Recently there has been a lot of publicity around the topic of postpartum depression (PPD). Typically the reports originate from a case where depression led to catastrophic consequences. It is sad that it often takes a tragedy before a problem like this is publicly more acknowledged. But sadly reports are often one-sided and are missing vital information about preexisting risk factors that are frequently not picked up by the family doctor. There is often denial on behalf of the mother and family, the mother is getting no support from support groups, even though there are such groups. And swift treatment that would be available is often not given. The results are finally making headlines. Once a mother is desperate and deeply depressed (“psychotic depression”) she is capable of killing the baby, herself and others who are close. PPD affects 15% of mothers (Ref.1); a small percentage of them may have postpartum psychosis, which is the most severe form of PPD.
Risk factors for postpartum depression
In Ref. 1 several risk factors are reviewed that can lead to postpartum depression. For instance, a history of a major depressive episode or anxiety attacks during the pregnancy has been found among mothers who developed PPD. However, there may also have been a history of dysphoria (intense feeling of discontent) before her periods in the past; stressful events during the pregnancy or right after birth. Often there is poor social support or a marital conflict. Other factors are low income, young maternal age or immigrant status with deprivation. A lack of support from the partner can also be a major factor.
Up to 85% of women experience postpartum blues within the first 10 days after the delivery of the baby. Symptoms such as mood swings, fatigue, confusion, tearfulness, mild elation and irritability are common during these initial days following her delivery. Progesterone levels following delivery are decreased for at least one month, sometimes up to 3 months. This leads to sleep problems (insomnia), which coupled with the baby crying in the middle of the night causes more sleep disruption. Abnormal brain wave pattern have been documented on women following the birth of a child.
Only 1 in 500 mothers after birth develop what physicians call “postpartum psychosis”, which is a recognized psychiatric emergency. The symptoms here are extreme mood swings with confusion, poor judgment, disordered thoughts (“delusions”), paranoia (where they think that someone is after them or it is the baby’s fault that they feel that way). Erratic behavior and impaired functioning are also part of this symptom complex. It is this state that needs to be monitored in a psychiatric unit as it is associated with a high suicide and homicide rate. A psychiatrist with experience in treating PPD needs to treat the patient.
Urbanization leads to a lack of support, which is particularly devastating to new mothers who need all the support they can get. This is reflected in a higher percentage of PPD in urban areas versus the percentage of PPD in more rural areas where there is more family support.
Hormone changes with postpartum depression
Some people would say that they couldn’t understand why a woman who just had a baby would not be happy and content. Most women are, but if the stress from the pregnancy and from childbearing were too much for the system, there is a point where the hormones are no longer balanced and the coping mechanisms are undermined.
Serotonin concentrations in the brain of women during pregnancy are kept at a higher level due to higher estrogen levels that slow down the degradation of serotonin. Serotonin is the brain hormone that makes you feel good. Estrogens and progesterone are very high during the pregnancy, but this changes right after the baby’s delivery and during the time of recovery in the first few days and weeks. Studies have shown that there was a 15% higher thyroid autoantibody rate in postpartum depression patients when compared to non-depressed postpartum mothers. This was weakly associated with postpartum depression and was responding favorably to thyroid replacement therapy. Progesterone levels were much lower in depressed and nondepressed patients following delivery because with the delivery the placental source of natural progesterone was removed. In a group of patients where progesterone was replaced, no significant improvement of PPD was observed, but they did not explain whether the progesterone replacement was done with bioidentical hormones or synthetic hormones.
Dr. Michael Platt described a case of a postpartum woman who was hypothyroid as well (Ref.2). She responded to hormone replacement with thyroid hormones and progesterone by shedding 60 pounds (she always had a weight problem) over 10 months changing from a size 20 to a size 4. She was able to wean herself off the anti-depressants. In breast feeding women this could be a significant difference as women on bioidentical progesterone can breast feed and will positively influence their breast fed child’s brain development (brain cells have a lot of progesterone receptors, which are stimulated by progesterone).
A recent Canadian study involving pregnant women and women after delivery of their babies showed that there was a significant drop of progesterone levels in saliva samples for several weeks, particularly with breast feeding. The authors explained that the lack of ovulation with a lack of progesterone synthesis in the ovaries was responsible for this. It takes several weeks for most women to regain regular menstrual cycles. It would follow from this that there is room for bioidentical progesterone replacement in the first few months of the postpartum period until the ovaries have resumed their normal cyclical hormone activity.
Conventional treatment for postpartum depression
With baby blues the symptoms are much less severe (compared to PPD) and are starting 2 to 3 days after childbirth, resolving spontaneously within 10 days after delivery. PPD occurs within 3 months following delivery and responds to treatment with antidepressants and psychotherapy such as cognitive behavioral therapy. Breast feeding needs to be stopped, as it is known that metabolites of the antidepressants end up in breast milk. Typically, a less toxic antidepressant is used like paroxetine (Paxil), otherwise citalopram (Celexa), and fluoxetine (Prozac). In the rare cases where PPD is so severe that psychotic symptoms are present (postpartum psychosis) hospitalization is mandatory (Ref.3). Some of these cases may require electroconvulsive therapy (ECT) and/or lithium treatment for mood stabilization. Thyroid hormone therapy has also shown a beneficial effect in treating antidepressant-resistant cases of PPD (Ref.4).
Alternative treatment of postpartum depression
Although review texts of the treatment of PPD mention that estrogen replacement in postnatal women with PPD was beneficial, there is a warning that this could cause blood clots and anticoagulant measures would have to be combined with this to prevent deep vein thrombosis; suggestions for progesterone replacement were mentioned, which is a treatment modality where blood clots are no danger, but formal trials have not been done, so it is being ignored by most medical professionals. Here is forum of women who have taken postpartum progesterone with positive effects.
Dr. Katherina Dalton published a trial involving 30 PPD patients with a positive response rate of 95% when treated with natural progesterone.
Before treatment patients were suffering from an average of 7.57 symptoms, after the treatment only 2.1 symptoms remained. (Figures with details regarding this study can be found under the above link).
There are many uncontrolled observations like this where natural progesterone creams are incorporated into a holistic approach to treating PPD. Dr. Mercola describes here how useful natural progesterone therapy can be. He also cautions that it should be taken cyclically to mimic nature’s biorhythm to allow progesterone receptors to recover in between treatments.
There are many websites that have useful information about natural progesterone cream treatment for PPD, such as this.
It is common sense that a woman may need natural progesterone following a delivery, because she just got rid of her placenta, which was a virtual progesterone factory protecting her body and the baby’s brain all throughout the pregnancy. Even if a woman decides to only use natural progesterone in a cyclical fashion for 3 to 6 months, the majority of women would not experience the baby blues or PPD. When regular menstrual cycles have been re established, the patient’s own ovarian progesterone production has resumed and progesterone cream is no longer needed until after the birth of the next child or at the arrival of menopause. Medicine is full of examples where common sense was applied for effective treatment options despite missing randomized studies.
Natural progesterone treatment of PPD is one such example, where intuitively it was tried and it worked in many patients. Whether or not a randomized trial has been done does not concern the progesterone receptors (they just do not like the synthetic versions of progesterone, as they block the receptors leading to progesterone deficiency!). Natural progesterone treatment can also be combined with traditional treatments of PPD.
More information on postpartum depression: http://nethealthbook.com/mental-illness-mental-disorders/mood-disorders/postpartum-depression/
1.Teri Pearlstein, MD, Margaret Howard, PhD, Amy Salisbury, PhD and Caron Zlotnick, PhD: “Postpartum depression” : American Journal of Obstetrics and Gynecology – Volume 200, Issue 4 (April 2009)
2. Dr. Michael E. Platt: The Miracle of Bio-Identical Hormones; 2nd edition, © 2007 Clancy Lane Publishing, Rancho Mirage, Ca/USA (p.53-55).
3. Bope & Kellerman: Conn’s Current Therapy 2013, 1st ed.© 2012 Saunders
4. Jacobson: Psychiatric Secrets, 2nd ed. © 2001 Hanley and Belfus
Last edited Nov. 7, 2014