PSYC 388 WOMEN'S REPRODUCTIVE & MOOD DISORDERS Lecture 1 PDF

Lecture 1: The Menstrual Cycle Sept. 10/24 Video: First Moon Party - Preconception change people view of periods (children before talking about it with their friends) Female reproductive system - Endome...

Lecture 1: The Menstrual Cycle Sept. 10/24 Video: First Moon Party - Preconception change people view of periods (children before talking about it with their friends) Female reproductive system - Endometrium- lining - Fallopian tubes - Ovaries - follicles develop - Cervix - HPG axis -hypothalamus releases: GnRh - causes pituitary gland to release LH or FSH - stimulate ovaries to produce estrogen and progesterone The Menstrual cycle - Benign of cycle starts with first day of bleeding - Uterine lining (endometrium) is being shed - Follicles in ovaries are very small and releasing small amounts of estrogen - body temp is low, Low leels of FSH and LH - But follicle starts to grow Phases: 1. Menstruation ○ Marks the first day of a new menstrual cycle ○ Discharge of bloody fluid containing endometrial and blood cells ○ Typically lasts 3-5 days ○ Triggered by decline in estrogen and progesterone (especially progesterone) from the last cycle Vasoconstriction causes endometrial tissue to die (blood vessels that feed endometrium constrict - causes endometrium to die and shed) Uterine contractions cause it to be expelled 2. Follicular Phase ○ Early follicular phase: overlaps with menstruation Follicles contained in the ovaries are small (as they grow bigger they produce more estrogen) Because of this, estradiol levels are very low Cervical mucus is dry ○ Late follicular phase Gradual rise in FSH stimulates the ovarian follicles  Follicles in ovaries grow and one emerges as dominant, due to FSH - it stimulates follicles Follicles compete with each other for dominance A dominant follicle (occasionally 2) will mature, becoming a fluid-filled Graafian follicle, which contains an ovum (egg) Sometimes 2 - twins As follicles grow, they release more and more estradiol Estradiol stimulates the thickening of the endometrium (lining of the uterus) - if one becomes pregnant Estradiol also stimulates the cervix to produce increasing amounts of cervical mucus - aimed to facilitate conception Image - peak: Prior to ovulation: peak in estradiol - triggers luteinizing hormone Ovulation tests detect peaks in LH - have 12 hours before ovulation will occur 3. Ovulation ○ Once estradiol levels reach a certain threshold, a surge of LH is triggered (related to the frequency of GnRH pulses - GnRH released by hypothalamus sometimes causes FSH to be released in follicular phase and causes surge in LH - all due to pulses of GnRH) ○ LH matures the egg and weakens the follicular wall, facilitating ovulation ○ Once released, the ovum is swept up into the fallopian tube 4. Luteal Phase ○ Corpus luteum: solid body formed after the ovum is released into the fallopian tube - releases progesterone and some estradiol Produces significant amounts of progesterone, which is critical to making the endometrium receptive to implantation of a blastocyst (i.e. pre-embryo) Difficulty to conceive can be due to low progesterone ○ High estradiol & progesterone inhibit FSH & LH - so you do not ovulate again ○ High progesterone causes cervical mucus to dry up ○ If ovum is not fertilized, corpus luteum disintegrates after 14ish days, resulting in a drop of estradiol and progesterone (resulting in menstruation) *overall length is typically 28 days: 14 for follicular and 14 for luteal and ovulation *While cycle overall can vary, luteal phase is pretty consistent in length: 14 days but follicular phase varies *progesterone makes body temp rise - aura rings can asses basal body temp To complicate things:  This textbook description of the menstrual cycle isn’t entirely accurate Research conducted at the UofS has confirmed that multiple follicle waves are possible across the cycle: dominant thinking was that follicular phase occurs once and one becomes dominant - but there can be multiple follicular waves ○ Harvesting eggs: believe we can only do it during follicular phase: but there are multiple opportunities to harvest follicles ○ Some people will have rise and fall of estrogen multiple times than typically expected The stages of reproductive aging (STRAW) Stages: Reproductive - Starts with first onset of menstruation - Early stage: adolescence - Normal to have variability in menstrual cycle length (sabilizes in 20s) - Average age is 12 (12-13 or as late as 16) - Irregularity is normal again towards the end of reproductive stage Menopausal transition - Final menstrual period Postmenopause Reproductive lifespan - 20 million follicles - Declines over time - 35-40 - number of follicles we have decline much more rapidly - decline in pregnancy - At some point, critical low level is reached - small number is left and impact your production of hormones; irregularity happens in HPG axis - Number and quality of follicles decline in late 30s Why is the average age of menarche declining: Not a bad tings, related to improved living standards and nutrition Getting period earlier does not mean we stop to conceive earlier as well - depends on quality not just quantity of follicle In the past: ○ Improving living standards, nutrition More recent ○ Higher rates of obesity ○ Exposure to endocrine disrupting chemicals Mimic shape of hormone and attach to hormone receptors - triggers abnormal processes in body and can cause severe health consequences Exposure to EDCs can happen in the womb, in air, water etc Made their way in food chain, plastic, chemical, cosmetics and fragrance, pesticides all have EDCs ○ Greater exposure to light - even artificial light Chickens exposed to light 24h - produce more eggs and reach puberty quicker ○ Extreme exposure to plastic Consequences: increases risk of estrogen-dependent cancers How do I know when / if i'm ovulating: Signs of ovulation ○ Lots of “egg-white” cervical mucus followed by sudden drying up (mucus facilitates transportation of sperm) ○ Increase in libido leading up to ovulation ○ Ovarian pain during ovulation (also known as “mittelschmertz”) ○ Mid-cycle increase in basal body temperature Period begins 12-15 days after suspected ovulation Note that in healthy women, about 10% of menstrual cycles are anovulatory (i.e. ovulation doesn’t occur) - occurs a few time in life: can be due to illness or psychological stress What about the Pill? Most birth control pills contain both synthetic estrogen and progesterone (called progestogen - different types cause different symptoms) Estrogen and progesterone feed back in the HPG axis to prevent FSH and LH release ○ Result: no ovulation The progestogen also prevents the production of fertile cervical mucus (and its included in conception) ○ Can take progestogen only pill - for mother that are breastfeeding During pill-free intervals, you experience withdrawal from estrogen and progestogen, resulting in bleeding ○ Induces shedding of the lining (in a sense - not a real period - only shedding of uterine lining) Dangerous to be exposed to estrogen and progestogen high level without having a period Mixed findings if oral contraceptives have an effect on onset of menopause (prevent follicle from being released - are there more to be released once OC are stopped) What about IUDs? Both types of IUDs (copper and hormonal) are inserted in the uterus ○ Copper - device put in uterus, does not release hormones Works exclusively by causing inflammatory reaction Does not work for people sensitive to hormones ○ Mirena (hormonal IUD) - releases hormones The presence of an IUD in the uterus creates an inflammatory reaction that prevents fertilization of the ovum by sperm All phases of the menstrual cycle still occur - but lining of uterus is not building up Hormonal IUDs also release a progestogen, which prevents fertile cervical mucus and prevents thickening of the uterine lining ○ Depends whether if prevents ovulation - it does in the start but not later on Bith not a recommended treatment for PMDD Why aren't my periods regular? Occasional irregularity is nothing to worry about but chronically irregular periods is something to look into 10% of people experience anovulatory cycle Possible causes of menstrual irregularity ○ Stress can cause occasional irregularity ○ Thyroid dysfunction ○ Excessive exercise ○ Eating disorders ○ Uncontrolled diabetes  ○ Primary ovarian insufficiency ○ Most common: polycystic ovarian syndrome Polycystic Ovarian Syndrome (PCOS) 5-10% of women Symptoms: 2 out of 3 of the following criteria: ○ 1. Menstrual irregularity ○ 2. Signs of elevated testosterone (e.g. acne, excess body hair, hair loss - too high testosterone for you - not high in general necessarily) ○ 3. Polycystic ovaries (via ultrasound) ○ If you have first 2 - do not need ultrasound Responds well to low glycemic index diet (regulating blood sugar - follow diabetes diet, limiting dairy) & exercise Many people go on birth control to regulate their cycle Most people find out about it when they try to conceive *if uterine lining keep building up w/o a period - might develop cancer - a risk for PCOS if no period PMS AND PMDD The history of PMS 1931: Karen Horney writes a paper entitled “Premenstrual Tensions” ○ Disturbances before getting a period (irritability, anxiousness, depression etc) 1953: Dr. Katharina Dalton, British gynecologist, coined the term “premenstrual syndrome” ○ Devoted her career to researching, writing about and treating PMS ○ Believed PMS was due to deficient progesterone - not completely true but right track If you took supplements it would improve symptoms - actually worsens it ○ Estimated rate to be 30% - (people affected by hormonal fluctuations is 15-20%) ○ Testified in over 50 trials in which the defendant had committed crimes in the premenstrual phase 1987: “Late luteal phase disorder” appears in the Appendix of the Diagnostic and Statistical Manual of Mental Disorders (DSM) ○ In appendix - not recognized with other more validated conditions ○ It was a thing of interest 2012: Premenstrual Dysphoric Disorder (PMDD) ‘upgrades’ to the front of the DSM Inclusion of PMDD in the DSM: a controversial decision - Still today people believe it should not be in DSM Arguments against Pathologized normal variations in mood - it is normal for mood to fluctuate over the cycle Allows big pharma to re-patent old antidepressants for this new purpose (fluoxetine patent was running out - so they rebranded it for women - Sarafem) ○ SSRIs are an effective treatment for PMDD Encourages the deception of women as highly emotional and irrational Discussion points: The idea that most women suffer from severe PMS is widely held Might this have any possible negative consequences in our society? - Makes it seem like they are less competent and stable, reliable - not a good candidate for a president - Makes it seem like they should be excused of any wrongdoing - women get a reputation of being unstable - lose leadership positions Arguments for: Existence is supported by a large body of research Facilitates diagnosis, treatment, and research Validates the experiences of many women Common depictions of PMS: women as moody, bitchy etc Quality of life in PMDD in comparison to other mental health illness Quality of life is same level of MDD, panic disorder or PTSD Level of suffering same as other well recognized conditions DSM - 5 criteria for PMDD: A. In most menstrual cycles, 5+ symptoms (at least one emotional symptom) present in the premenstrual phase and are absent in the week following menses. 1. Depressed mood, feelings of hopelessness or self-deprecating thoughts 2. Affective lability 3. Marked anxiety, tension, feelings of being “on edge” 4. Persistent anger, irritability, interpersonal conflicts a. Need one of first 4 5. Decreased interest in usual activities  6. Difficulty concentrating 7. Lethargy, lack of energy 8. Changes in appetite, overeating or specific food cravings 9. Hypersomnia or insomnia 10. Feeling overwhelmed or out of control 11. Other physical symptoms such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating or weight gain B. Symptoms impair work, interpersonal or social function. C. Not merely a premenstrual exacerbation of another disorder. D. Confirmed via prospective daily ratings for 2 cycles. - Need to be asymptomatic outside of luteal phase The 20-item Daily record of severity problems tracker Rate symptoms daily Interpreting daily ratings: For a diagnosis of PMDD: At least 5 symptoms (including 1 core) increase in severity by at least 30% from the premenstrual week to the postmenstrual week (days 4-10) Ratings must be at least in the “moderate” range during the premenstrual week Ratings must be no higher than “mild” in the postmenstrual week PMDD assessment: why prospective ratings are critical A woman needs to track her symptoms daily for two menstrual cycles and have symptoms in the late luteal phase that resolve with the onset of menstruation Is this really necessary? Yes! About 60% of the time, retrospective reports of premenstrual symptoms don’t match prospective tracking ○ If we just ask one would have an overreport or underreport Unfortunately, clinicians only use prospective tracking 12% of the time - can lead to misdiagnosis What % of AFAB (individuals assigned female at birth) have PMDD? - 1.6% - people feel this is an underestimate - But current definition of DSM is overly exclusive - Suicidality is reported by a lot of people, but suicidal indentation is not seen in criteria - If one has 3 symptoms (for example: core ones) and suicidality - does not meet criteria but is likely PMDD - Another issue: 30 % insecure but what if one has extreme increase in symptoms but other symptoms only incarse 20% PMDD prevalence: Strict DSM-5 diagnosis ○ 1-2% Clinically significant but sub-threshold symptoms: ○ 13-19% ○ E.g.