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Effect of mental health on reproduction

Introduction

Reproductive health (RH) is defined by the World Health Organization (WHO) as a condition of mental, physical, and social well-being in all aspects of the reproductive system at all phases of life. The right of women and men to be educated and to have access to effective, safe, inexpensive, and acceptable family planning techniques of their choosing is implicit in this (WHO,2018). Little is known about women with significant mental illnesses (SMI) and their rights to affordable preventative and curative services in relation to RH risky behaviours. Women with SMI are commonly treated and rehabilitated across a variety of professions, including reproductive health. Despite this, mental-health treatments give little attention to the RH issues that women with SMI face.

Gender difference

Many psychiatric diseases have a distinct gender difference in their epidemiology and phenomenology. Mood and anxiety disorders, in particular, are more common (and more frequently reported) in women than in men (Kuehner, 2003; Wittchen et al., 2011). This is especially true during the era of a woman’s fertile life, which spans the menarche to the menopausal transition. Suicidal conduct has a distinct gender and age pattern, with completed suicide being more prevalent in older men and attempted suicide being more common among young women (Hawton, 2000).
Screenshon

Mental health disorders

1. Mood disorders

Depression was determined to be the most significant contribution to the burden of disease in
women in a recent study that tried to determine the 12-month incidence of mental disorders
across Europe (and alcohol abuse in men). The F:M ratios for major depression (age range:
14 years and older) and bipolar disorder (age range: 18–65 years) were 2.3 and 1.2,
respectively, in the same study. Furthermore, 30.3 million persons in Europe suffered from
serious depression in 2011, with 3.0 million suffering from bipolar illness (Wittchen et al.,
2011). Despite the fact that there are no significant variations in the prevalence, clinical
presentation, or treatment response of bipolar I disease between men and women, bipolar
II/hypomania appears to be more prevalent in women than in men (Di Florio & Jones, 2010).
There is also ample proof of an elevated risk of recurrence/relapse in the postpartum period
(Jones & Craddock, 2005; Di Florio et al., 2013), and women with bipolar disorder concerns
of menstrual irregularity and premenstrual mood worsening (Blehar et al., 1998; Rasgon et
al., 2003), as well as mood lability during the perimenopausal transition.


2. Premenstrual Syndrome and Premenstrual Dysphoric Disorder

Premenstrual Syndrome (PMS) is a broad term for a group of severe, recurrent symptoms that
occur during the menstrual cycle (Johnson, 1987). These symptoms begin seven to ten days
before menstruation and stop when menstruation begins. Anxiety, irritability, nervousness
(often leading to conduct that is harmful to oneself, family, and society), abdominal bloating,
water and salt retention, mastalgia, sweet cravings, increased appetite, palpitation, weight
gain, exhaustion, headache, and the shakes are all common PMS symptoms. Depressive
symptoms, insomnia, bewilderment, and an increased risk of suicide are all signs of a less
common but more severe condition (Abraham, 1983). PMS/PMDD and depressive/anxiety
disorders have a reciprocal relationship: women with premenstrual dysphoric patterns are
more likely to have previous and future bouts of major depressive disorders (MDD). PMDD
and other mood disorders have a comorbidity rate of more than 20% (Wittchen et al., 2002;
Forrester-Knauss et al., 2011), while anxiety disorders have a comorbidity rate of 44.7
percent (Wittchen et al., 2002; Forrester-Knauss et al., 2011). Women with PMS/PMDD, on
the other hand, are more likely to have previous MDD (Critchlow et al., 2001). The
premenstrual period appears to be a risk factor for the exacerbation of pre-existing psychiatric
symptoms or disorders (Endicott & Halbreich, 1988), such as increased alcohol consumption
in the case of alcoholism, increased symptom severity in the case of schizophrenia, or even
higher rates of suicide attempts (Keye et al., 1986)


3. Perinatal disorders

Major depressive disorder (MDD) during pregnancy has the same characteristics as MDD in
other stages of a woman’s life (American Psychiatric Association, 2000). According to Gavin
et al., 2005, approximately 18.4% of pregnant women experience depressive symptoms, with
12.7% experiencing a major depressive episode (MDE). Substance and alcohol misuse,
cigarette smoking during pregnancy, self-rated poor general health, a lower education level
(Marcus et al., 2003), family or personal past history of negative life events, depression, lack
of social (and partner) support, domestic violence, and unintended pregnancy are all potential
risk factors for depressive symptoms during pregnancy (Marcus et al., 2003). (Lancaster et
al., 2010). Anxiety disorders are extremely common during pregnancy in general (Ross &
McLean, 2006). In a study of anxiety disorders and depression in the perinatal period, SutterDallay and colleagues (2004) discovered that 24% of participants had anxiety disorders and
5.7% had MDD during pregnancy, with a high rate of comorbidity. Women who have anxiety
disorders during pregnancy are more likely to develop depressive symptoms and/or disorders
in the perinatal period (Sutter-Dallay et al., 2004; Banti et al., 2011), and women who have
depressive symptoms during pregnancy are more likely to develop postpartum depression
(Sutter-Dallay et al., 2004) (Lee & Chung, 2007).
The perinatal period is also a high-risk phase for other psychiatric disorders, which is
frequently linked to the withdrawal of pharmacological treatment. In about 0.05% to 0.2% of
new moms, severe post-partum psychosis develops, especially in women who had previously
been diagnosed with bipolar disorder (Di Florio et al., 2013).


4. Perimenopausal disorders

Menopause is regarded to be a delicate time in a woman’s life, partly because of its extensive
psychological and social implications and partly because of the significant hormonal changes
it entails. Despite the fact that the female predominance in the prevalence of depressive
disorder appears to be a little less apparent after menopause (Weissman & Olfson, 1995), and
the majority of women do not develop depressive symptoms or disorders as a result of the
menopausal transition, a subgroup of women appears to be more vulnerable to mood
impairment during the perimenopause.
Taken together, these findings support the concept that hormonal fluctuation, rather than rise
or decrease (Freeman et al., 2006), contributes to the psychological distress that is common
during this reproductive phase (Harsh et al., 2009). Other risk factors for perimenopausal
depression include a young age at menarche, irregular and heavy menstrual bleeding during
the first five years of menstruation, a previous history of depression (Hay et al., 1994),
premenstrual dysphoria (Steinberg et al., 2008), and stressful life events during the
menopausal transition (Cohen et al., 2006).


5. Suicidal behavior and menstrual cycle phase

The results of studies looking into the links between suicidal conduct and reproductive life in
women have been inconsistent, with some finding no link (Mann et al., 1999) and others
finding a link between completed suicide and menstrual cycle phase. Suicide is more
common in the pre-ovulatory or paramenstrual phases, according to Targum et al. (1991) and
Gisselmann et al. (1996), while McKinon and colleagues (1959) discovered a link between
suicide (and accidental death) and the luteal phase, with a peak in the mid-luteal phase. Other
researchers (Dogra et al., 2007) discovered a link between suicide and the late luteal/early
follicular phase (menstrual haemorrhage), with 15% to 100% of women committing suicide
while menstruating.


The prevalence of suicide conduct (ideation, plans, and attempts) increased gradually from
women with no premenstrual symptoms to women with moderate/severe PMS to women with
PMDD, according to recent data from a nationwide representative sample of American
women (Pilver et al., 2013). In the same research, moderate/severe PMS was linked to a
higher risk of suicide ideation (OR 1.49), whereas PMDD was linked to a higher risk of
suicidal ideation (OR 2.22), intentions (OR 2.27) and attempts (OR 2.27) in women (OR
2.10).

Role of hormones

Estrogen increases serotonin (and noradrenalin) levels via inhibiting monoamine oxidases
and increasing the activity of tryptophan hydroxylase, the rate-limiting enzyme in serotonin
production. Estrogen also alters the distribution and regulation of serotoninergic receptors by
modulating the expression and activity of serotonin reuptake transporters (Rubinow et al.,
1998; Genazzani et al., 2007; Gasbarri et al., 2012). Progesterone is involved in the
regulation of the serotonergic, opioidergic, and cholinergic systems and has cognitive and
neuroprotective characteristics (Pluchino et al., 2009). The quantity and binding affinity of
platelet serotonin transporters and receptors varies with menstrual cycle phase and is
connected with oestrogen and progesterone concentrations, according to Wihlbäck et al.
(2004). Jovanovic et al. (2009) found no differences in the binding potentials of serotonin
receptors or serotonin transporters between the follicular and luteal phases of healthy women.

The effects of gonadal hormones (oestrogen, progesterone, and testosterone) on the central
nervous system can be seen even in the foetus. Indeed, gonadal steroids have a role in sexual
brain differentiation, and they promote specific organisational and developmental changes in
the brain once the gonads emerge. The testosterone produced by the male gonads is converted
to estradiol, which binds to oestrogen receptors in the growing brain, masculinizing and
defeminizing the male brain. The maternal estrogens are bound by the -fetoprotein in the
female foetus, inhibiting masculinisation–defeminisation of the female brain (Lenz et al.,
2010). As an outcome, brain sexual differentiation starts during the second trimester of
pregnancy and continues until the child is fully mature (Swaab, 2007).


Mental illness and reproductive health

Women with schizophrenia and mood disorders have lower fertility (Miller, 1997), more
lifetime sexual partners [59], high rates of sexual risk behaviours (Bengtson and Tops, 2007;
Holloway, 1982), unwanted pregnancies (Miller, 1997), lower rate of marriage, low
contraceptive use (Holloway, 1982), fewer planned pregnancies and live births (Nimgaonkar
et al., 1997), severe parenting troubles, and child custody loss (Rele and Wylie, 2007) and are
at significantly increased risk for HIV infection (Dickerson et al., 2004). Approximately half
of women with SMI are sexually active, and 43% of moderately impaired women become
pregnant (Chamberlain et al., 1984). The mental disability and stigma experienced by women
with SMI make gynaecological counselling and examination more difficult and time-
consuming (Sladyk, 1990). Severe depression symptoms, antidepressant use, and
cardiovascular disease all appear to be strong predictors of sexual dysfunction (Minihan and
Dean, 1990).


Every psychiatric examination should include a sexual history (Perlman et al., 2007; Rele and
Wylie, 2007). Anxiety (11.2%), sadness (8.4%), psychoactive substance misuse disorder
(6.8%), bipolar mood disorder (0.4%), sexual dysfunction (6.8%), and schizophrenia (0.4%)
are seen among the 34% of individuals with sexually transmitted illnesses who have
psychiatric disorders (Elkins and Anderson, 1992). Only 41.9 % of psychiatric outpatients are
tested for HIV,” says the report (Desai et al., 2007). Furthermore, antidepressants produce
vaginal dryness and increased production of interleukin-10 (IL-10), which triggers the risk of
STD transmission irrespective of the other risk factors (Schover, 2008). The extent to which a
prior psychiatric disorder can affect pregnancy is still a matter of contention among scientists
(Cohen et al., 2006; Gentile, 2005). According to some evidence, women with depressive
disorders have a higher risk of infant pulmonary hypertension and neonatal mortality
(Chamber et al., 2006; Cohen et al., 2006). Stress to a mother within the first trimester may
influence the risk of schizophrenia in the kids (Khashan et al., 2008).
Women who had an abortion had higher rates of later mental health issues such as depression,
anxiety, suicidal behaviour, and substance abuse (Hein et al., 1980). The high rate of
unwanted pregnancies among the mentally ill population necessitates the development of an
effective, easy, unobjectionable, and economical form of contraception for those with SMI
(Kreutner, 1981).


Conclusion

The domain of mental health would gain from the standardization of screening tools and cutoffs, as well as research that employs diagnostic techniques to confirm mental health
problems rather than only determining symptom severity. The use of rigorous clinical
diagnostic interviews to assess mental health issues would provide a more accurate clinical
picture of the mental health burden among adolescents who have had a sexual or reproductive
health event.


Since there is evidence that teenagers rarely use mental health services, these initiatives
should focus on how to connect identified adolescents to the care they require. Additional
research could identify risk and protective factors in adolescents who have had such a health
event by comparing those who developed mental health issues to those who did not; this
strategy could help determine whether targeted interventions can help adolescents who have
had such a health event build resiliency.

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