Several of you have mentioned your postpartum depression or anxiety getting worse when you return to having periods after your baby is born. You wonder whether this is an indication that you aren't really getting better at all.

If, like me, you are someone who had a perinatal mood or anxiety disorder and also has had premenstrual dysphoric disorder, you can't help but think they are connected in some way. I asked Marlene Freeman, MD, of the Massachusetts General Hospital Center for Women's Mental Health whether there is a known interconnection between postpartum depression and other types of depression that seem to be hormonally related, like premenstrual dysphoric disorder, which is depression and anxiety before your period, and depression during perimenopause. Her answer surprised me:

Postpartum depression. Premenstrual dysphoric disorder (PMDD). Perimenopausal depression. Depression associated with breast milk let down. Mood worsening or improvement with oral contraceptives. Many types of mood disturbances experienced by women over the reproductive cycle are associated with fluctuations of or exposures to gonadal (sex) hormones, primarily estrogen and progesterone.

A woman might experience any of the above. These are real, biologically driven mood disorders or disturbances. It seems intuitive that hormonal changes cause postpartum depression, premenstrual dysphoria (PMDD) and perimenopausal depression, but intuition is not always right, or at least as sophisticated as reality.

There is no simple relationship for women overall between hormones and mood. Variability among women and variability among the lifespan for each woman tells us how complicated the relationship can be. Consider that all postpartum women experience abrupt changes after delivery of estrogen and progesterone levels. A majority of women experience “the baby blues,” but a substantial minority will develop postpartum depression or anxiety.

No single hormonal factor has been found consistently to differentiate those who develop PPD and those who do not. Postpartum depression may certainly be triggered by hormonal changes in some women. However, it is difficult to predict who will be sensitive to hormonal changes. Some women will experience a crashing, immediate-onset depression after delivery, some will experience a sense of being overwhelmed with more gradual mood worsening into a depression, and some women will have depression that started during pregnancy and continued into the postpartum. It is not clear that postpartum depression is a single entity, and it definitely does not appear to have a single cause. We know if a woman has experienced PPD before she is at risk after future deliveries. It is less clear if she is at future risk for PMDD or perimenopausal depression, but it makes good sense to at least monitor her mood and suspect that mood worsening could occur during other reproductive events that are associated with hormonal fluctuations.

Some women will notice the onset of premenstrual dysphoric disorder (PMDD) after they have had children. Some women who already have PPD will notice their mood worsening even more during the premenstrual part of their cycles after their menstrual cycle has resumed. It is reasonable to assume that rather than PPD worsening during the premenstrual (or late luteal) phase, she may be experiencing premenstrual mood worsening or premenstrual mood exacerbation (PME). First line treatments for PMDD and PME are serotonergic antidepressants such as SSRIs, and often higher doses are required during the premenstrual phase of the cycle. [In other words, a mom already on an antidepressant for PPD whose moods worsen during PMS may need a higher dose during that part of the month prior to her period.]

To date, hormonal therapies are used to treat PMDD (in the form of oral contraceptives), hot flashes (estrogen, in numerous forms), and perimenopausal depression (often estrogen and progesterone in combination with an antidepressant). Hormonal treatments have not received adequate study for women with postpartum depression and anxiety. It may certainly be the case that at least a subset of women whose postpartum depression is primarily hormonally driven will be especially responsive to estrogen for example. Studies are underway to assess this as a possible treatment for PPD, as well as to assess which women are most likely to find this as a beneficial treatment.

There is a lot of data backing up the relationship between estrogen and neurotransmitters thought most responsible for mood. However, the actual experience of each woman is different.

I was surprised, because, as Dr. Freeman mentioned, it seems so intuitive that all of these things would be directly related. If your moods are worsening when your period returns, it looks like you may need to look at that as a separate issue from your postpartum depression or anxiety, and talk to your doctor about potential treatment with oral contraceptives and/or a potential temporary increase in your antidepressant. It is comforting, though, to note that a worsening in mood is NOT an indication that you are doomed to having PPD forever or that you've gone back to square one. Like me, you may also have PMDD. As more and more research is done, I hope one day to better understand why I'm so sensitive to hormonal changes, whenever they occur.