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Sad unhappy girl. Depression, apathy and bad mood concept. Dark clouds and rain above the woman head. Vector illustration, cartoon flat style.
A girl’s body signals that she has become a young woman, able to bear a child. A young woman gives birth to a soft, tiny new human being. A middle-aged woman says goodbye to those complicated years of monthly blood and pain and worry.
You’d think these would be happy times, and for many, they are. But they’re also times of dramatic hormonal change that, when combined with genetic predisposition or sleep deprivation or stress, can trigger a serious flare of depression. This may explain why, the world over, twice as many women as men suffer from depression—a gender difference that emerges at puberty.
Hormone levels rise and fall to prepare the body for fertility or its end, but they also influence brain systems connected to mood and stress response. One major risk factor for depression is family history, but genes aren’t sufficient cause, notes Dr. Cynthia Rogers, associate professor of psychiatry and pediatrics at the Washington University School of Medicine and director of the Washington University Medical Center’s Perinatal Behavioral Health Service. “In the right environment, people at more genetic risk might do just fine. There are also environmental factors—trauma, acute stress, chronic stress, lack of sleep, inflammation, diet, toxins.” Hunting for a single cause is pointless, because hormones interact in complicated ways with other physiological and psychological changes and predispositions.
Hormones also prompt the brain to release other compounds. Exciting new research, done in part at Wash. U., identified a neurosteroid that’s just been approved by the FDA as a medicine called Zulresso (brexanolone). The brain uses its naturally occurring form for damage control, alleviating the effects of stress during pregnancy. This hormone decreases at the same time progesterone does, at childbirth. That leaves some women, especially those with a genetic predisposition to and history of depression, vulnerable to postpartum depression (experienced by one in nine women in the U.S.).
In postpartum depression, not only has progesterone plummeted but also “your body has changed, you have this new being that does not sleep like a normal person and, if you’re breastfeeding, requires you for sustenance,” notes Dr. Denise Hooks-Anderson, associate professor of family and community medicine at Saint Louis University. “That’s a lot of pressure. And lack of sleep can cause your mind to go all kinds of places.” She urges women to seek help from their mother, mother-in-law, sister, or friend, just so they can get a consistent four hours of sleep. Somehow women have gotten the idea they have to do it all alone, she says. “I don’t know how we came up with that. If you do have that village, please use it.”
When she sees teenage girls, Hooks-Anderson makes sure to take a thorough history and do a careful exam so she can rule out concrete causes: “I want to know if a teenage girl is being bullied. Is she getting enough sleep? Are there stressors at home; is there any abuse; does she feel safe? Kids are more stressed now—in some cases, to the point of suicide.”
Research also links many cases of first-onset depression to estrogen loss at menopause, though Hooks-Anderson more often sees irritability and insomnia. To ease symptoms, she starts with “black cohosh, then certain antidepressants, and if symptoms are really severe, we talk about hormone replacement, which is the only thing that will completely ease the symptoms but does come with risks.”
And at every stage of a woman’s life, she checks the thyroid hormones, which affect almost every system of the body. “It has to be at a sweet spot. If it’s too low, that can cause depression; too high, and it can cause anxiety.” She pauses. “We’re complicated beings.”
