A commentary on some of the best research in this field published in the past year
portions of this article originally appeared on NASPOG.org in the Winter 2013 newsletter. They are reprinted with the permission of the North American Society for Psychosocial Obstetrics and Gynecology.
By its very nature, the field of obstetrics and gynecology is steeped in psychosocial issues. Because of the complex interplay of hormones and behavior, as well as the many instances in our field when social behaviors affect medical outcomes, psychosocial issues affect nearly all aspects of women’s health. To provide optimal care for women, ob/gyn physicians should be comfortable dealing with such issues and should be knowledgeable about new developments in psychological and social topics that pertain to obstetrics and gynecology. The following highlights of research published within the past year reflect the breadth of issues in the field.
Klevens J, Kee R, Trick W, et al. Effect of screening for partner violence on women’s quality of life: a randomized controlled trial.Journal of the American Medical Association. 2012;308(7):681-689.
While domestic violence is widely viewed as a public health issue with diverse adverse effects on health, the utility of universal screening has not yet been proven to improve outcomes. The authors of this study sought to demonstrate whether a computerized screening tool and routine distribution of information on partner violence improved quality of life (QOL) for a primary care population. They enrolled 2708 women who were attending one of 10 primary health clinics in Cook County, Illinois. The women were randomized into 3 groups: one that was screened for partner violence and given a list of resources if screening was positive, one that received only the list of resources, and a control group that received neither. One year later, participants were asked to complete a series of questionnaires describing QOL issues and mental health. There was no difference among the 3 groups in any QOL measures or mental health components. There were also no differences among the groups in missed work days, hospital or emergency department visits, contact with partner violence agencies, or recurrence of partner violence.
At face value, the results of this study are discouraging in demonstrating a lack of improved health among women screened for intimate partner violence. It may be that a single intervention is insufficient to spur women to seek help for this problem, or that such intervention would be better received from a provider with whom a woman has multiple visits and develops a rapport and trust. The study also suggests that providing a list of resources may not be an effective means of communicating options for intervention.
Universal screening may still have some benefit. Encouraging clinicians to screen all patients for domestic violence keeps the topic in mind so they remain aware of the possibility that this exposure can occur in any social stratum. It also signals to patients that it is an issue that the medical community considers important and worthy of intervention. In any case, it would behoove the medical community to find effective ways to screen for and treat domestic violence rather than giving up on routine screening entirely.
Straub H, Adams M, Kim JJ, Silver RK. Antenatal depressive symptoms increase the likelihood of preterm birth. American Journal of Obstetrics and Gynecology. 2012;207(4):329.e1-4.
Psychosocial stress has been identified as a risk factor for preterm delivery in the past, but the degree to which maternal depression may contribute to preterm labor is unclear. This study aimed to clarify whether such an association exists. The study examined the pregnancy outcomes of 14,175 women who were administered the Edinburgh Postnatal Depression Scale as a routine screening test between weeks 24 and 28 of pregnancy. Women who screened positive were significantly more likely to deliver before 37 weeks (13.9%) than their asymptomatic counterparts (10.3%), with an adjusted odds ratio of 1.3 (95% CI, 1.09-1.35). Significant differences were demonstrated at each gestational age breakpoint (< 28, < 32, and < 34 weeks), and there was also an increased risk in screen-positive women among the 1019 with prior preterm birth.
It is unclear whether the differences demonstrated in this study reflect a causal effect or simply association. There is a biologically plausible mechanism to explain earlier delivery in depressed women, in that depression may be associated with derangements of the hypothalamic-pituitary axis and elevated levels of corticotropin-releasing hormone (CRH). Studies have linked excessive CRH levels to preterm birth. On the other hand, a number of other factors may be involved, including other stressors in the home environment, sleep hygiene, nutrition, and access to and use of health care. Nevertheless, this study contributes to the growing body of evidence that depression adversely affects pregnancy, and that treatment for symptomatic women should not be withheld during pregnancy. Whether intervention with antidepressants or psychotherapy can reduce the risk of preterm delivery in this group remains to be seen.
Baller EB, Wei SM, Kohn PD, et al. Abnormalities of dorsolateral prefrontal function in women with premenstrual dysphoric disorder: a multimodal neuroimaging study.American Journal of Psychiatry. 2013;170(3):305-314.
Premenstrual dysphoric disorder (PMDD) is a condition marked by profound changes in affect, cognition, and behavior in the luteal phase, yet there are no hormonal markers to differentiate women with this disorder from healthy controls. This study was done to determine how brain function differs in women with PMDD by using neuroimaging of brain areas that are likely to be affected during luteal phase symptoms. The authors compared the functional magnetic resonance imaging (fMRI) scans of 14 women with prospectively documented PMDD and 14 controls during each of 3 hormonal conditions: leuprolide-induced ovarian suppression, leuprolide with estradiol, and leuprolide with progesterone. Positron emission tomography (PET) scans were also performed on 15 women in each category. Women were given a memory task to perform during the scan to assess prefrontal function. In both PET and fMRI scans, a greater prefrontal activation was observed in women with a diagnosis of PMDD, indicating dysregulation in the working memory neural circuitry. Furthermore, these changes appeared to be more pronounced in women with greater degrees of PMDD-related symptomatology.
Women suffering from PMDD are often frustrated by the common perception that it is not a legitimate disease, or that it is merely an exaggeration of normal premenstrual symptoms. The lack of measurable hormonal changes that identify susceptible women has not helped their case, and has frustrated researchers seeking to identify novel treatments for refractory cases. By identifying a reproducible, biological phenomenon that differentiates women with PMDD from normal controls, this study legitimizes PMDD as a condition based in changes of brain physiology. It may also help to direct future research that will improve function and QOL for women who struggle with this condition.
Toffol E, Heikinheimo O, Koponen P, et al. Further evidence for lack of negative associations between hormonal contraception and mental health. Contraception. 2012;86(5):470-480.
Although hormonal contraception (HC) is generally well-tolerated and has few adverse effects, concern remains among segments of the public that its use will have an adverse effect on mood. The authors of this study aimed to clarify whether there is a difference in affect and psychological symptoms between HC users and nonusers. The study analyzed data obtained as part of a large cross-sectional population study carried out every 5 years in Finland. Information was analyzed from 8586 women of reproductive age who were asked about various aspects of reproductive health and screened with a modified Beck Depression Inventory (BDI) as well as a questionnaire on somatic and psychological symptoms. Women using combined oral contraceptives were compared to women using the levonorgestrel intrauterine device (IUD) and to women who were not using HC. Although the group using oral contraceptives tended to be younger, more educated, and single, there was an association between oral contraceptive use and lower BDI score (indicating better mood) that persisted after controlling for these confounding factors. No noteworthy associations were apparent between IUD use and any of the items of interest.
Literature on the mental health side effects of HC has been inconsistent. Studies examining the reasons for discontinuation of effective contraception often list changes in mood or well-being as contributing factors. This population-based study suggests that not only do oral contraceptives not have a negative impact on mood, but they might actually improve it. Certainly, it would be unreasonable to suggest that oral contraceptives should be prescribed with the intention of mood elevation, and there will no doubt be idiosyncratic reactions among subgroups of women vulnerable to depressed mood. Still, prescribers can remain confident that HCs should not be expected to contribute to depressed mood, and women considering starting these methods should know that such an effect is unlikely.
Erekson EA, Martin DK, Zhu K et al. Sexual function in older women after oophorectomy.Obstetrics and Gynecology. 2012;120(4):833-842.
Perimenopausal women undergoing hysterectomy are often counseled that surgical menopause may have a detrimental effect on postoperative sexual function, although the literature examining sexual function following oophorectomy is conflicting. The authors of this study compared sexual function in older women who had undergone bilateral oophorectomy with those who had not. They analyzed data from 1352 women between the ages of 57 and 85 who were part of the National Social Life, Health and Aging Project. Because sexual ideation would not be affected by the presence of a partner or physical limitations, this was made the primary outcome of interest. The 26% of women who had undergone oophorectomy were not significantly different in measures of sexual ideation or function from the women whose ovaries remained intact.
Women who are deciding whether or not to retain their ovaries at the time of hysterectomy are often counseled about sexual side effects that may result from their surgery. Oophorectomy, according to conventional wisdom, may have a detrimental effect on sexual function, presumably by eliminating the small amount of testosterone still secreted by the postmenopausal ovary, the clinical significance of which is unclear. This study adds to the growing body of evidence that sexual function in older women is multifactorial and not likely to be influenced in the long term by small changes in androgen concentration. Women faced with the decision of whether to remove their ovaries can base their decisions on other medical issues, and need not feel that the surgery will doom them to less-fulfilling sex lives.
Mozurkewich EL, Clinton CM, Chilimigras JL, et al. The Mothers, Omega-3, and Mental Health Study: a double-blind, randomized controlled trial. American Journal of Obstetrics and Gynecology. 2013;208(4):313.e1-9.
Fish oils are being increasingly used as food supplements for a variety of medical indications, including depressed mood. Women with low levels of omega-3 fatty acids, found in these oils, are more likely to develop perinatal depression. In this study, the authors explore the hypothesis that supplementation with docosahexaenoic acid (DHA) or eicosapentaenoic acid (EPA) may prevent depression in women at risk. They enrolled 126 pregnant women with either a history of depression or a moderately elevated score on the Edinburgh Postnatal Depression Scale. The women were randomized to receive either a fish oil rich in DHA, a fish oil rich in EPA, or a soy oil placebo. Although serum levels of fatty acids rose appropriately in the groups receiving supplements, there were no significant differences among the groups in measures of depressed mood at 26-28 weeks, 34-36 weeks, and 6-8 weeks postpartum. Those who had used the DHA supplement delivered at later gestational age and their infants had higher birth weights on average.
Depression in pregnancy and the postpartum period may be associated with significant morbidity, and medications to treat or prevent this condition may improve both maternal and fetal well-being. Rather than use antidepressants that are proven effective but carry a small risk of adverse effect, many patients are drawn to so-called natural remedies that are perceived to be safe. While fish oils have been demonstrated to have some use in preventing depression in the general population, this study shows no benefit in using them for this purpose in pregnancy. For now, it would appear that antidepressants such as selective serotonin reuptake inhibitors remain a better choice for patients at risk of significant morbidity associated with peripartum depression.
Dr. Schaffir is the president of the North American Society for Psychosocial Obstetrics and Gynecology and Associate Professor in the Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, Columbus.
The North American Society for Psychosocial Obstetrics and Gynecology is a multidisciplinary group comprised of gynecologists, psychiatrists, social workers, and psychologists whose goal is to encourage scientific study and clinical discourse on psychosocial issues in women’s health.