postpartum depression is compromised by concerns for effects in the infants of breast-feeding mothers, but increasing evidence suggests the relative safety of the antidepressant medica- tions, and the risk calculation should be made on an indi- vidual basis. Estradiol may be effective for postpartum depression and for moderate-to-severe major depression in the perimenopause. In spite of its frequent use, proges- terone is not effective for the mood and behavioral symp- toms  of  PMS/PMDD,  postpartum  depression,  or  peri- menopausal depressive symptoms. Dialogues Clin Neurosci. 2002;4:177-191. pproximately 20% of women experience an episode of major depression, a rate that is twice that of men.1 The period of greatest vulnerability for women appears to be the childbearing years, with the initial onset of depression most likely to occur between the ages  of  25  and  44.2  Several  forms  of  depression  are unique to women because of their apparent association with changes in reproductive hormones: premenstrual dysphorias, including premenstrual syndromes (PMSs) and premenstrual dysphoric disorder (PMDD), post- partum depression (PPD), and depression in the peri- menopausal period. The link among these depressive disorders appears to be a sensitivity to normal shifts in gonadal hormones, which affect neuroregulatory systems that play a role in affective disorders.3,4 Such shifts occur during the menstrual cycle, in pregnancy and postpar- tum, and with ovarian aging in the years leading to the menopause. Historically, depression has been underrecognized and undertreated. Until recently, diagnostic criteria were imprecise,  clinical  trials  of  purported  treatments  for menstrually related depressions were lacking or poorly done, and treatment options were generally unsupported P h a r m a c o l o g i c a l   a s p e c t s 1 7 7 Treatment of depression associated with the menstrual cycle: premenstrual dysphoria, postpartum depression, and the perimenopause Ellen W. Freeman, PhD A Keywords:   depression;  premenstrual  syndrome;  postpartum  depression;  peri- menopause; antidepressant; estrogen; gonadal hormone; treatment Author    affiliations:    Research    professor,    Departments    of    Obstetrics/ Gynecology and Psychiatry, University of Pennsylvania, Pa, USA Corresponding   author:    Department   of   Obstetrics   and   Gynecology,   2 Dulles/Mudd   Suite,   Hospital   of   the   University   of   Pennsylvania,   3400 Spruce Street, Philadelphia, PA 19104, USA (e-mail: freemane@mail.med.upenn.edu)