Klevens J, Kee R, Trick W, et al.

Effect of screening for partner violence on women's quality of life: a randomized controlled trial.

JAMA 2012; 308(7): 681-9.

Summary

The authors of this study approached women who were attending one of 10 primary health clinics in Cook County, Illinois. They randomized 2708 women into one of three groups: one that was screened for partner violence and given a list of resources if screening was positive, one that only received the list of resources, and a control group that received neither. One year later, participants were asked to complete a series of questionnaires describing quality of life issues and mental health.   There was no difference between the three groups in any QOL or mental health components. There were also no differences between groups in missed days of work, hospital or emergency department visits, contact with partner violence agencies, or recurrence of partner violence.

Commentary

At face value, the results of this study are discouraging in demonstrating a lack of improved health among women who are screened for intimate partner violence. It may be that a single intervention is insufficient to spur women to seek help for this problem, or that such intervention would be better received from a provider with whom a woman has multiple visits and develops rapport and trust. The outcomes measured may not completely reflect subtle changes in women's outlook that can nevertheless contribute to improved mental health. In any case, it would behoove the medical community to find more effective ways to screen for and treat domestic violence rather than giving up on routine screening entirely.

Straub H, Adams M, Kim JJ, Silver RK.

Antenatal depressive symptoms increase the likelihood of preterm birth.

American Journal of Obstetrics and Gynecology 2012; 207: 329.e1-4.

Summary

This large cohort study examined the pregnancy outcomes of 14,175 women who were administered the Edinburgh Postnatal Depression Scale as a routine screening test between weeks 24 and 28 of pregnancy. Women who screened positive were significantly more likely to deliver before 37 weeks (13.9%) than their asymptomatic counterparts (10.3%), with an adjusted odds ratio of 1.3 (95% CI 1.09-1.35). Significant differences were demonstrated at each gestational age breakpoint (< 28, < 32, and <34 weeks), and there was also an increased risk among screen-positive women among the 1019 with prior preterm birth.

Commentary

It is unclear whether the differences demonstrated in this study reflect a causal effect or simply association. There is a biologically plausible mechanism to explain earlier delivery in depressed women, in that depression may be associated with derangements of the hypothalamic-pituitary axis and elevated levels of corticotropin-releasing hormone. Studies have linked excessive CRH levels to preterm birth. On the other hand, a number of other factors may be involved including other stressors in the home environment, sleep hygiene, nutrition, and access to and use of health care.

Nevertheless, the study contributes to the growing body of evidence that depression adversely affects pregnancy, and that treatment for symptomatic women should not be withheld due to pregnancy. Whether intervention with antidepressants or psychotherapy can reduce the risk of preterm delivery in this group remains to be seen.

Toffol E, Heikinheimo O, Koponen P, et al.

Further evidence for lack of negative associations between hormonal contraception and mental health.

Contraception 2012; 86: 470-80.

Summary

This study analyzes data obtained as part of a large cross-sectional population study carried out every five years in Finland. Information was analyzed from a total of 8586 women of reproductive age, who were asked about various aspects of reproductive health and screened with a modified Beck Depression Inventory as well as a questionnaire on somatic and psychological symptoms. Women currently using combined oral contraceptives were compared to women using the levonorgestrel IUD and to women who were not using hormonal contraception. Although the group using oral contraceptives tended to be younger, more educated and single, there was an association between oral contraceptive use and lower BDI score that persisted after controlling for these confounding factors. No noteworthy associations were apparent between the IUD use and any of the items of interest.

Commentary

Literature on the mental health side effects of hormonal contraception has been inconsistent. Studies examining the reasons for discontinuation of effective contraception often list changes in mood or well-being as contributing factors. This population-based study suggests that not only do oral contraceptives not have a negative impact on mood, but they might actually improve it. Certainly, it would be unreasonable to suggest that oral contraceptives should be prescribed with the intention of mood elevation, and there will no doubt be idiosyncratic reactions among subgroups of women vulnerable to depressed mood. Still, prescribers can remain confident that hormonal contraceptives should not be expected to contribute to depressed mood, and women considering starting these methods should know that such an effect is unlikely.

Hayes RM, Wu P, Shelton RC et al.

Maternal antidepressant use and adverse outcomes: a cohort study of 228,876 pregnancies.

American Journal of Obstetrics and Gynecology 2012; 207: 49.e1-9.

Summary

This large cohort study examined the use of antidepressants in a very large group of pregnant women over a period of 13 years from 1995-2007. Data for this study were obtained from the Tennessee Medicaid program database and birth certificates. Of 23,280 women who were given prescriptions for antidepressants prior to pregnancy, 75% filled none in the second or third trimesters. Among the 10.7% who continued antidepressant use through pregnancy, there was an association between filling prescriptions in the second trimester with preterm birth, but not in the third trimester. The only adverse neonatal effect of note was an increase in episodes of neonatal convulsions in infants of women who took SSRIs in the third trimester; however, only one additional case of infant convulsions was noted for every 117 women using SSRI medications.

Commentary

This study is notable for its large size, although the largely administrative database did not furnish information about symptoms or depression severity. The possibility of an association between preterm labor and antidepressant use merits further investigation, particularly in light of the commentary above regarding the effects of depression on preterm labor. Similarly, the increase in neonatal convulsions associated with antidepressant use is small but worthy of exploration and potential discussion when counseling women about therapy during pregnancy.

Perhaps what is most notable in this study is the large majority of women who discontinue antidepressant therapy when they find out they are pregnant. Whether they do so autonomously or are following recommendations of their providers is unclear, but the figure suggests that there may be a large proportion of women with depression inadequately treated during pregnancy.

Erekson EA, Martin DK, Zhu K et al.

Summary

The authors compared sexual function in older women who had undergone bilateral oophorectomy with those who did not. They analyzed data from 1352 women between the ages of 57 and 85 who were part of the National Social Life, Health and Aging Project. Because sexual ideation would not be affected by the presence of a partner or physical limitations, this was made the primary outcome of interest. The 26% of women who had undergone oophorectomy were not significantly different in measures of sexual function from the women whose ovaries remained intact.

Commentary

Women who are deciding on whether or not to retain their ovaries at the time of hysterectomy are often counseled about sexual side effects that may result from their surgery. Oophorectomy, according to conventional wisdom, may have a detrimental effect on sexual function, presumably by eliminating the small amount of testosterone still secreted by the postmenopausal ovary, whose clinical significance is unclear. This study adds to the growing body of evidence that sexual function in older women is multifactorial and not likely to be influenced in the long term by small changes in androgen concentration. Women faced with the decision of whether to remove their ovaries can base their decisions on their medical issues, and need not feel that the surgery will doom them to a less fulfilling sex life.