Current Psychiatry Reports

, Volume 4, Issue 6, pp 419–428 | Cite as

The clinical nature and formal diagnosis of premenstrual, postpartum, and perimenopausal affective disorders

  • Andrea J. Rapkin
  • Judith A. Mikacich
  • Babak Moatakef-Imani
  • Natalie Rasgon


Various mood and anxiety disorders are more prevalent in reproductive-aged women, and appear to be linked to hormonal and reproductive events. Premenstrual affective disorders consist of premenstrual syndrome, premenstrual dysphoric disorder, and premenstrual exacerbation of mood or anxiety disorders. Postpartum affective disorders can range from postpartum “blues” to postpartum depression with or without psychosis, and also include anxiety disorders, such as panic disorder, generalized anxiety disorder, social phobia, and obsessive-compulsive disorder. In perimenopausal women, the vulnerability to mood and anxiety disorders is increased. All of these disorders share risk factors, and have etiologic features in common, such as exposure to the rise and fall of ovarian sex steroids. The following is a review of these syndromes and their etiology, diagnosis, and treatment.


Anxiety Disorder Luteal Phase Panic Disorder Postpartum Depression Allopregnanolone 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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References and Recommended Reading

  1. 1.
    Weissman MM, Klerman GL: Sex differences and the epidemiology of depression. Arch Gen Psychiatry 1977, 34:98–111.PubMedGoogle Scholar
  2. 2.
    Freeman MP, Smith KW, Freeman SA, et al.: The impact of reproductive events on the course of bipolar disorder in women. J Clin Psychiatry 2002, 63:284–287.PubMedGoogle Scholar
  3. 3.
    Harrison WM, Rabkin JG, Endicott J: Psychiatric evaluation of premenstrual changes. Psychosomatics 1985, 26:789–799.PubMedGoogle Scholar
  4. 4.
    American College of Obstetricians and Gynecologists: ACOG Practice Bulletin: Premenstrual Syndromes. Washington, DC; American College of Obstetricians and Gynecologists: 2000:1–9.Google Scholar
  5. 5.
    Freeman EW, Schweizer E, Rickels K: Personality factors in women with premenstrual syndrome. Psychosom Med 1995, 57:453–459.PubMedGoogle Scholar
  6. 6.
    Soares CN, Cohen LS, Otto MW, Harlow BL: Characteristics of women with premenstrual dysphoric disorder (PMDD) who did or did not report history of depression: a preliminary report from the Harvard Study of Moods and Cycles. J Womens Health Gend Based Med 2001, 10:873–878.PubMedCrossRefGoogle Scholar
  7. 7.
    Hammarback S, Damber JE, Backstrom CT: Relationship between symptom severity and hormone changes in women with premenstrual syndrome. J Clin Endocrinol Metab 1989, 68:125–130.PubMedGoogle Scholar
  8. 8.
    Pearlstein TB, Frank E, Rivera-Tovar A, et al.: Prevalence of axis I and axis II disorders in women with late luteal phase dysphoric disorder. J Affect Disord 1990, 20:129–134.PubMedCrossRefGoogle Scholar
  9. 9.
    Rapkin AJ: Progesterone, GABA and mood disorders in women. Arch Womens Ment Health 1999, 2:97–105.CrossRefGoogle Scholar
  10. 10.
    Rapkin AJ, Mikacich JA: Premenstrual syndrome: gynecology or psychiatry? Reprod Med Rev 2001, 9:223–239.CrossRefGoogle Scholar
  11. 11.
    Holzbauer M: Physiological aspects of steroids with anaesthetic properties. Med Biol 1976, 54:227–242.PubMedGoogle Scholar
  12. 12.
    Smith SS, Gong QH, Hsu FC, Markowitz RS, et al.: GABAA receptor alpha-4 subunit suppression prevents withdrawal properties of an endogenous steroid. Nature 1998, 392:926–929.PubMedCrossRefGoogle Scholar
  13. 13.
    Rapkin AJ, Morgan M, Goldman L, et al.: Progesterone metabolite allopregnanolone in women with premenstrual syndrome. Obstet Gynecol 1997, 90:709–714.PubMedCrossRefGoogle Scholar
  14. 14.
    Monteleone P, Luisi S, Tonetti A, et al.: Allopregnanolone concentrations and premenstrual syndrome. Eur J Endocrinol 2000, 142:269–273.PubMedCrossRefGoogle Scholar
  15. 15.
    Wang M, Seippel L, Purdy RH, Backstrom T: Relationship between symptom severity and steroid variation in women with premenstrual syndrome: study on serum pregnenolone, pregnenolone sulfate, 5 alpha-pregnane-3, 20-dione and 3 alpha-hydroxy-5 alpha-pregnan-20-one. J Clin Endocrinol Metab 1996, 81:1076–1082.PubMedCrossRefGoogle Scholar
  16. 16.
    Schmidt PJ, Purdy RH, Moore PH, et al.: Circulating levels of anxiolytic steroids in the luteal phase in women with premenstrual syndrome and in control subjects. J Clin Endocrinol Metab 1994, 79:1256–1260.PubMedCrossRefGoogle Scholar
  17. 17.
    Girdler SS, Straneva PA, Light KC, et al.: Allopregnanolone levels and reactivity to mental stress in premenstrual dysphoric disorder. Biol Psychiatry 2001, 49:788–797.PubMedCrossRefGoogle Scholar
  18. 18.
    Sundstrom I, Andersson A, Nyberg S, et al.: Patients with premenstrual syndrome have a different sensitivity to a neuroactive steroid during the menstrual cycle compared to control subjects. Neuroendocrinology 1998, 12:16–18.Google Scholar
  19. 19.
    Uzunov DP, Cooper TB, Costa E, Guidotti A: Fluoxetine-elicited changes in brain neurosteroid content measured by negative ion mass fragmentography. Proc Natl Acad Sci U S A 1996, 93:599–604.CrossRefGoogle Scholar
  20. 20.
    Pearlstein TB, Stone AB, Lund SA, et al.: Comparison of fluoxetine, bupropion, and placebo in the treatment of premenstrual dysphoric disorder. J Clin Psychopharmacol 1997, 17:261–266.PubMedCrossRefGoogle Scholar
  21. 21.
    Steiner M, Steinberg S, Stewart D, et al.: Fluoxetine in the treatment of premenstrual dysphoria. N Engl J Med 1995, 332:1529–1534.PubMedCrossRefGoogle Scholar
  22. 22.
    Yonkers KA, Halbreich U, Freeman E, et al.: Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment: a randomized controlled trial. JAMA 1997, 278:983–988.PubMedCrossRefGoogle Scholar
  23. 23.
    Halbreich U, Smoller JW: Intermittent luteal phase sertraline treatment of dysphoric premenstrual syndrome. J Clin Psychiatry 1997, 58:399–402.PubMedGoogle Scholar
  24. 24.
    Wikander L, Sundblad C, Andersch B, et al.: Citalopram in premenstrual dysphoria: is intermittent treatment during luteal phases more effective than continuous medication throughout the menstrual cycle? J Clin Psychopharmacol 1998, 18:390–398.PubMedCrossRefGoogle Scholar
  25. 25.
    Freeman EW, Rickels K, Yonkers KA, et al.: Venlafaxine in the treatment of premenstrual dysphoric disorder. Obstet Gynecol 2001, 98:737–744. Venlafaxine is shown in this randomized, controlled trial to be significantly more efficacious than placebo in the treatment of PMDD, reinforcing the use of SSRIs in premenstrual mood disorders.PubMedCrossRefGoogle Scholar
  26. 26.
    Muse KN, Cetel NS, Futterman LA, Yen SSC: The premenstrual syndrome: effects of "medical ovariectomy." N Engl J Med 1984, 311:1345–1349.PubMedCrossRefGoogle Scholar
  27. 27.
    Mortola JF, Girton L, Fischer U: Successful treatment of severe premenstrual syndrome by combined use of gonadotropinreleasing hormone agonist and estrogen/progestin. J Clin Endocrinol Metab 1991, 71:252–252.CrossRefGoogle Scholar
  28. 28.
    Mezrow G, Shoupe D, Spicer D, et al.: Depot leuprolide acetate with estrogen and progestin add-back for long-term treatment of premenstrual syndrome. Fertil Steril 1994, 62:932–937.PubMedGoogle Scholar
  29. 29.
    Halbreich U, Rojansky N, Palter S: Elimination of ovulation and menstrual cyclicity (with danazol) improves dysphoric premenstrual syndromes. Fertil Steril 1991, 56:1066–1069.PubMedGoogle Scholar
  30. 30.
    Freeman EW, Kroll R, Rapkin A, et al.: Evaluation of a unique oral contraceptive in the treatment of premenstrual dysphoric disorder. J Womens Health Gend Based Med 2001, 20:561–596. The authors present data supporting the use of a novel oral contraceptive containing the progestin drospirenone, a spironolactone derivative, in the treatment of PMDD.CrossRefGoogle Scholar
  31. 31.
    Lam RW, Carter D, Misri S, et al.: A controlled study of light therapy in women with late luteal phase dysphoric disorder. Psychiatry Res 1999, 86:185–192.PubMedCrossRefGoogle Scholar
  32. 32.
    Steinberg S, Annable L, Young SN, Liyanage N: A placebo-controlled clinical trial of L-tryptophan in premenstrual dysphoria. Biol Psychiatry 1999, 45:313–320.PubMedCrossRefGoogle Scholar
  33. 33.
    Thys-Jacobs S, Starkey P, Bernstein D, Tian J: Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Am J Obstet Gynecol 1998, 179:444–452.PubMedCrossRefGoogle Scholar
  34. 34.
    Civic D, Holt UL: Maternal depressive symptoms and child behavior problems in nationally representative normal birth weight sample. Matern Child Health J 2000, 4:251–261.CrossRefGoogle Scholar
  35. 35.
    Small R, Brown S, Lumley J, Astbury J: Missing voices: what women say and do about depression after childbirth. J Reprod Infant Psychol 1994, 12:19–22.Google Scholar
  36. 36.
    Brown S, Lumley J: Physical health problems after childbirth and maternal depression at six to seven months postpartum. Br J Obstet Gynaecol 2000, 107:1194–2001.Google Scholar
  37. 37.
    Jones HW, Venis JA: Identification and classification of postpartum psychiatric disorders. J Psychol Nursing 2001, 39:23–29.Google Scholar
  38. 38.
    Hapgood CC, Elkind GS, Wright JJ: Maternity blues: phenomena and relationship to later postpartum depression. Aust N Z J Psychiatry 1988, 22:299–306.PubMedGoogle Scholar
  39. 39.
    Harris B, Lovett L, Newcombe RG, et al.: Maternity blues and major endocrine changes. BMJ 1994, 308:949–953.PubMedGoogle Scholar
  40. 40.
    Nappi R, Petraglia F, Luisi S, et al.: Serum allopregnanolone in women with postpartum blues. Obstet Gynecol 2001, 97:77–80. The authors showed that serum levels of allopregnanolone were significantly decreased in postpartum women with "maternity blues," confirming the importance of neuroactive metabolites in the psychologic adjustments to pregnancy and motherhood.PubMedCrossRefGoogle Scholar
  41. 41.
    Jossefson A, Berg G, Nardin C, et al.: Prevalence of depressive symptoms in late pregnancy and postpartum. Acta Obstet Gynecol Scand 2001, 80:251–255.CrossRefGoogle Scholar
  42. 42.
    American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorder, edn 4. Washington, DC: American Psychiatric Press; 1994.Google Scholar
  43. 43.
    Harris B, Huckle P, Thomas R, et al.: The hormonal environment of postnatal depression. Br J Psychiatry 1989, 154:660–667.PubMedGoogle Scholar
  44. 44.
    Dankner R, Goldberg RP, Fisch RZ, Crum RM: Cultural elements of postpartum depression: a study of 327 Jewish Jerusalem women. J Reprod Med 2000, 45:97–104.PubMedGoogle Scholar
  45. 45.
    O’Hara MW, Schlecte JA, Lewis DA, et al.: Controlled prospective study of postpartum mood disorders. J Abnorm Psychol 1991, 100:63–73.PubMedCrossRefGoogle Scholar
  46. 46.
    Jennings KD, Ross S, Popper S, et al.: Thought of harming infants in depressed and not depressed mothers. J Affect Disord 1999, 54:21–28.PubMedCrossRefGoogle Scholar
  47. 47.
    Miller LJ: Pharmacotherapy during the perinatal period. Dir Psychiatry 1998, 18:49–63.Google Scholar
  48. 48.
    Altshuler LL, Cohen SL, Moline ML, et al.: The expert consensus guideline series: treatment of depression in women 2001. Postgrad Med 2001, 110:1–116. This special report consists of the composite recommendations of a panel of women’s health experts in the treatment of depression during various reproductive life stages.Google Scholar
  49. 49.
    Hendrick V, Fukuchi A, Altshuler L, et al.: Use of sertraline, paroxetine and fluvoxamine by nursing women. Br J Psychiatry 2002, 180:85–86.CrossRefGoogle Scholar
  50. 50.
    Burch KG, Wells BG: Fluoxetine/norfluoxetine concentration in mother’s milk. Pediatrics 1992, 89:676–677.PubMedGoogle Scholar
  51. 51.
    Ahokas A, Kaukoranata J, Wahlbeck K, Aito M: Estrogen deficiency in severe postpartum depression: successful treatment with sublingual physiologic 17-beta-estradiol. A Preliminary Study. J Clin Psychiatry 2001, 62:332–336.PubMedCrossRefGoogle Scholar
  52. 52.
    Klier CM, Muzik M, Rosenblum KL, Lenz G: Interpersonal psychotherapy adapted for the group setting in the treatment of postpartum depression. J Psycother Pract Res 2000, 10:124–131.Google Scholar
  53. 53.
    Misri S, Kostaras X, Fox D, et al.: The impact of partner support in the treatment of postpartum psychosis. Can J Psychiatry 2000, 45:554–558.PubMedGoogle Scholar
  54. 54.
    Berle JO: Severe postpartum depression and psychosis: when is electroconvulsive therapy the treatment of choice? Tidsskr Nor Laegeforen 1999, 30:3000–3003.Google Scholar
  55. 55.
    Attia E, Downey J, Oberman M: Postpartum psychosis. In In Postpartum Mood Disorder, Edited by Miller LJ. Washington DC: American Psychiatric Press; 1999:99–117.Google Scholar
  56. 56.
    Kendel RE, Chalmers JC, Platz C: Epidemiology of puerperal psychoses. Br J Psychiatry 1987, 150:662–673.CrossRefGoogle Scholar
  57. 57.
    Rohde A, Marneros A: Postpartum psychosis: onset and long term course. Psycho Path 1993, 26:203–209.Google Scholar
  58. 58.
    Parry BL: Postpartum psychiatric syndrome. In In Comprehensive Textbook of Psychiatry, vol 1. Edited by Kaplan H, Sandock B. Philadelphia: Williams & Wilkins; 1990:1059–1066.Google Scholar
  59. 59.
    Aokas A, Aito M, Rimon R: Positive treatment effect of estradiol in postpartum psychosis: a pilot study. J Clin Psychiatry 2000, 61:166–169.CrossRefGoogle Scholar
  60. 60.
    Hendrick V, Altshuler L, Suri R: Hormonal change in postpartum and amplification for postpartum depression. Psychosomatics 1998, 39:93–101.PubMedGoogle Scholar
  61. 61.
    Burt VK, Hendrick VC: Women’s Mental Health. Washington, DC: American Psychiatric Press; 1997:63–77.Google Scholar
  62. 62.
    Stewart DE, Klompen Havwer JL, Kendell RE, Van Hulst AM: Prophylactic lithium in puerperal psychosis: the experience of three centers. Br J Psychiatry 1991, 158:393–397.PubMedGoogle Scholar
  63. 63.
    Bourdon KH, Boyd JH, Rae DS, et al.: Gender differences in phobias: results of the ECA community survey. J Anxiety Disord 1998, 2:227–241.CrossRefGoogle Scholar
  64. 64.
    Brown CS: Depression and anxiety disorder. Obstet Gynecol Clin North Am 2001, 28:241–268.PubMedCrossRefGoogle Scholar
  65. 65.
    Williams KE, Koran LM: Obsessive-compulsive disorder in pregnancy, the puerperium and the premenstrual. J Clin Psychiatry 1997, 58:330–334.PubMedGoogle Scholar
  66. 66.
    Chambless DL, Sanderson WC: An update on empirically validated therapies. Clin Psychol 1996, 49:5–22.Google Scholar
  67. 67.
    Craske MG, Brown TA, Barlow DH: Behavioral treatment of panic disorder: a two-year follow-up. Behav Ther 1991, 22:289–304.CrossRefGoogle Scholar
  68. 68.
    Weisberg RB, Paquette JA: Screening and treatment of anxiety disorders in pregnant and lactating women. Womens Health Issues 2002, 12:32–36.PubMedCrossRefGoogle Scholar
  69. 69.
    Harlow BL, Cohen LS, Otto MW, et al.: Prevalence and predictors of depressive symptoms in older premenopausal women. Arch Gen Psychiatry 1999, 56:418–424. The results of questionnaires sent to women aged 36 to 44 years corroborate the prevalence of depression reported by other community-based studies. In addition, the results support a relationship between depressive symptoms and various risk factors: marital status, cigarette smoking, nulliparity, and premenstrual symptoms.PubMedCrossRefGoogle Scholar
  70. 70.
    Novaes C, Almeida OP: Premenstrual syndrome and psychiatric morbidity at the menopause. J Psychosom Obstet Gynecol 1999, 20:56–57.Google Scholar
  71. 71.
    Novaes C, Almeida OP, de Melo NR: Mental health among perimenopausal women attending a menopause clinic: possible association with premenstrual syndrome? Climacteric 1998, 1:264–270.PubMedGoogle Scholar
  72. 72.
    Avis NE, Brambilla D, McKinlay SM, Vass K: A longitudinal analysis of the association between menopause and depression: results from the Massachusetts Women’s Health Study. Ann Epidemiol 1994, 4:214–220.PubMedCrossRefGoogle Scholar
  73. 73.
    Judd HL, Fournet N: Changes of ovarian hormonal function with aging. Exp Gerontol 1994, 29:285–298.PubMedCrossRefGoogle Scholar
  74. 74.
    Schmidt PJ, Roca CA, Bloch M, Rubinow DR: The perimenopause and affective disorders. Semin Reprod Endocrinol 1997, 15:91–100.PubMedCrossRefGoogle Scholar
  75. 75.
    Banger M: Affective syndrome during perimenopause. Maturitas 2002, 41(suppl):S13-S18.PubMedCrossRefGoogle Scholar
  76. 76.
    Joffe H, Cohen LS: Estrogen, serotonin, and mood disturbance: where is the therapeutic bridge? Biol Psychiatry 1998, 44:798–811.PubMedCrossRefGoogle Scholar
  77. 77.
    Becht MC, Van Erp CF, Teeuwisse TM, et al.: Measuring depression in women around menopausal age: toward a validation of the Edinburgh Depression Scale. J Affect Disord 2001, 63:209–213.PubMedCrossRefGoogle Scholar
  78. 78.
    Sagsoz N, Oguzturk O, Bayram M, Kamaci M: Anxiety and depression before and after the menopause. Arch Gynecol Obstet 2001, 264:199–202.PubMedCrossRefGoogle Scholar
  79. 79.
    Beck AT, Waard CH, Mendelson M, et al.: An inventory for measuring depression. Arch Gen Psychiatry 1961, 4:561–571.PubMedGoogle Scholar
  80. 80.
    Hilditch JR, Lewis J: The menopause-specific quality of life questionnaire. Maturitas 1996, 24:161–175.PubMedGoogle Scholar
  81. 81.
    McEwen BS, Alves SE, Bulloch K, Weiland NG: Ovarian steroids and the brain: implications for cognition and aging. Neurology 1997, 48(suppl):S8-S15.PubMedGoogle Scholar
  82. 82.
    Parry BL, Newton RP: Chronobiological basis of female-specific mood disorders. Neuropsychopharmacology 2001, 25:S102-S108.PubMedCrossRefGoogle Scholar
  83. 83.
    Soares CN, Almeida OP, Joffe H, Cohen LS: Efficacy of estradiol for the treatment of depressive disorders in perimenopausal women: a double blind, randomized, placebo-controlled trial. Arch Gen Psychiatry 2001, 58:529–534.PubMedCrossRefGoogle Scholar
  84. 84.
    Schmidt PJ, Nieman L, Danaceau MA, et al.: Estrogen replacement in perimenopause-related depression: a preliminary report. Am J Obstet Gynecol 2000, 183:414–420. This report of a randomized, controlled trial of 17-beta-estradiol in depressed perimenopausal women demonstrates the effectiveness of estrogen in treating perimenopausal depression independent of its effectiveness in alleviating vasomotor symptoms.PubMedCrossRefGoogle Scholar
  85. 85.
    Hollander LE, Freeman EW, Sammel MD, et al.: Sleep quality, estradiol levels, and behavioral factors in late reproductive age women. Obstet Gynecol 2001, 98:391–397.PubMedCrossRefGoogle Scholar
  86. 86.
    Altshuler LL: The use of SSRIs in depressive disorders specific to women. J Clin Psychiatry 2002, 63(suppl):3–8.PubMedGoogle Scholar
  87. 87.
    Rasgon NL, Altshuler LL, Fairbanks LA, et al.: Estrogen replacement therapy in the treatment of major depressive disorder in perimenopausal women. J Clin Psychiatry 2002, 63(suppl):45–48.PubMedGoogle Scholar
  88. 88.
    Casper RF, Dodin S, Reid RL, et al.: The effect of 20 mg ethinyl estradiol/1 mg norethindrone acetate, a low-dose oral contraceptive, on vaginal bleeding patterns, hot flashes, and quality of life in symptomatic perimenopausal women. J North Am Menopause Soc 1997, 4:139–147.Google Scholar

Copyright information

© Current Science Inc 2002

Authors and Affiliations

  • Andrea J. Rapkin
    • 1
  • Judith A. Mikacich
  • Babak Moatakef-Imani
  • Natalie Rasgon
  1. 1.Department of Obstetrics and GynecologyUniversity of California, Los Angeles Medical CenterLos AngelesUSA

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