Stories from the ER

A young woman sat in the emergency area of the obstetrics unit. She was extremely pale and explained that she suddenly experienced severe abdominal pain and bleeding; she had only just found out she was pregnant a few weeks ago. When she started to throw up, she was rushed to the operating room. She had a life-threatening ectopic pregnancy.

A 42 year old woman sat in the examination room with her husband. She had arrived earlier that day because of cramping and vaginal bleeding; she had been 12 weeks pregnant. She was crying and said, “I know it’s gone.” It was her 5th miscarriage.

A 24 year old woman was in labor with her 6th pregnancy. She had a history of abuse, occasional substance use, had been homeless, and was a victim of physical and emotional abuse in romantic relationships. Several of her previous children had been removed from her custody and were living with relatives. 

My story

When I was a 3rd year medical student on my obstetrics and gynecology (OB/Gyn) rotation, I assisted in evaluating and treating these women with their medical emergencies. While they were there, I did my best to offer support and reassurance. But I worried about them. What happens when they leave the hospital? Who will the woman who suffered the ruptured ectopic talk to about the flashbacks she experiences when she thinks of the hospital? Who will address the depression and anxiety crippling the woman who has had so many miscarriages? Who will be there to work through the trauma and substance use issues that continue to disrupt the life of the mother who just lost custody of her 6th child?

I knew that if I chose to become an obstetrician I could support women during these seminal experiences in their lives, but I was more concerned about what happened next. Who would be there for them AFTER the procedure? I wondered if I could make a lasting impact on the after-effects of the traumas they experienced. I decided to pursue psychiatry and incorporate these concerns in my clinical practice.

So what is reproductive psychiatry?

As I progressed through my training I was fortunate to meet several mentors who introduced me to the field of reproductive psychiatry. I had never heard of this discipline of psychiatry before, defined by the Johns Hopkins Center for Women’s Reproductive Mental Health as “the study and treatment of psychiatric illness during reproductive transitions – that is, during times characterized by hormonal flux and/or social role change. Specifically, that means pregnancy, the postpartum period, infertility, pregnancy loss, premenstrual dysphoric disorder, and perimenopause.” I have now centered reproductive mental health concerns in my daily psychiatric practice and love to educate friends, colleagues, and patients about these issues.

Do I need a reproductive psychiatrist?

After reading all of this, you might ask, “okay, so how do I know if I need to see a reproductive psychiatrist?” While the conditions I mentioned above are not uncommon, they are not the only reasons you might think about talking to a reproductive psychiatrist. Consider the following:

• There is evidence that up to 8% of menstruating individuals experience premenstrual dysphoric disorder (PMDD)
• Up to 40% of women experiencing infertility also suffer from depression and/or anxiety
• Around 20% of patients will develop postpartum depression or anxiety disorders, with higher rates in low-income communities and people of color 
• 5-10% of menstruating individuals meet criteria for Polycystic Ovarian Syndrome (PCOS) and of them, up to 50% may experience depression and/or anxiety
• There is an increased risk of depressive episodes and anxiety during the menopausal transition 

Chances are good that you or someone close to you falls in one of these categories. For many patients, access to a good therapist and a support network will be enough to work through mental health challenges. However, there are some who will need more than therapy and support. 

When therapy is not enough 

In those situations, psychiatric medication might mean the difference between barely functioning and feeling like yourself again! But choosing to take medication is not always an easy decision and comes with many considerations, such as:

• Am I pregnant now or thinking of getting pregnant?
• Do I have any other medical issues or take any other medications that might interfere with psychiatric medications?
• What about breastfeeding? Is it safe to take medications then?
• What about side effects? How will this medication affect me?
  

In these situations, your OB and/or your general psychiatrist might not be aware of the latest research and recommendations about psychiatric medications. That’s where a reproductive psychiatrist comes in!

What makes a reproductive psychiatrist special?

Most reproductive psychiatrists have completed specialized training during their medical and residency training and beyond. They understand how to care for patients experiencing mental health concerns related to their reproductive status. Many providers are affiliated with large academic centers, such as the Massachusetts General Hospital Center for Women’s Mental Health, and/or advocacy groups like Postpartum Support International. Although reproductive psychiatry is becoming more widespread, it can be difficult to find a provider in your area. But that doesn’t mean you shouldn’t have access to quality advice from a reproductive psychiatrist! Postpartum Support International has a FREE perinatal psychiatric consult line for medical providers who want to know how best to care for their patients; you can ask your provider if they are aware of this resource. Both of these organizations are great places to start whether you are a provider or patient and will empower you to ask questions and get the treatment you deserve from all of your providers.