In this phase of life, individuals begin to accept financial and emotional self-responsibility, to differentiate from the family of origin, and to develop intimate relationships with peers.
Healthy Behaviors and Health Care Maintenance
Safety in relation to sexuality, substance use, contraception, motor vehicles, and preventive care are ultimately the patient’s responsibility, but the physician can play an important role in establishing lifelong healthy habits and collaboration in this realm. The physician who uses gender-neutral and nonjudgmental styles of history-taking and is alert to patient cues will be more likely to be told about challenges for the patient that may have long-term modifiable consequences such as gender-identity issues, substance abuse, unsafe sex, intimate partner violence, eating disorders, and depression. Engaging with patients in partnership works best, allowing them to identify pros and cons of their choices, and supporting their ability to make changes if needed. Autonomous motivation to change and patient belief in ability to make a change are positively associated with successful changes in behavior and maintenance of those changes.
Identity also includes a patient’s self-definition of her cultural role within the context of her family of origin, and this can impact her health and illness behavior (see Chapter 15). If, for example, she feels great pressure to succeed as an engineer, but prefers to be an artist, this dissonance can cause stress-related symptoms that bring her to the health care system. Somatoform behavior and medically unexplained symptoms (MUS) are common across all cultures and may be reinforced in preference to the expression of emotions in some families, masking a mental health disorder.
For women, unique issues regarding culture can relate to appearance and behavior as well. Some women may feel pressure from the dominant culture regarding slender body weight, but conflict may arise if their internal or family value system and/or sex partner is concordant with a larger body habitus. Other women could be encouraged verbally and through their cultural customs to be subservient to men, though this can be manifested to varying degrees, and may or may not result in conflict. Social support may be lacking as immigrant women become more acculturated in the United States. Also, immigrants engaged in a cultural transition process may experience criticism from older relatives as they assimilate to the prevailing culture and from younger relatives or friends if they maintain connection with the culture of origin. Traditional cultures may promote respect for elders and traditional gender roles, often a family-strengthening behavior, but reinforce secrecy around family violence and abuse. It is important for physicians to remember that family violence may include intimate partner violence, violence from extended family, and honor crimes (violence toward a woman whose behavior is interpreted as shaming the family). These issues may affect women of all ages uniquely, in their traditional role in the family, and physicians should be alert for clues that problems are occurring and when warranted use direct inquiry or screening.
Pregnancy and Infertility: Psychosocial Issues
Almost half of the 6.7 million pregnancies in the United States each year (3.2 million) are unintended, and more than half of these unintended pregnancies are continued. Given these statistics and the risks of neural tube defects, it is appropriate for providers to advise all women of childbearing age who are not using effective contraception to take a daily multivitamin. Unintended birth is more common in women aged 18–24 years and in lower income women, and is associated with worse maternal and neonatal outcomes than intended birth. These include late presentation to prenatal care, smoking and drinking during pregnancy, premature birth, negative pediatric mental health effects, and not breast-feeding. Nearly 40% of unintended pregnancies end in abortion; at current rates, 30% of women will have an abortion in their lifetime.
Several factors contribute to unintended pregnancy, most importantly not using effective contraception at all or consistently. Fifty-four percent of women undergoing abortion report that they had used a contraceptive, most commonly the pill or condoms, during the month they became pregnant. Forty-six percent had not used contraception, and of these women many reported concerns about contraceptives, a quarter had had unexpected sex, and 1% had had forced sex. Contraceptive nonuse was more common among black, Hispanic, poor, and uneducated women.
To help women prevent unintended pregnancy it is imperative that clinicians counsel reproductive-aged, heterosexual women who are not trying to become pregnant about contraception. They should include the highest efficacy reversible methods such as intrauterine contraception and implants in the discussion, address patient’s concerns about methods, and help women choose the best method for them. Although oral contraceptives are the most commonly prescribed reversible contraceptives, they have a high failure rate of up to 8%, and require women to fill a regular prescription and take it daily. One recent study found that women, on average, do not take five pills each month, which likely contributes to its high failure rate. In contrast, the long-acting reversible methods have much lower failure rates of less than 1%.
Pregnancy Options Counseling and Referral: Professional Responsibility
Clinicians should provide objective, nonjudgmental pregnancy options counseling to women with newly diagnosed pregnancies. This includes asking women whether the pregnancy was intended and is desired; educating them about the options of pregnancy continuation, including adoption, and pregnancy termination; offering supportive counseling if they are undecided; and providing appropriate referrals. At times this can be challenging for individual clinicians who have strong feelings about the woman’s preference. For some, they may feel morally opposed to and uncomfortable referring a woman for abortion. For others, they may feel that her desire to continue the pregnancy is not wise due to factors such as her age, resources, relationship status, or potential interference with her educational or career goals. These feelings may interfere with one’s ability to provide unbiased counseling and referral for patients. This raises the issue of conscientious refusal and whether clinicians can opt out of such counseling.
The vast majority of U.S. states allow health care providers to decline direct participation in abortion services; 10 states permit clinicians to refuse to provide contraception for patients, and 6 permit pharmacists to refuse to dispense contraceptives. However, ethicists and medical organizations, such as the American Congress of Obstetricians and Gynecologists (ACOG), argue that it is the clinician’s responsibility to provide a timely referral when they do not, due to conscience, provide the services the patient requests. Studies show that in practice most physicians support these guidelines. To provide women adequate counseling and referral, it may be helpful for clinicians and office staff to clarify their values about pregnancy options through facilitated discussion of different scenarios and to decide on a policy about counseling and referral.
Many well-designed studies have demonstrated that abortion is not associated with poor mental health outcomes. However, unintended pregnancy can be stressful for patients and requires significant psychosocial support, regardless of decision about pregnancy outcome. Women with unintended pregnancy are more likely to have a history of depression than women with intended pregnancy, and these women are at higher risk of a depressive episode at the time of or after an abortion. Thus, it is important to screen women with unintended pregnancy, regardless of their plans for the pregnancy, for depression. Also, whereas most women experience great relief after abortion, a few seek support as they grieve the loss of the pregnancy and may be referred to counseling services (http://yourbackline.org/).
When a woman seeks an abortion it is important to refer her as early as possible, because although abortion is extremely safe, its morbidity increases as women enter and proceed through the second trimester (although it is still lower than term birth). Women who have had an abortion are at increased risk of having a repeat, unintended pregnancy and therefore require extra support for choosing and using contraception effectively. Also, studies have found that two modifiable factors, intimate partner violence and substance use, increase a woman’s risk of abortion and therefore warrant screening and subsequent referral.
Psychosocial stress is common in individuals struggling with infertility, increases as treatment becomes more complex, and makes discontinuation of treatment more likely. Although studies of baseline stress and conception rates with fertility treatments are mixed, a recent large meta-analysis found no relationship between baseline stress and pregnancy rates. The prevalence of psychiatric disorders also appears to be higher in infertility. Risk factors include past psychiatric illness, particularly discontinuation of medication due to anticipated pregnancy; longer duration of infertility; and history of pregnancy loss. Therefore, it is important to screen these patients for psychiatric illness, especially for anxiety and depression, as well as for the effects of infertility on various aspects of their lives and their stress levels.
Many studies have been conducted on the effect of psychosocial support–including counseling, support groups, and training in relaxation techniques and stress management–on pregnancy rates. Some studies have shown increased birth rates in patients participating in these services. A meta-analysis found an increased relative risk of pregnancy in patients participating in support groups compared with controls. Thus, it is important to screen patients seeking to become fertile for psychiatric illness and treat appropriately, and to recommend participation in a support group or similar social intervention.
Premenstrual Syndrome and Premenstrual Dysphoric Disorder
Premenstrual syndrome (PMS) is characterized by cyclic occurrences of a variety of symptoms prior to and resolving within a few days of the onset of menses. As many as 150 symptoms have been attributed to PMS, but the most common are fatigue, irritability, bloating, anxiety or tension, breast tenderness, mood lability, depression, and food cravings. Whereas up to 80% of women describe at least one PMS symptom, the more severe form, premenstrual dysphoric disorder (PMDD), occurs in only 3–8% of women and impairs daily living. Five symptoms characterize PMDD: (1) sadness, hopelessness, or being self-critical; (2) tension or anxiety; (3) labile mood interspersed with frequent tearfulness; (4) persistent irritability or anger; and (5) increased relational conflicts. Additional emotional and physical symptoms may also be present, and other psychiatric illnesses must be ruled out.
Because of varied symptoms and overlap with other conditions, a prospective daily symptom scale–demonstrating onset of symptoms around the time of ovulation and cessation of symptoms after the menses–is critical for diagnosis. Several calendars have been validated, including the Calendar of Premenstrual Experiences (COPE), in which women document symptoms daily on a 4-point Likert scale for 10 physical and 12 behavioral symptoms. A total score of less than 40 during days 3–9 of the cycle combined with a score greater than 42 during the last 7 days of the cycle is an effective screening tool for PMDD.
Treatment for PMS is approached in a stepwise fashion, first with behavioral changes and progressing to pharmacotherapy. Encouraging the patient to exercise regularly, limit salt and caffeine intake, and keep a regular sleep schedule may be beneficial. Calcium and vitamin D supplementation are associated with a lower incidence of PMS symptoms. The prospective daily symptom scale may be therapeutic as well as diagnostic by allowing the patient to be proactive in anticipating, managing, and avoiding symptoms. Since stress has been shown to increase symptoms, relaxation exercises and counseling may be effective.
Most patients with PMDD require pharmacological therapy for significant improvement. The SSRIs are considered first-line therapy and have been proven to be effective in multiple studies, for both behavioral and physical symptoms. Fluoxetine is FDA-approved for this indication at doses between 20 mg and 60 mg, with lower doses equally effective and better tolerated. Other effective SSRIs are sertraline, paroxetine, and citalopram, and all can be administered continuously throughout the month, intermittently from ovulation to the onset of menstruation, or semi-intermittently with increased doses in the late luteal phase. The benzodiazepine alprazolam can be used in the luteal phase to reduce symptoms, but with less effect than SSRIs. Patients who do not respond to SSRIs or anxiolytics can try agents to suppress ovulation; options include continuous oral contraception or contraceptive rings (the patch cannot be used continuously due to increasing weekly levels of ethinyl estradiol). One pill formulation with drospirenone improves PMS when prescribed traditionally, with a hormone-free interval, but only in comparison with placebo and only in the short term compared with other pill formulations (by 2 years symptoms are equivalent to the effects of other pills). Also, GnRH analogues, which require add-back estrogen therapy if used for more than 6 months, can treat symptoms. Other treatments showing some benefit are vitamin B6 supplementation and spironolactone.
Women with a history of major depression are at highest risk of depression in pregnancy. Other risk factors include discontinuing or decreasing antidepressant medications. In the absence of suicidal or homicidal ideation, nonpharmacological treatments are advised. Psychotherapy for depression has been shown to be equally effective when compared to antidepressant medications (see Chapter 25). Often the focus of psychotherapy in this setting is on the transition to motherhood and the acquisition of the requisite skills.
The decision about prescription of psychotropic medications is complex: The risk of medication exposure to the fetus must be balanced against the risk of untreated depression for the mother, other children in the home and, ultimately, the infant. Decisions about medication include factors such as the severity of the depression, the number of prior depressive episodes, and a woman’s history of response to medications. All the evidence comes from observational studies.
Overall, experts recommend sertraline as the preferred drug for treatment of depression in pregnant women.
During the postpartum period, women can experience mood changes, including postpartum blues, postpartum depression, panic disorder, and postpartum psychosis. Transient postpartum blues are common, occur within a few days of delivery in 40–80% of women, include mood swings, irritability, sadness and crying spells, and resolve within 2 weeks. Postpartum depression has been estimated to occur in 5–9% of women. The clinical diagnostic criteria are feeling depressed or hopeless most of the day almost daily for at least two consecutive weeks, with onset usually within 1 month but up to within a year of birth. The biggest risk factor for postpartum depression is a personal history of depression. Other risk factors include lack of social support, history of miscarriage or other pregnancy loss, not breast-feeding, pregestational or gestational diabetes, and family psychiatric history. Some of the symptoms of postpartum depression such as fatigue, sleeping problems, and decreased sexual drive are common symptoms of the immediate postpartum period, making the disorder more difficult to detect. Feeling overwhelmed or guilty, being unable to care for or bond with the baby, or not sleeping even when the baby is sleeping, should all alert the clinician to the possibility of the diagnosis.
The Edinburgh Postnatal Depression Scale has been validated and used in multiple settings to screen for postpartum depression. Clinicians should ask about mood, appetite, sleep, and being overwhelmed during postpartum visits. A woman who expresses thoughts about harming herself or the baby should receive immediate evaluation by a mental health professional. When evaluating a woman for possible postpartum depression, thyroid disorders should be ruled out, as both hypothyroidism and hyperthyroidism are more common in the postpartum period.
Women with mild to moderate symptoms should be initially treated with nonpharmacological measures including sleep hygiene, education, psychotherapy, CBT, or family therapy.
There are no randomized controlled trials of pharmacotherapy for postpartum depression, so recommendations are based upon observational studies and extrapolation from the general population. Antidepressant drugs are generally initiated in the same fashion as in the usual treatment of major depression, using a medication previously effective whenever possible. The SSRIs are the drug of first choice, given their safety profile and relative low risk of side effects, with the evidence slightly favoring sertraline and paroxetine. Although there is limited evidence about antidepressant use in breast-feeding women, there are only few reports of adverse effects. The benefits of depression treatment and of breast-feeding are generally felt to outweigh the risks of the medications.
Young adult women may present to their physicians with IBS, as it is the most common gastrointestinal disorder seen in primary care. It is characterized by chronic abdominal pain and altered bowel habits in the absence of an organic cause. IBS is estimated to occur in 1–20% of the population with a female predominance of 1.5:1. Only about 15% seek medical care for their condition, yet the volume of patients is large and the burden to society in health care costs and missed work is significant.
The pathophysiology of IBS remains unknown. It is thought to be a disorder of gastrointestinal motility, dysregulation of the nervous system, increased visceral sensitivity, and possibly bacterial overgrowth. Psychosocial stressors have been shown to precipitate and exacerbate symptoms but are not thought to be a cause of the underlying condition. Women who have a history of physical or sexual abuse are more likely than controls to suffer from IBS and other functional bowel disease. Patients with a history of abuse have poorer health outcomes as manifested by an increase in pain, physician visits, and surgical procedures than patients without an abuse history. Although women seeking treatment for IBS are more likely to suffer from depression, anxiety, panic disorder, somatization, or other mental illness, those who do not seek treatment have the same incidence of these problems as the general population. Hence, it is unclear whether psychiatric stressors exacerbate the disease or contribute to the underlying etiology, perhaps varying in different individuals. Other conditions related to IBS include sleep disturbance, depression, and fibromyalgia. Interestingly, health-related quality of life appears to be more related to extraintestinal symptoms rather than traditionally elicited gastrointestinal symptoms in patients with IBS.
Effective treatment for IBS involves an integrated behavioral and pharmacological stepwise approach individualized to the patient’s main symptom. Treatment for mild disease can involve only education, bulking laxatives, and antispasmodics. Both the SSRIs and the tricyclic antidepressants (TCAs) are effective for symptom relief in some patients but the TCAs can exacerbate constipation. Loperamide is helpful for treatment of diarrhea, but does not relieve other symptoms. Rifamaxin, a nonabsorbable antibiotic given for a short course, has been shown to relieve some symptoms of IBS. Newer treatments include alosetron, a 5-hydroxytryptamine-4 (5-HT-4) antagonist, which was removed from the market because of serious complications, but is now again available for limited use. Cognitive behavioral therapy (CBT) has been shown to be helpful in several studies. Dynamic psychotherapy and hypnotherapy have also been shown to be useful in reducing IBS symptoms, although results are somewhat mixed and effects were of short term in some studies. In the largest trial testing CBT in women, CBT was significantly more effective than education alone. Certain subgroups of IBS sufferers may be especially responsive to CBT. Simple educational interventions designed to help patients learn more about their bodies and IBS can be helpful in reducing anxiety and improving health-related quality of life. However–similar to other disorders overlapping with a history of childhood or adult abuse, sexual trauma, psychiatric comorbidities, or somatization disorder–sensitive communication strategies and avoidance of unneeded interventions are crucial.