Postpartum depression and hormonal imbalance – an underexplored connection

Dr Haleema Sheikh, pictured, of The Marion Gluck Clinic explains how the possible causes of PPD can be grouped into biological factors, social factors, and psychological factors

Postpartum depression PPD is a complex mood disorder that can affect as many as 1 in 7 women after childbirth. It is more persistent and challenging than the ‘baby blues’ which affects about 75% of all women and starts on the fourth or fifth day after giving birth but usually settles quickly. PPD can emerge within four weeks post-delivery but may also manifest as late as 30 weeks post-partum so health practitioners should remain vigilant in trying to identify patients.

Pregnancy is a stressful high energy intensive period in a woman’s life where she is literally creating another human from her own body. A pregnant mother will give up her ‘good stuff’ to make the best baby that she can so looking after women’s lifestyle and health before getting pregnant and during pregnancy can have a significant impact on pregnancy outcomes including post-partum depression.

There appears to be a significant neuroendocrine component and changes in reproductive hormones in post-partum depression which set it apart from general depression. It arises from rapid shifts in numerous biological and endocrine systems, such as the immune system, the hypothalamic-pituitary-adrenal (HPA) axis, and lactation hormones.

The HPA axis, which regulates stress responses through cortisol our survival hormone undergoes changes during and after pregnancy and can play a significant role in the drop in mood. Additionally, rapid post-delivery shifts in hormones like estradiol and progesterone can trigger depressive symptoms in susceptible women. Hormones such as oxytocin and prolactin, which are involved in lactation, are also significant factors in PPD’s development, with decreased oxytocin levels being linked to depression and difficulties in breastfeeding.

PPD has some similarities to other types of depression yet has distinctive symptoms that may include feelings of hopelessness, guilt, worthlessness, irritability, and restlessness. Additionally, women with PPD may experience challenges with concentration, memory, and decision-making, along with a loss of energy, sleeping issues, and changes in appetite. In severe situations, PPD may lead to thoughts of self-harm and poor emotional bonding with the baby.

Alongside the emotional difficulties of PPD, the intensive physical demands of caring for a newborn and lack of sleep can often be overwhelming for many women. Our understanding of mental health issues is evolving and there appears to be a significant metabolic component with issues with brain energy production in the neuronal mitochondria (power house of the cell). The mitochondria can be affected by nutrition/ sleep/ toxins/stress and the better shape a woman is in going into pregnancy the more robust and resilient her brain mitochondria function will be during pregnancy and post-partum.

The possible causes of PPD can be grouped into biological factors, social factors, and psychological factors. This is helpful for healthcare professionals to be aware of to try to pick up at-risk and affected women early.

Biological Factors

In addition to the dramatic drop in estrogen and progesterone after childbirth autoimmune conditions such as Hashimoto’s thyroid disease and postpartum thyroiditis, an inflammation of the thyroid gland following childbirth, have been associated with various psychiatric disorders, including depression. These conditions involve a dysregulated immune system.

Social factors

Poor social support is a significant contributing factor in the likelihood of developing PPD- supportive relationships are protective and on an evolutionary level historically we were more likely to survive if we were part of a tribe because of cooperation. Isolation can put us into a survival state and persistent raised cortisol will exacerbate the drop in reproductive hormones post-partum. Thus, healthcare providers should be aware of such risks in single-parent families, domestic abuse victims and those who are struggling financially as well.

Psychological Factors

A previous personal history or family history of depression post-partum and those who have suffered from PMS/PMDD are more likely to develop PPD- important risk factors to be aware of and ensure support is put in early. Other risk factors include marital or relationship conflict, ambivalence about the pregnancy, pregnancy complications, and the strain of having a baby with special needs or a baby who cries a lot

The mainstream treatments for PPD are psychotherapy such as cognitive behavioural therapy +/- and psychotropic medication such as antidepressants. The main antidepressants used are SSRI’s which are thought to work by enhancing the serotonergic system in the brain.

However, there also appear to be other physiological processes which can be supported to provide holistic care and increase the likelihood of mainstay treatments working

The health of the gut microbiome plays a significant role in mood as 85% of the body’s serotonin is actually in the gut and there is more communication going upwards via the gut-brain axis than downwards.  Thus, supporting gut health with a well-balanced diet and using probiotics can also potentially support the management of PPD symptoms.  Some studies also suggest that micronutrient deficiencies, particularly vitamin D and certain B vitamins, may be implicated in the development of PPD, Good nutrition should be an important part of antenatal care.

Omega 3 fatty acids (found in oily fish salmon mackerel sardines, herring, and certain marine algae) are anti-inflammatory and incorporated into the cell membranes. They are incredibly important for brain health and improve the communication between neurones. During pregnancy a mother will deplete her own omega 3 stores to make her baby’s brain – thus supplementation 1.5g/day in the antenatal period can offer advantages for the mother and developing foetus.  The addition of omega-3 fish oil to conventional antidepressant treatment can significantly increase the response rate also worth noting

Interestingly there is also some research on psychoneuroimmunology of PPD which has linked trace minerals such as zinc and selenium to the condition. There is more and more research coming out on the importance of nutrition and mental health.

Ashwagandha an adaptogenic herb has been shown to reduce general stress levels in women with PPD and helps balance the dysregulated HPA axis.

Gentle exercise and movement which improves mitochondrial function and energy production has also shown a reduction in depression rating scales in PPD women.

Lifestyle support can play a crucial role in managing PPD. Women should be encouraged to prioritise adequate sleep where the brain does important repair work; sleep deprivation can elevate depressive symptoms Additionally, frequent sunlight exposure is encouraged, particularly to boost vitamin D levels and there is a link between limited daylight exposure during the third trimester of pregnancy and higher PPD risk.

Healthcare professionals involved in prenatal and antenatal care are in a unique position to identify high-risk women and empower them to make useful lifestyle changes and foster supportive community relationships, either through local mother groups or other support networks. These can provide a sense of understanding and shared experience and such interactions can be healing and make a huge difference.

Postpartum depression is a complex mood disorder affecting not only the mother’s mental health but also their ability to care for and bond with their newborn. Thus, it can have far-reaching consequences. Conventional treatments like CBT and medications are commonly used effectively but there is also now a growing interest in more holistic approaches to PPD that focus on identifying and rectifying underlying physiological imbalances dietary and lifestyle modifications and using supportive supplements when needed.

Image: Sent by The Marion Gluck Clinic

Staff Writer