Hormones and PPD: My Journey Continues…

I’m not sure why exactly, but sharing this post is somewhat more uncomfortable than some of my previous posts. In an effort of transparency and the hope of helping someone else, I write the continuation of my journey with postpartum depression and anxiety.

I wasn’t sure at first how my hormones were related to my postpartum depression, but I realized that it’s a piece of my postpartum journey. There are no two identical experiences with PPD and there are still no definitive causes of PPD, so these are the factors that contributed for me.

• History of anxiety and previous symptoms of PPD
• Traumatic birth
• NICU stay
• Uncertain life circumstances
• Hormonal depletion and imbalance

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Could it be Your Hormones?

This current chapter in my journey started with a friend asking me if I had had my hormones checked. She shared her experiences of needing to take hormones to stabilize her mood and improve her depression and anxiety. I was appreciative that she shared her experience, but I didn’t feel it had any similarity to my situation. I had a baby and then I had depression and anxiety, therefore it was postpartum depression. No need to look any further. I ultimately conceded that I would go see “the hormone doctor” if it would make my family happy, but I knew nothing would come of it.

I went to my first appointment and was surprised at how emotional the appointment was for me. I had to share what precipitated me coming to the appointment, and describing everything from my perinatal symptoms to Declan’s birth, and then the aftermath, was overwhelming. I was given a prescription to get my blood drawn and set up a follow up appointment weeks down the road.

My Results…

When I finally came to my results appointment I was so nervous. I didn’t know what to expect, but I was so worried there was something else wrong with me, and I just wasn’t sure I could handle wrapping my mind around another deficiency. The doctor was very nice and candid and quickly shared that I had depleted levels of all my hormones and while depleted, they were also imbalanced. She felt that this would explain a laundry list of my symptoms from the insomnia, constipation, depression, anxiety, low sex drive, to the mental fogginess. She prescribed a bunch of herbal supplements (Pregnenolone, Ashwaghanda, Magnesium Citrate, Active B Complex, Vitamin D, and Saw Palmetto) in the hopes of replenishing my hormone stores and balancing them at the same time.

Now what?

I suppose I should’ve felt good, great even, that I had an answer and a plan. But it just made me feel more uncertain and overwhelmed. None of my physicians agreed on the cause of my symptoms or the best way to treat them. Who was I supposed to listen to? And if I chose the wrong one, how much time would I loose working towards actually getting better? I felt lost in the middle of a maze that I didn’t know the way out of. I felt unsure about everything. Was it my hormones all along? Can I still say I had postpartum depression? Do I have both? And if so, how do you treat them concurrently? Those were just the surface questions. In the deep and darkest corners of my mind, I wondered why it had taken this long to come up with this answer. How much time had I lost not going down this path? Why hadn’t God intervened sooner?

Ultimately, I decided I had nothing to loose by starting the herbal supplements.

Another big piece of her recommendation was to have my Mirena IUD removed. I had a Mirena IUD after Rocco was born and another after Declan was born. I loved it. I felt great, I had no problems with it, no period to mess around with, and I never had to remember to take another pill. I had read articles about the “Mirena crash” and negative side effects of Mirena, but mostly blew it off, assuming the women making those claims were a little off their rocker. But my physician said based on my lab work, I was the worst candidate for this type of iud and should have it removed as soon as possible. Apparently there are different generations of progesterone and I need to be taking a birth control with a first-generation progesterone and estrogen. I didn’t like the idea but felt like there was no point in doing this half-assed, it was either all or nothing. So I set up my appointment and had my iud removed and started taking Junel birth control pills right after.

Waiting…

So now I wait. Wait for all the supplements and medications to do their jobs. I will have my blood work redone after three months to see if they have made any difference.

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Postpartum Depression

I have written a previous post about PPD, Raising Awareness: What is Postpartum Depression?, but felt it appropriate to add more information relevant to the underlying causes of PPD given this new turn on my journey.  In research, PPD is defined as:

• Depression that began before or during pregnancy;
• Depression that occurred in the context of childhood trauma history, traumatic labor and delivery, thyroid dysfunction, psychosocial stress, or sleep deprivation;
• Depression that occurred with OCD, PTSD, generalized anxiety disorder, or personality changes.

Unfortunately, despite centuries of women having children and ongoing research, no definitive underlying cause for PPD has been identified.  Risk factors are acknowledged, but at this time, causes are only hypothesized.  Additionally, expert opinions vary as to the timing of the onset of PPD.

• According to the American College of Obstetrics and Gynecologists (ACOG), perinatal depression, aka, postpartum depression (PPD), includes major and minor depressive episodes that occur during pregnancy or in the first 12 months after delivery.
• The Diagnostic and Statistical Manual of Metal Disorders, Fifth Edition (DSM-5) states that a major depressive episode or major depression qualifies as peripartum if onset occurs during pregnancy or in the 4 weeks following delivery.

There is no clear definition of when postpartum depression can occur, even among experts.  In terms of duration,

• 38% of women with postpartum depression experienced chronic symptoms
• 50% of women experienced postpartum depression for over 1 year
• 30% were still depressed up to 3 years after giving birth

Reproductive Hormones

The female reproductive system is primarily regulated by five hormones, each with specific roles.  The two most relevant to mood are estrogen and progesterone.  It has been suggested that reproductive hormones may play a role in PPD because of the association between the rapid changes in hormone levels that occur at delivery and the onset of depressive symptoms.  Additionally, reproductive hormones play a major role in basic emotional processing, arousal, cognition, and motivation, and regulated the biological systems involved in major depression.

1. Estrogen- affects the brain (mood), bones, heart, skin, and other tissues.  Symptoms associated with low estrogen include: hot flashes, night sweats, trouble sleeping, mood swings, dry skin, migraines, depression, difficulty concentrating, fatigue, and vaginal dryness.  If left untreated, low estrogen can lead to infertility.  The main form of estrogen in the body is estradiol which interacts with the brain similar to antidepressant medications.
2. Progesterone- regulates neurotransmitter synthesis, release, and transport.  Neurotransmitters can affect a wide variety of both physical and psychological functions, including heart rate,  sleep, appetite, mood, and fear.

There is evidence that suggests that hormone instability in the perinatal period could contribute to mood dysregulation in PPD.

Thyroid Hormones

Thyroid hormones have been proposed as a bio marker of PPD because of the relationship between thyroid dysfunction and depression. Estrogen increases T4 (thyroxine) levels. So, thyroid dysfunction may contribute to PPD for some women.

Lactation Hormones

The hormones oxytocin and prolactin involved in lactation have also been implicated in PPD. Failed lactation and PPD commonly co-occur. Not only do these hormones regulate lactation, but they also influence maternal mood and behavior. Estrogen and progesterone modulate oxytocin expression in the brain. Lower levels of oxytocin during the third trimester are associated with increased depression during pregnancy and the immediate postpartum period.

Hypothamus-Pituitary-Adrenal Function

Hypothamic-pituitary-adrenal (HPA) axis dysfunction has been implicated in PPD as well. Hyperactivity of this axis resulting in high levels of cortisol, is one of the most consistent findings among individuals with depression. In pregnancy, the HPA axis is dysregulated and doesn’t normalize until 12 weeks post delivery.

Immune Dysregulation

Immune dysregulation has also been suggested to contribute to the development of PPD. The immune axis is regulated by estradiol. During pregnancy anti-inflammatory cytokines are increased and are responsible for immunosuppression to promote pregnancy maintenance. Delivery causes a rapid shift in the immune system from anti-inflammatory to a pro inflammatory state. Patients with depression have been shown to have higher levels of proinflammatory markers.

Genetics

Evidence of a genetic vulnerability to PPD has been suggested by multiple studies.

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Answering Questions

I have people ask me all the time, “How are you feeling?” I know they want an honest answer, but I also know they want the answer to be positive. Either way, I don’t really know how I’m doing. I’m not worse, I’ve certainly improved since this all started. I’m not 100% or in a place I’d want to stay, so how do you answer that? I’m getting there?

I do feel more myself than I have in a while, but I still have bouts of depression where I feel down, worthless, or apathetic. I still have anxiety over things that never used to worry me like driving a car, or worrying about our escape plan if our house catches fire. I still feel the pangs of guilt and failure as a mother and wife and even occasionally still wonder if they would all be better off without me. So with all that said can I really say I’m doing well? But I feel like my time has run out on saying that I’m still struggling. All I can do is hope I won’t struggle much longer.

References

• Schiller et al. The Role of Reproductive Hormones in Postpartum Depression. CNS Spectr. Feb 2015; 20(1): 48-59.
• What is Estrogen?
• What are the Symptoms of Low Estrogen in Women and How Are They Treated?
• How Long Does Postpartum Depression Last?  Medical News Today.