I originally wanted to write a post about the use of hormones as a treatment in postpartum depression, but I was unable to find an article from a legitimate source on this. If you know of one, please do share! Instead, I will be reviewing an article called Low Levels of ‘Anti-Anxiety’ Hormone Linked to Postpartum Depression found in Johns Hopkins News.
I really like that this article initially focuses on why this type of research is important: the health of the infant. We spend a lot of time talking about the mother and her symptoms, but in reality, we are trying to help the infant have a better quality of life, which is greatly impacted by a mother with mental illness.
The article then goes on to describe the small study that was performed by Johns Hopkins and the University of North Carolina, while making readers aware of the limitations of the study. Research studies can be easily manipulated to try and persuade people towards a bias, but I think Johns Hopkins News does a good job on reporting why we cannot use this study to draw any definitive conclusions.
I often get the question of whether or not hormone levels should be tested when a woman is experiencing mental illness in the postpartum period. As this article points out, research has shown that the hormone levels in the postpartum period give us no information on whether or not someone will get postpartum depression. In other words, women with postpartum progesterone levels at X amount, are not more likely to get mental illness than those women with postpartum progesterone levels at a higher amount than X. It seems that it is more complicated than simple levels, and that it is more likely the degree at which levels change in a certain subtype of women that makes them more vulnerable to mental illness postpartum.
This study wanted to look at whether progesterone and allopregnanolone levels during pregnancy could help predict which women were more likely to experience a relapse in their mental illness 1 month and 3 months postpartum. All of these women had a previous diagnosis of a mood disorder, and most had more than one mental illness diagnosis. What they found was that progesterone levels in the second and third trimester had no correlation with postpartum relapse. Allopregnanolone (the metabolite of progesterone that acts on neurotransmitters in the brain) levels in the second trimester only, however, was correlated with postpartum mental illness relapse. Interestingly, third trimester levels of allopregnanolone were not. Their hope is that this will lead to further research that can help us predict, with better accuracy, who is more likely to develop postpartum mental illness. Interestingly, allopregnanolone acts on GABA receptors in our brain to decrease anxiety and pain. Brexanolone, the new FDA approved drug for postpartum depression, is the synthetic form of this hormone metabolite.
I want to use this article to point out that research around hormones and their link to perinatal mental illness is still very new. We do not fully understand the ways in which estrogen and progesterone impact our brain health and central nervous system. Furthermore, research has also shown that giving a woman hormone replacements postpartum has no significant improvement in mental health symptoms, except for the new drug, brexanolone. Even the evidence around brexanolone’s treatment of postpartum depression is not very strong in comparison to some other treatments though. This information about hormones postpartum is important for two reasons: First, testing hormone levels postpartum is not evidence-based and has no research supporting its utility in predicting perinatal mental illness. Second, giving hormones postpartum to treat postpartum depression is also not evidence-based. Even though hormones naturally occur in our body, we know from a lot of research that exogenous hormones (hormones that we ingest or absorb) have associated risks. It’s important to have a discussion with a trusted physician prior to taking exogenous hormones for this reason.
By Sarah Rivers Deal, PhD, LPC With Perinatal Loss month in October, I wanted to introduce myself through this blog as well as cast a light in the often dark places that hold this kind of silent, disenfranchised grief. As a psychotherapist that specializes and has been trained in infertility counseling, I too experienced my own reproductive trauma. Five years of fertility and alternative medicine treatments yielded a roller coaster of emotions, existential crises, and ultimately, two small graves in our back yard. Allow me to share something I wrote after my first miscarriage. We read to know that we are not alone – and – you are not alone. If you’re like me, the struggle to create life took over my life. It was all I thought out, dreamt about, planned for, spoke about, made exceptions for, ate for, stopped drinking my favorite red wine for – you name it. Life became hinged on hypotheticals – What if we get pregnant after I accept this new position? What if I accept this invitation then can’t travel in a few months because I’m pregnant? Should we buy the house in the better school district or wait until little one is here? What if little one never gets here? As much as I tried to balance my life, infertility crept in at every turn. In her insightful memoir, The Art of Waiting, Belle Boggs describes this all-consuming experience, calling it the Take Over – “…the problem with infertility is that it is not a patient, serene kind of waiting, not a simple delay in your plans; it happens for many of us in the context of consuming struggle, staggering expense, devastating loss.” Deciding to pursue fertility treatments put my barrenness on the front burner, making it difficult to escape. After five years in fertility clinics, more people had seen my vagina than the inside of my home. What was supposed to be private and magical between my partner and I was now public and scientific. All around me, women were “blessed” with babies, flaunting them as little “miracles.” These terms are especially painful for those struggling to conceive, as it implies that certain people are chosen while others are not. As much as I tried to participate in the world, being around pregnant women or infants was hazardous to my mental health. I remember attending my first baby shower in several years, believing I was safe now because my partner and I were months away from our daughter (by way of adoption) being born. Hope had begun to blossom again in my heart, as I believed that soon I would be a mom too. While I was emotionally prepared for my friend Serena to be eight months pregnant (after years of trying and two miscarriages), I wasn’t informed that the shower host was visibly pregnant too, and to boot – after only one round of I.V.F. with the same doctor I used. As we munched on our blue painted cookies shaped like pacifiers, I learned that the champagne drinking host had a 9-year-old son already, and became recently engaged after finding out about the pregnancy. I wish I could say I genuinely celebrated her happy news, but on the inside, I was fuming. On the drive home, with no other car in sight, I blasted the radio and screamed bloody murder. Despite various challenging life experiences up to this point, I still somehow believed in the concept of justice – a philosophy of how fairness is administered. To put it simply, it seemed unfair to me that this host woman was pregnant and going to be a mom – for the second time – and all I had to show were memorial stones in my yard commemorating two pregnancy losses. Unfair that I had earned high marks for effort and still wasn’t getting to graduate. Unfair that I wasn’t stroking my own belly, marveling at the miracle of science and creation itself. Infertility or perinatal loss may be experienced as an existential crisis, planting seeds of doubt in life questions you thought you had basically addressed, figured out, or had plenty of time to answer. What legacy will I leave behind? Who will carry on my values? Who will remember me after I’m gone? Am I broken? Dr. Anne Malavé, mental health expert in the field of infertility, wrote – “Infertility is like trying to find your children. The child, the imagined and expected child whose presence is palpable yet missing, feels near. It feels like searching for a lost child–you keep looking and searching around every corner. To stop trying can feel like an abandonment of an actual baby, of “my/our own baby.” Pamela Mahoney Tsigdinos in her raw, genuine book Silent Sorority, poignantly captures this existential crisis – “One instant you are like everyone else. The next, you’re not. Your DNA now ends with you. You are infertile. Your branch of the family tree will forever be just a truncated twig. You’ve been denied a rite of passage, a biological imperative. You had no say in the matter. It wasn’t a conscious choice. The comfortable sense of continuity and legacy others take for granted disappears in an instant.” After experiencing perinatal loss in 1999, Amy Douglas poetically wrote: “A life inside me, a love so strong. She died inside me, but the love lives on. It broke my heart for her to go. I love her, I need her like she’ll never know.” If infertility and/or pregnancy loss have ever been downplayed as a less significant human loss, Tsigdinos, Malavé, and Douglas legitimize the profound aftershocks of devastation experienced by those affected. From my personal and professional experience, I want you to know that the takeover is part of the journey. Well- meaning partners and friends might advise you to find a hobby to try to get your mind off of it, to relax, but that probably won’t help. It IS where you are right now, and that’s okay. Most people will be uncomfortable with your discomfort, and you’ll likely receive your fair share of unsolicited and unhelpful advice. Being the recipient of said advice, I tried to remind myself to listen to their intentions, not words. Week after week, clients that struggled with infertility would say something like – “These next few weeks I want to focus on my work and getting back into exercise” or “I want to start hanging out with my friends again and expanding my social circle.” We would set vague or concrete goals, depending on the client, and vow to focus on balance and self-care. And then, week after week, these same clients would come in ashamed, embarrassingly admitting that even if they did go to the gym or see an old friend, the ghost of infertility haunted them. They wanted to be more present in the here-and-now, they really did. Although I truly believe the takeover must run its course, there may be some coping skills and strategies to help it along. And I’m certain that whatever I tell you won’t always work. Some days the takeover will allow some wiggle room to remember the other aspects of your life; other days – it won’t. If you’ve felt quite low more days than not, and for an extended period of time, please check it out with a doctor. I will share with you the most salient professional (and personal) guidance here, and hope that on a few days, it might help. But please, don’t beat yourself up if it doesn’t. Honor the takeover, but also look for windows where you can see the larger picture. 1. Do something that has direct, observable results. You likely have felt powerless for a while. I want to you to do something, no matter how simple, where you can see results. Start with something easy. Make your bed. If you feel relatively competent cooking, use a recipe to create something, then share it with someone. Plant something that you can watch grow. Start with a plant that’s native and more likely to survive; you do not need a failure right now. Rearrange furniture in your space; a new look often evokes new feelings. 2. Practice Self-Compassion Breaks. I adopted this idea from the lovely Dr. Kristin Neff, a self-compassion researcher and professor from my town in Austin, Texas. Here’s the step-by-step process: a) When you notice that the Take Over has happened, say to yourself: “This is a moment of suffering” or “This hurts.” (It may help to place one hand over your heart = self-soothing gesture) b) Then say, “Suffering is a part of life.” c) Then, “May I give myself the compassion or understanding that I need right now.” Then breathe in and out, consciously and with intention. 3. Mindfulness (paying attention on purpose) is an Eastern practice, but its application has hit Western shores, and I’m a firm believer that it’s a necessary healing tool in your toolbox. You can become a conscious consumer of your mind, observing with a curious and gentle sense what’s going on in there. None of us would believe that a face cream could make us look a certain way after a few applications. However, we often experience our thoughts as facts, then experience powerful emotions as a result. It’s important to get some space from our thoughts, and see them for what they are – potentially unhelpful narratives. Use the letters N-N-R to remember the steps: a) Notice. Your mind is an active, interesting narrator that tries to piece information together but often falls short. Become a neutral, curious observer of your mind. Think of it as a radio, always playing music (some songs on repeat). b) Name (thoughts, feelings, body sensations, urges). For example, you may be ruminating (circular thinking that goes nowhere except down) something like “It’s not fair Tamara is pregnant. She didn’t even want another baby” and so on. As soon as you notice you’re stuck on a loop, say to yourself – “That’s a thought” You may notice tightness in your chest. Ask yourself what your feeling. Then say, “I’m having a feeling of sadness.” Noticing and naming gives you critical space to honor what’s going on with you without letting it suck you in automatically. c) Re-engage: Get back to what you were doing before you got caught in the loop. Re-engage in the moment. 4. Make a playlist or soundtrack for various themes throughout your fertility/infertility journey. For example, weeks before my 2nd I.V.F. transfer, I made a compilation of uplifting songs, burned them on a CD that I titled “Hope,” and played it every chance I got. A week after my first miscarriage, I made another playlist, calling it “Coping.” These songs were instrumental in helping me process the often contradictory emotions I experienced. Your body’s limitations don’t define you. Focus on what your body CAN do for you right now. Can you walk, jog, skip, hop, swim, or hug someone? It’s easy and completely understandable to get caught on a failure-loop narrative. But you’re not a failure. This is your roadblock, your life challenge, your grief and sorrow, your call to action. Answer the call, my friends. Above all, be patient with yourself. You are not alone. (Originally written September 2017; Revised September 2020) Dr. Sarah Rivers Deal is an Austin-based licensed professional counselor that specializes in infertility and reproductive trauma. She’s a member of the American Society for Reproductive Medicine (ASRM) and has participated in numerous trainings on infertility counseling and perinatal loss.
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