The Impact of Eating Disorders on Reproductive Health: Mitigating the Risk.

Importance: While eating disorders (EDs) affect people of all ages, reproductive stages, and genders, they are most prevalent in women of reproductive age and can have a profound impact on fertility and obstetric outcomes. Due to the high prevalence and health consequences, EDs in this group of women require specific attention.Objective: To discuss the implications of EDs in infertility, pregnancy, and the postpartum period and to introduce tools to aid in identifying disordered eating and appropriate treatment recommendations for women with suspected EDs.Evidence Review: A comprehensive literature search was conducted of articles available on PubMed, last updated retrieval date March 27, 2023. Chain searching was used to identify other relevant articles. The following search terms were included: (pregnancy OR postpartum) AND (bulimia nervosa OR eating disorder OR anorexia nervosa OR binge eating disorder) AND (obstetric outcome OR infant outcome OR infant development OR depression OR anxiety); (fertility OR infertility) AND (bulimia nervosa OR eating disorder OR anorexia nervosa OR binge eating disorder OR weight suppression OR eating disorder not otherwise specified OR other specified feeding and eating disorder OR atypical anorexia nervosa OR binge eating OR low weight); and eating disorders AND PCOS. Articles pertinent to the impact of eating disorders on fertility and the impact of perinatal eating disorders on infant and mother were selected.Findings: Perinatal EDs impact maternal mental health and obstetric and infant outcomes. They can have a long-lasting effect on the offspring via epigenetic changes. EDs are also a common and treatable cause of infertility.Conclusions and Relevance: Recognition and treatment of EDs in women prior to conception can minimize obstetric risks to the woman and potential long-term adverse effects on the offspring. For women with infertility, recognition and treatment of EDs can increase the probability of conception.Prim Care Companion CNS Disord 2023;25(4):22nr03475. Author affiliations are listed at the end of this article.

Body Dysmorphic Disorder in Women.

Body dysmorphic disorder (BDD) consists of distressing or impairing preoccupation with perceived defects in physical appearance that are actually nonexistent or only slight. This common and often-severe disorder, which affects more women than men, frequently goes unrecognized. BDD is associated with marked impairment in functioning, poor quality of life, and high rates of suicidality. Most patients seek cosmetic treatment, which virtually never improves BDD symptoms. In contrast, serotonin-reuptake inhibitors, often at high doses, and cognitive behavioral therapy that is tailored to BDD's unique clinical features are often effective. This article provides a clinical overview of BDD, including BDD in women.

Breastfeeding and pumping as maladaptive weight control behaviors.

It is well recognized by the general public that breastfeeding expends calories. In our clinical practice, a number of postpartum women with a history of or a current eating disorder (ED) report using breastfeeding and/or pumping breast milk to influence their body shape and weight. This appears to be either a form of weight control behavior or, in some cases, a compensation for perceived overeating or binge eating. Breastfeeding and pumping have not generally been identified as maladaptive weight control behaviors, nor have they been a subject of research to date. We suggest that this practice should be investigated to determine how common it is, its potential role in maintaining EDs or contributing to relapse in the postpartum period, and to better understand other potential harms it may cause to both the mother and infant/child. PUBLIC SIGNIFICANCE: Breastfeeding and pumping may be used as maladaptive methods of weight control by women with EDs. This behavior is under-recognized in clinical practice and has received little research attention. We argue that maladaptive breastfeeding and pumping warrant further investigation, as the behaviors may play an important role in maintaining an ED or in contributing to relapse during the postpartum period and may also indirectly harm the infant/child.

Premenstrual dysphoric disorder and sexual function: a narrative review.

INTRODUCTION: Premenstrual dysphoric disorder (PMDD) and female sexual dysfunction (FSD) are 2 prevalent illnesses in women that cause distress and affect quality of life. There are plausible biological, social, and psychological links between these 2 conditions. Nevertheless, few studies have examined sexual function in women with PMDD. OBJECTIVES: In this narrative review we summarize the existing literature on sexual function in women with PMDD and with the broader diagnostic classification of premenstrual syndrome and discus the differences between PMDD and more general premenstrual symptomatology, as well as why studying sexual function specifically in PMDD is necessary. We explored reasons why these 2 illnesses may be comorbid and the importance of studying sexual function in this population of women. METHODS: PubMed literature searches were conducted using relevant keywords. RESULTS: Currently, there are few studies examining PMDD and FSD, and the studies available have significant methodologic limitations. CONCLUSIONS: Investigation of sexual function in women with PMDD is needed. Awareness of the comorbidities for PMDD and FSD can allow implementation of targeted interventions for women suffering from these disorders.

Clinical Implications of the Neurosteroid Allopregnanolone in Reproductive Depression.

ABSTRACT: Certain women develop depression with fluctuations in hormone levels whereas other women do not; this hormonally driven depression has been termed reproductive depression. The pathophysiology of reproductive depression differs from that of major depressive disorder, and this distinction has important clinical-including treatment-implications. Recent advances have revealed that the neurosteroid, allopregnanolone, plays a central role in reproductive depression. Appreciation of allopregnanolone's role in reproductive depression aids in selecting targeted treatments and in predicting symptom worsening during subsequent reproductive stages, and it can be used to reduce risk of relapse. This knowledge is also guiding the development of new pharmacologic treatments for reproductive depression.

Comorbidity and healthcare utilization in patients with treatment resistant depression: A large-scale retrospective cohort analysis using electronic health records.

BACKGROUND: Medical comorbidity and healthcare utilization in patients with treatment resistant depression (TRD) is usually reported in convenience samples, making estimates unreliable. There is only limited large-scale clinical research on comorbidities and healthcare utilization in TRD patients. METHODS: Electronic Health Record data from over 3.3 million patients from the INSIGHT Clinical Research Network in New York City was used to define TRD as initiation of a third antidepressant regimen in a 12-month period among patients diagnosed with major depressive disorder (MDD). Age and sex matched TRD and non-TRD MDD patients were compared for anxiety disorder, 27 comorbid medical conditions, and healthcare utilization. RESULTS: Out of 30,218 individuals diagnosed with MDD, 15.2 % of patients met the criteria for TRD (n = 4605). Compared to MDD patients without TRD, the TRD patients had higher rates of anxiety disorder and physical comorbidities. They also had higher odds of ischemic heart disease (OR = 1.38), stroke/transient ischemic attack (OR = 1.57), chronic kidney diseases (OR = 1.53), arthritis (OR = 1.52), hip/pelvic fractures (OR = 2.14), and cancers (OR = 1.41). As compared to non-TRD MDD, TRD patients had higher rates of emergency room visits, and inpatient stays. In relation to patients without MDD, both TRD and non-TRD MDD patients had significantly higher levels of anxiety disorder and physical comorbidities. LIMITATIONS: The INSIGHT-CRN data lack information on depression severity and medication adherence. CONCLUSIONS: TRD patients compared to non-TRD MDD patients have a substantially higher prevalence of various psychiatric and medical comorbidities and higher health care utilization. These findings highlight the challenges of developing interventions and care coordination strategies to meet the complex clinical needs of TRD patients.

Perinatal Planning Guide: Mitigating Perinatal Mood and Anxiety Disorders During the COVID-19 Pandemic.

Women are at high risk for and more vulnerable to perinatal mood and anxiety disorders (PMADs) during the coronavirus disease 2019 (COVID-19) pandemic. While access to specialized perinatal mental health services is limited, clinicians with whom women have ongoing relationships are in a unique position to counsel about prevention of PMADs. These clinicians include primary care, obstetric, and general mental health clinicians. By providing a woman with practical guidance and psychoeducation for perinatal planning (eg, about sleep, exercise, nutrition, and the importance of social supports), clinicians can mitigate a woman's risk of PMADs. This practical guidance must be modified to fit the social context of the COVID-19 pandemic. This guidance can prevent or attenuate unnecessary suffering on the part of the mother and have a long-lasting impact on her child. This review provides a perinatal planning guide that outlines important topics to discuss and problem solve with women in the context of the COVID-19 pandemic.

GABAA dysregulation as an explanatory model for late-onset postpartum depression associated with weaning and resumption of menstruation.

It is well established that a subgroup of women are particularly vulnerable to affective dysregulation during times of hormonal fluctuation. One underrecognized reproductive transition may be late-onset postpartum depression (PPD) in the context of weaning from breastfeeding and the resumption of menstruation. The goal of this review is to propose a biologically plausible mechanism for affective dysregulation during these transitions. The relationship between affective symptoms and neurohormonal changes associated with weaning will be investigated through a hypothesis-driven review of relevant literature. Neurosteroids, like allopregnanolone (ALLO), are widely recognized for augmenting GABAergic inhibition and having a powerful anxiolytic effect (Belelli D and Lambert JL, Nature Reviews Neuroscience 6:565-575, 2005). However, when ALLO is administered after prolonged withdrawal, there may be a paradoxical anxiogenic effect (Smith et al., Psychopharmacology 186:323-333, 2006; Shen et al., Nat Neurosci 10:469-477, 2007). Weaning from breastfeeding is a physiologic example of fluctuating levels of ALLO after prolonged withdrawal. We propose that the complex hormonal milieu during weaning and resumption of menstruation may modify GABAA receptors such that ALLO may contribute to rather than ameliorate depressive symptoms in vulnerable individuals. The proposed model provides an initial step for understanding the mechanisms by which the changing hormonal environment during weaning and resumption of menstruation may contribute to an increased risk of depression in a subgroup of women who are hormonally sensitive. Future research investigating this model would be valuable both to identify women at increased risk for developing mood symptoms late in postpartum and to inform treatment for this and related reproductive depressive disorders.

Considerations in Treating Insomnia During Pregnancy: A Literature Review.

BACKGROUND: The prevalence of pregnancy-associated insomnia is high. Although insomnia may flow from normal physiologic features of pregnancy, it may also be an early warning sign of a relapse, or a trigger for a relapse, of a psychiatric illness. Those at risk for psychiatric illnesses may require medications as well as behavioral and psychotherapeutic interventions, to prevent relapse in the perinatal period. Unfortunately, few reviews of psychotropics used to treat pregnancy-related sleep disorders exist. OBJECTIVE: We discuss issues related to sleep and sleep disorders in pregnancy in the context of co-morbid psychiatric illness, and review the literature on the commonly-used medications (e.g., benzodiazepines, sedative-hypnotics, antihistamines, trazodone, and melatonin) for insomnia during pregnancy.

Protection against hormone-mediated mood symptoms.

We present the case of a woman with bipolar I disorder with severe premenstrual mood instability, confusion, and psychosis resembling the clinical features of postpartum psychosis when estrogen levels are expected to be low, and hypomania when estrogen levels are expected to be elevated. While depressive symptoms across the menstrual cycle have been extensively documented in the literature, there is little information regarding manic and hypomanic symptoms. In addition, we describe the successful treatment of her menstrual-cycle related symptoms. Approaches to the management of menstrual psychosis have not been systematically studied, and clinical guidelines do not exist. Clinical experiences such as the one reported here, in which the clinical formulation of the patient was consistent with known neuroendocrine phenomena and in which the treatment approach was successful, are crucial to developing promising approaches that can be tested in controlled trials.

Selective serotonin reuptake inhibitors for depression in pregnancy.

Perinatal depression is associated with a high risk of morbidity and mortality and may have long-term consequences on child development. The US Preventive Services Task Force has recently recognized the importance of identifying and treating women with depression in the perinatal period. However, screening and accessing appropriate treatment come with logistical challenges. In many areas, there may not be sufficient access to psychiatric care, and, until these resources develop, the burden may inadvertently fall on obstetricians. As a result, understanding the risks of perinatal depression in comparison with the risks of treatment is important. Many studies of selective serotonin reuptake inhibitors in pregnancy fail to control for underlying depressive illness, which can lead to misinterpretation of selective serotonin reuptake inhibitor risk by clinicians. This review discusses the risks and benefits of selective serotonin reuptake inhibitor treatment in pregnancy within the context of perinatal depression. Whereas selective serotonin reuptake inhibitors may be associated with certain risks, the absolute risks are low and may be outweighed by the risks of untreated depression for many women and their offspring.