Balancing Minds and Hormones: Unraveling the Impact of Contraceptives on Young Girls’ Mental Health
Janani Devkumar
August 2024
The growing association between mental health and hormonal contraceptive use is becoming an issue of rising concern for young girls. Due to the wide scope of benefits provided from hormonal birth control, ranging from acne management to pregnancy prevention, the utilization of this medicine has become more prevalent among adolescents. As a consequence, the mental health implications of these medications have come under growing inspection. This article focuses on the relationship between hormonal contraceptives and mental health disorders in young adolescents, further highlighting the significance of well-informed decisions for the betterment of young girl’s healthcare.
The Impact of Hormonal Contraceptives on Mental Health
Hormonal contraceptives, including birth control pills, injections, and implants, are put into effect by changing the body’s natural hormone levels in attempts to avoid accidental pregnancies. These methods, despite having a high efficiency rate, have the potential to affect the brain’s chemistry. This could cause alterations in the adolescents mood as well and negatively impact their mental health. The two main hormones that are influenced by contraceptives are estrogen and progesterone, which are responsible for inflicting changes to the mental health of the individual.
A study published in JAMA Psychiatry led to the conclusion that young girls that utilize hormonal contraceptives were 80% more likely and in greater risk of being diagnosed with depression in comparison to those who did not use these methods. [1] In addition, a separate study brought awareness to the unfavorable consequences that resulted from the usage of these medications by highlighting that young adolescents who used combined oral contraceptives had a 70% increased risk of developing symptoms of anxiety compared to those who did not. [2]
Risk Factors Involved
Various factors can increase the risk of experiencing mental health issues from hormonal contraceptives. This includes pre-existing mental health conditions, such as a previous experience or history with depression or anxiety. In addition, genetic proneness, such as a family history of mental health disorders, can also influence the extent to which a girl’s body reacts in a negative manner to these hormones.
Research that was conducted by the University of Copenhagen found that teenage girls who possessed a history of mental health issues had almost double the risk of experiencing worsening symptoms after starting hormonal contraceptives. [3] To expand, a longitudinal study expressed that those with a family history of depression had a higher likelihood of developing symptoms related to depression following the introduction of hormonal birth control into their system. [4]
Conclusion
The correlation between mental health disorders and hormonal contraceptives for adolescent girls is a complex and highly prevalent issue in today’s society. Despite the benefits that result from taking these medications, the potential negative consequences on mental health for those who take them cannot be overlooked. It is important to understand that great consideration must go into deciding whether or not hormonal contraceptives are the best route for young girls.
References
[1] Skovlund, C. W., Morch, L. S., Kessing, L. V., & Lidegaard, Ø. (2016). Association of hormonal contraception with depression. JAMA Psychiatry, 73(11), 1154-1162.
[2] Zettermark, S., Perez Vicente, R., & Merlo, J. (2018). Hormonal contraceptive use among adolescent girls and subsequent depression: A nationwide population-based cohort study. BMJ Open, 8(11), e024813.
[3] University of Copenhagen. (2017). Impact of hormonal contraception on mental health in young women. Scandinavian Journal of Public Health, 45(5), 483-491.
[4] Bratke, S., & Sundström, A. (2020). Hormonal contraception and the risk of mental health disorders: A systematic review. Journal of Psychiatric Research, 126, 75-85.
The Silent Toll: How Workplace Stress Disrupts Women’s Menstrual Health in High-Pressure Careers
Janani Devkumar
August 2024
The workplaces in today’s modern society stand responsible for stimulating high stresses and intense pressures in their employees. Despite the shared experiences of tension among both men and women, demanding professions inflict unique challenges particularly for females in regard to their menstrual health. Research depicts a strong correlation between workplace stress and menstrual irregularities that are highly prevalent in female employees who are placed in demanding positions in their field of labor. This article delves into the specifics of these consequences while simultaneously highlighting the need for better support systems for women placed in these high-pressure environments.
Stress can be responsible for a variety of hormonal changes that occur within the body. This can be initially stimulated by the release of cortisol, which can be otherwise referred to as the “stress hormone”. As the levels of cortisol rises, it impedes a region of the brain primarily known for its regulation of the menstrual cycle: the hypothalamus. Disruptions to this section can stimulate imbalances in hormones including estrogen and progesterone. This further links to menstrual inconsistencies, such as missed periods, unpredictable cycles, and intensified symptoms.[1]
A study conducted by the American Psychological Association illustrated that women who are involved in work atmospheres with intense pressure are more likely to experience menstrual irregularities. The research further reported an approximation of 40% claiming to have pissed periods and 25% possessing an experience with significantly heavier menstrual bleeding during periods of high stress. [2] In addition, another study put forth the notion that women participating in high-pressure areas of work, such as medicine and law, had a 33% higher chance of experiencing extreme menstrual cramps in comparison to women who were involved in fields that were less demanding. [3]
Nurturing a Healthier Work Environment
In order to alleviate the stress that the workplace imposes on menstruation for women in high stress jobs, employers must take measures to create a healthy atmosphere. This may include promoting flexible work policies, such as remote work positions, which can assist women in managing their stress with greater care. A study published in the Journal of Occupational Health Psychology further explored how flexible work patterns diminished menstrual interferences in 60% of women participants. [4]
Conclusion
Workplace stress is difficult to avoid in modern life and fields of work, however its impact on women’s menstrual health should not be left unnoticed. Through efforts to understand the association between stress and menstruation as well as fostering supportive work environments, employers can help reduce some of the burdens placed on women active in high-stress jobs.
References
[1] Chandraratna, S., & Harlow, S. D. (2022). Stress and menstrual cycle irregularity: A prospective study of the effect of workplace stress. Journal of Women’s Health, 31(3), 300-306.
[2] American Psychological Association. (2023). Stress and menstrual health: How workplace pressure affects women’s cycles. APA Research, 45(2), 112-119.
[3] Cousins, S., & Maguire, K. (2021). The impact of occupational stress on menstrual health among women in high-stress professions: A review. Women’s Health Issues, 31(6), 452-460.
[4] Allen, R., & Parker, J. (2022). The effect of flexible work policies on women’s health outcomes in high-stress jobs. Journal of Occupational Health Psychology, 27(3), 205-213.
Amenorrhea: How The Absence of Menstruation Can Be a Problem
Gabriela Castro May 2024
If you have a uterus, there’s a chance your period has not always come on a regular monthly basis. The chronic absence of a period can be indicative of a medical condition called amenorrhea. There are two types of amenorrhea–primary and secondary.[4] Primary amenorrhea refers to those with uteruses who have not had their first period (also known as “menarche”) by age 15.[3] Secondary amenorrhea is the absence of 3 or more consecutive periods by someone who has begun to menstruate previously.[3]
The central feature of amenorrhea is a lack of menstruation. Other symptoms associated with amenorrhea can vary in part due to its causes, including::
Milky nipple discharge[3]
Hair loss[3]
Headache[3]
Vision changes[3]
Excess facial hair[3]
Pelvic pain[3]
Acne[3]
Primary Amenorrhea Causes
Primary amenorrhea is caused primarily by hormonal imbalances and genetic abnormalities.[5]
Having hypothalamic issues can prevent the onset of menstruation.[5]
Issues with the pituitary gland such as pituitary tumors can inhibit menstruation.[5]
Low body weight, excessive exercise, and eating disorders can cause stress which affects hormone production (particularly in the pituitary gland or hypothalamus leading to amenorrhea).[3]
Genetic abnormalities such as a lack of reproductive organs or a structural abnormality obstructing the vagina can block visible bleeding.[3] Chromosomal issues such as Turner syndrome–which is caused by a missing or partly missing X chromosome–or genetic disorders like androgen insensitivity syndrome–often characterized by high testosterone levels–may affect menstruation.[5]
Secondary Amenorrhea Causes
Secondary amenorrhea has a wider variety of causes.
It can be brought on naturally through pregnancy, breastfeeding, or menopause.[5] This type of amenorrhea can be brought on by hormone imbalance in ways similar to primary amenorrhea.
Hypothalamic amenorrhea–associated with low body weight, body fat, high stress, extreme exercise–can result in secondary amenorrhea.[5] Other hormonal imbalances that result in amenorrhea can be overactive or underactive thyroid, or pituitary tumors.[5][3]
Uterine scarring as a result of various medical interventions (including dilation and curettage (D&C), cesarean section, or treatment for uterine fibroids) may cause amenorrhea.[5][3]
Medications such as contraceptives, antipsychotics, antidepressants, blood pressure medications, chemotherapy radiation, and allergy medications are also known to cause secondary amenorrhea.[5][3]
Prevalence
With the wide array of underlying causes, you might be wondering, how common is amenhorrea? When focusing on women who menstruate, the American College of Obstetricians and Gynecologists estimated that 1 in 25 women who are not pregnant, breastfeeding, or going through menopause experience amenorrhea at some point in their lives.[1] If you struggle with amenorrhea, you should know you are not alone.
Treatments
If you or someone you know is struggling with amenorrhea, it can be a sign of a deeper issue especially if it is not because of natural causes like pregnancy or menopause. That is why it is important to discuss your menstrual cycle with your healthcare provider, including any other symptoms you’ve been experiencing. Depending on the root cause of amenorrhea, treatment can vary from psychological therapy, stress management, eating disorder treatment, changing medications, surgery, chemotherapy, or radiation.[2] Whatever the cause is, you do not have to endure amenorrhea without help or guidance. Taking the first step by sharing your concern with your health care provider and a trusted loved one will ensure you are in good hands and supported in your recovery.
[4] Fragile x-associated primary ovarian insufficiency (Fxpoi) | nichd—Eunice kennedy shriver national institute of child health and human development. (2021, August 19). https://www.nichd.nih.gov/health/topics/fxpoi
Reviving Passion: Exploring Causes and Solutions for Low Libido
Paz Etcheverry, MS, PhD May 2024
Low libido means having a low appetite for sex and, just like vaginismus, it falls under the category of sexual disorders that afflict women. When coupled with elevated stress levels attributed to diminished libido, the condition is known as hypoactive sexual desire disorder.[19]
Low sex drive is the most common sexual issue reported by women.[18] Research reveals that low sexual desire impacts 26 out of every 100 premenopausal women,[10] while the prevalence increases to 52 out of every 100 menopausal women in the US.[19] And while low sex drive can affect women of all ages, studies suggest that younger women find low libido to have a greater lifestyle effect.[1]
Age is one major factor that can contribute to low libido. Starting at the age of 45, there is a decrease in sex hormones, primarily estrogen and testosterone. Low estrogen levels lead to vaginal dryness, which can make penetrative sex particularly painful, a condition known as dyspareunia. Furthermore, low estrogen levels lead to reduced sensitivity in the genital area, which can impede a woman’s ability to actively respond to sexual expression and cues.[1]
Testosterone is a major driver of sex as it enhances sexual desire and behavior. By the time women reach menopause, between ages 40 and 60, their testosterone levels are almost a quarter of what they used to be during their 20s.[1] Weight gain and depression can also decrease libido.[17] Relationship difficulties can have a considerable effect on sexual desire, along with emotional stress, the health of the partner, and family conflicts. Moreover, surgical procedures (like oophorectomies, which involve removing one of the two ovaries responsible for estrogen and testosterone production), health conditions, and certain medications such as SSRIs (selective serotonin reuptake inhibitors), can contribute to a diminished libido. These factors may result in the absence of sexual fantasies and a reduced desire for sexual activity.[1][10]
Treatment options for this condition include hormonal treatments and pharmaceutical drugs.
Estrogen
Possible options are oral and local estrogen, such as patches, creams, and rings inserted in the vagina. A caveat with oral estrogen: they lower levels of testosterone, which we know is a major driver of sexual desire. Hence, local estrogen options, which have minimal effects on testosterone levels, might be more suitable. Vaginal moisturizers, as well as water, oil, or silicone-based lubricants, can be used when vaginal dryness is suspected.[10]
Testosterone
Oral testosterone is not an option for women because of the effects it has on blood lipid levels. Instead, patches are recommended. Frequent adverse effects associated with testosterone patches include a rise in body hair or hirsutism (observed in 7% compared to 5% in controls), acne (reported in 9% compared to 7% in controls), and irritation at the patch site affecting up to 30% of participants. These effects resolve, however, following discontinuation of treatment.[10] Additionally, there are testosterone creams and gels that, when applied to the upper thighs, abdomen, and forearms, can enhance sexual desire without significant side effects,[6][7][16] although the risk of acne and hirsutism remains possible.
Tibolone
For menopausal women, tibolone may be a beneficial treatment option.[5][8] As a synthetic steroid, tibolone is marketed as hormone replacement therapy. However, there are concerns regarding the potential risk of stroke in older women using tibolone, despite its positive effects on breast cancer, fracture risk, and possibly colon cancer.[4]
Dehydroepiandrosterone or DHEA
Touted as the “elixir of youth”, DHEA is converted in various body tissues into estrogen and testosterone.[3] DHEA is available over-the-counter, but its safety remains unclear.[11]It is also unclear to what extent DHEA is beneficial, particularly for libido and general well-being..[12][20]
Flibanserin
Flibanserin is a drug that selectively influences neurotransmitter pathways that are associated with sexual desire.[10]In studies, a daily dose of 100 mg improved sexual desire in women.[9][15] However, the drug has some unwanted side effects such as nausea, dizziness, fatigue, and insomnia.[2]
Bupropion
Bupropion is a drug that enhances sexual desire.[13] Psychiatrists commonly recommend bupropion for the treatment of SSRI-induced low libido due to studies demonstrating its positive impact on desire, arousal, lubrication, orgasm, and satisfaction in women with SSRI-induced sexual dysfunction.[10][14]
There are multiple causes of low libido that may be physical, emotional, medical, or due to relationship conflicts. Treatment options are available to reignite sexual desire. Work with a trusted healthcare provider to explore the various options available and get back to feeling like you.
References
[1] AlAwlaqi, A., Amor, H., & Hammadeh, M. E. (2017). Role of hormones in hypoactive sexual desire disorder and current treatment. Journal of the Turkish German Gynecological Association, 18(4), 210–218. https://doi.org/10.4274/jtgga.2017.0071
[2] Baid, R., & Agarwal, R. (2018). Flibanserin: A controversial drug for female hypoactive sexual desire disorder. Industrial Psychiatry Journal, 27(1), 154–157. https://doi.org/10.4103/ipj.ipj_20_16
[3] Buffington C. K. (1998). DHEA: elixir of youth or mirror of age?. Journal of the American Geriatrics Society, 46(3), 391–392. https://doi.org/10.1111/j.1532-5415.1998.tb01062.x
[4] Cummings, S. R., Ettinger, B., Delmas, P. D., Kenemans, P., Stathopoulos, V., Verweij, P., Mol-Arts, M., Kloosterboer, L., Mosca, L., Christiansen, C., Bilezikian, J., Kerzberg, E. M., Johnson, S., Zanchetta, J., Grobbee, D. E., Seifert, W., Eastell, R., & LIFT Trial Investigators (2008). The effects of tibolone in older postmenopausal women. The New England Journal of Medicine, 359(7), 697–708. https://doi.org/10.1056/NEJMoa0800743
[5] Davis S. R. (2002). The effects of tibolone on mood and libido. Menopause (New York, N.Y.), 9(3), 162–170. https://doi.org/10.1097/00042192-200205000-00004
[6] El-Hage, G., Eden, J. A., & Manga, R. Z. (2007). A double-blind, randomized, placebo-controlled trial of the effect of testosterone cream on the sexual motivation of menopausal hysterectomized women with hypoactive sexual desire disorder. Climacteric: The Journal of the International Menopause Society, 10(4), 335–343. https://doi.org/10.1080
[7] Goldstat, R., Briganti, E., Tran, J., Wolfe, R., & Davis, S. R. (2003). Transdermal testosterone therapy improves well-being, mood, and sexual function in premenopausal women. Menopause (New York, N.Y.), 10(5), 390–398. https://doi.org/10.1097/01.GME.0000060256.03945.20
[8] Kamenov, Z. A., Todorova, M. K., & Christov, V. G. (2007). Effect of tibolone on sexual function in late postmenopausal women. Folia Medica, 49(1-2), 41–48.
[9] Katz, M., DeRogatis, L. R., Ackerman, R., Hedges, P., Lesko, L., Garcia, M., Jr, Sand, M., & BEGONIA trial investigators (2013). Efficacy of flibanserin in women with hypoactive sexual desire disorder: results from the BEGONIA trial. The Journal of Sexual Medicine, 10(7), 1807–1815. https://doi.org/10.1111/jsm.12189
[10] Maclaran, K., & Panay, N. (2011). Managing low sexual desire in women. Women’s Health (London, England), 7(5), 571–583. https://doi.org/10.2217/whe.11.54
[11] Omura Y. (2005). Beneficial effects and side effects of DHEA: true anti-aging and age-promoting effects, as well as anti-cancer and cancer-promoting effects of DHEA evaluated from the effects on the normal and cancer cell telomeres and other parameters. Acupuncture & Electro-therapeutics Research, 30(3-4), 219–261. https://doi.org/10.3727
[12] Panjari, M., & Davis, S. R. (2007). DHEA therapy for women: effect on sexual function and wellbeing. Human Reproduction Update, 13(3), 239–248. https://doi.org/10.1093/humupd/dml055
[13] Razali, N. A., Sidi, H., Choy, C. L., Roos, N. A. C., Baharudin, A., & Das, S. (2022). The Role of Bupropion in the Treatment of Women with Sexual Desire Disorder: A Systematic Review and Meta-Analysis. Current Neuropharmacology, 20(10), 1941–1955. https://doi.org/10.2174/1570159X20666220222145735
[14] Segraves, R. T., Clayton, A., Croft, H., Wolf, A., & Warnock, J. (2004). Bupropion sustained release for the treatment of hypoactive sexual desire disorder in premenopausal women. Journal of Clinical Psychopharmacology, 24(3), 339–342. https://doi.org/10.1097/01.jcp.0000125686.20338.c1
[15] Simon, J. A., Thorp, J., & Millheiser, L. (2019). Flibanserin for Premenopausal Hypoactive Sexual Desire Disorder: Pooled Analysis of Clinical Trials. Journal of Women’s Health (2002), 28(6), 769–777. https://doi.org/10.1089/jwh.2018.7516
[16] Singh, A. B., Lee, M. L., Sinha-Hikim, I., Kushnir, M., Meikle, W., Rockwood, A., Afework, S., & Bhasin, S. (2006). Pharmacokinetics of a testosterone gel in healthy postmenopausal women. The Journal of Clinical Endocrinology and Metabolism, 91(1), 136–144. https://doi.org/10.1210/jc.2005-1640
[17] Stanikova, D., Zsido, R. G., Luck, T., Pabst, A., Enzenbach, C., Bae, Y. J., Thiery, J., Ceglarek, U., Engel, C., Wirkner, K., Stanik, J., Kratzsch, J., Villringer, A., Riedel-Heller, S. G., & Sacher, J. (2019). Testosterone imbalance may link depression and increased body weight in premenopausal women. Translational Psychiatry, 9(1), 160. https://doi.org/10.1038/s41398-019-0487-5
[18] Sutherland, S. E., Rehman, U. S., & Goodnight, J. A. (2020). A Typology of Women with Low Sexual Desire. Archives of Sexual Behavior, 49(8), 2893–2905. https://doi.org/10.1007/s10508-020-01805-9
[19] West, S. L., D’Aloisio, A. A., Agans, R. P., Kalsbeek, W. D., Borisov, N. N., & Thorp, J. M. (2008). Prevalence of low sexual desire and hypoactive sexual desire disorder in a nationally representative sample of US women. Archives of Internal Medicine, 168(13), 1441–1449. https://doi.org/10.1001/archinte.168.13.1441 [20] Wierman, M. E., & Kiseljak-Vassiliades, K. (2022). Should Dehydroepiandrosterone Be Administered to Women?. The Journal of Clinical Endocrinology and Metabolism, 107(6), 1679–1685. https://doi.org/10.1210/clinem/dgac130
The Gender Gap in Alzheimer’s: Why Women Are at Higher Risk
Jessica Luu May 2024
Picture yourself in a room surrounded by people. If each person were to raise their hand to indicate they have Alzheimer’s, you might notice that more women would raise their hands than men. This isn’t a coincidence. Surprisingly, almost two-thirds of Americans living with Alzheimer’s are women.[1] But why is this the case? To understand this gender gap, we need to look at various factors that make women more susceptible to this neurodegenerative disease.
One of the most prominent theories explaining the higher incidence of Alzheimer’s in women involves hormonal changes, particularly those associated with menopause. Estrogen, a hormone that declines sharply during menopause, is believed to play a protective role in brain health. Estrogen receptors are found throughout the brain, and this hormone is known to have neuroprotective properties, including reducing inflammation, promoting synaptic growth, and enhancing cerebral blood flow.[2] This dramatic loss of estrogen during menopause could therefore, make women more vulnerable to the onset and progression of Alzheimer’s disease.
Genetics: The Inherited Risk
Genetics also plays a critical role in the risk of developing Alzheimer’s. The presence of the APOE-e4 allele, a variant of apolipoprotein E gene, is a well-known risk factor for Alzheimer’s disease.[5]Interestingly, research shows that women who carry the APOE-e4 allele are at a higher risk compared to men with the same genetic variant. The reasons behind this heightened vulnerability are not entirely understood, but they may involve differences in how the gene interacts with female-specific factors, such as hormonal changes and other epigenetic mechanisms.[5]
Social and Lifestyle Factors
Women have historically been primary caregivers, which can lead to chronic stress—a known risk factor for Alzheimer’s. Chronic stress elevates cortisol levels, and prolonged exposure to cortisol can cause damage to the hippocampus (the brain region responsible for memory consolidation)[3]. Additionally, women are more likely to experience depression and anxiety,[4] both of which are linked to an increased risk of Alzheimer’s. When you combine these mental health issues with the stress of caregiving and hormonal changes from menopause, it becomes clear why women are more disproportionately affected by the disease than men.
Building Resilience
However, there is hope. By understanding these factors, women can take proactive steps to reduce their risk:
Physical Activity: Engaging in regular exercises and strength training can increase blood flow to the brain and promote the health of brain cells, which may reduce the risk of Alzheimer’s.[1]
Healthy Diet: Eating a balanced diet rich in fruits, vegetables, whole grains, and lean proteins can provide essential nutrients that support brain health and may prevent progression of Alzheimer’s.[6]
Mental Stimulation: Keeping your brain active with activities like reading, puzzles, learning new skills, and socializing may build up mental stamina, which in the long run, can delay the onset of Alzheimer’s symptoms. [1]
Quality Sleep: Try to get 7-9 hours of sleep per night, as quality sleep is crucial for memory consolidation and brain health.[1]
Ultimately, by incorporating these changes into one’s daily routine, women can enhance their overall well-being all while mitigating their risk of Alzheimer’s.
As we continue to research more about Alzheimer’s and its effect on women, advocating for greater awareness and support is essential. By doing so, we can ensure that women everywhere can live their life to fullest, today and for generations to come. Together, we can work towards a healthier and brighter future where Alzheimer’s is better understood, prevented, and ultimately cured.
References:
[1] Alzheimer’s Association. (2024). “Alzheimer’s disease facts and figures.” Accessed 22 May 2024, Alzheimer’s Association. https://www.alz.org/alzheimers-dementia/facts-figures
[2] Alzheimer’s Society. (n.d.). “Hormones and Dementia Risk.” Accessed 22 May 2024, Alzheimer’s Society. https://www.alzheimers.org.uk/about-dementia/managing-the-risk-of-dementia
[3] Browning, M.E., Hocking, C., Hunter, M., Khan, Z., Middleton, C., (2022). “Increased Cortisol and Altered Dehydroepiandrosterone Sulfate Levels in Alzheimer’s Disease. Alzheimer’s Research and Therapy. Accessed 22 May 2024. https://alzres.biomedcentral.com/articles/10.1186/s13195-022-01139-9
[4] Fisher Center for Alzheimer’s Research. (2020). “Depression Increases the Risk for Alzheimer’s.” ALZinfo.org. Accessed 22 May 2024.
[6] Robbins, R. (2020) “What to Eat to Reduce Your Risk of Alzheimer’s Disease.” Harvard Health Blog. https://www.health.harvard.edu/blog/what-to-eat-to-reduce-your-risk-of-alzheimers-disease-20200508197 74
When a Painful Cramp isn’t Just a Painful Cramp: a Guide to Endometriosis
Tanvi Mehta June 2024
Endometriosis is a disease in which tissue similar to that in the lining of the uterus grows elsewhere within the body.[5] When this tissue is in the uterine lining, it regularly breaks down and leaves the body through the menstrual cycle. [4] However, when this tissue is produced outside the uterus it does not have means of exiting the body, causing inflammation and scarring within the pelvic region.[5]
Up to 30% of endometriosis patients do not present with any symptoms at all.[6] However, those that do, often present with excessively painful periods, pain with bowel movements and urination, pain during or after sex, excessive bleeding, infertility, irregular periods, fatigue, and spotting between periods.[3]
Patient Population
Around 10% of women have endometriosis and patients that get diagnosed are usually between the ages of 25 and 40, but endometriosis can start to present in teen years as well. Some risk factors include having a family history of endometriosis, starting periods at a young age (11 or younger), having shorter amounts of time between periods, and defects within your uterus or fallopian tubes.[1]
What does getting diagnosed look like?
Diagnosis begins with your doctor taking a thorough patient medical history which can often give insight. Questions like asking the patient if their periods have always been this painful or if they have any family history of endometriosis can often help doctors discern whether the patient is experiencing endometriosis or potentially another condition.[6]
If the doctor suspects endometriosis, typically they will start with a pelvic exam in which they feel around in the pelvic area with gloved hands for any unusual changes like cysts or irregular growths. Usually, areas of endometriosis cannot be felt in a pelvic exam unless a cyst has formed in the area. If the doctor suspects something, they may move onto ultrasounds which can help to show a better picture of the reproductive organs and any cysts on them. However, an ultrasound is unable to fully confirm the diagnosis and other options like Magnetic Resonance Imaging (MRI) might be needed to get a fuller picture. At this point, a clinical diagnosis based on imaging and symptoms can be made.
Treatment Options
Treatment can vary a lot depending on different factors like progression and severity of the disease, plans for future pregnancies, and age. Medications are often used to symptomatically treat patients’ pain as well as increase fertility.
While these medications may work short-term, the long-term solution to relieve the chronic discomfort from endometriosis is surgery. The problem with surgery is that even with it, symptoms may come back in a few years depending on the disease severity.[1] Laparoscopy, a surgical procedure to check inside the abdomen for signs of endometriosis, is used to get information about the progression of endometriosis growths and also remove them. [4] In severe cases, a hysterectomy may be the best option, considering the progression of the disease and the amount of scar tissue. A hysterectomy is a surgical procedure in which the uterus is entirely removed from the patient’s abdomen.[1]
Causes
Scientists still do not exactly know what the cause of endometriosis is, but it is likely caused by multiple factors like genetics and altered immune system function. The most common theory explaining its origin is the retrograde menstruation theory. This theory suggests that some menstrual blood and uterine lining tissue, which normally exits through the vagina, flows back into the fallopian tubes and pelvis. Thus, endometrial cells attach and grow on tissues in the pelvis.[6]
Often Being Misdiagnosed and Overlooked
The problem with endometriosis diagnosis is that each person’s menstrual cycle experience is unique and subjective. Sometimes, what a patient might believe to be cramp pain at their regular tolerance level could actually be pain from endometriosis. Oppositely, what patients might tell their doctors is unusual extreme pain, might be dismissed as just period cramps. Endometriosis patients often do feel ignored and isolated as their broad symptoms are difficult to diagnose with such little attention being paid to endometriosis in the greater medical domain.[2]
Outlook
Endometriosis is a condition that can affect a person’s daily life, causing long-term pain, disruptions in menstrual cycles, and even infertility. However, patients with endometriosis can very much still have full and meaningful lives with proper diagnosis and treatment![1]
[2] Hudson, N. (2022). The missed disease? endometriosis as an example of ‘undone science.’ Reproductive Biomedicine & Society Online, 14, 20–27. https://doi.org/10.1016/j.rbms.2021.07.003
[4] Mayo Foundation for Medical Education and Research. (2023, October 12). Endometriosis. Mayo Clinic.https://www.mayoclinic.org/diseases-conditions/endometriosis/diagnosis-treatment/drc-20354661
[5] World Health Organization. (n.d.). Endometriosis. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/endometriosis#:~:text=Overview,period%20and%20last%20until%20menopause. [6] Yale Medicine. (2024, March 11). Endometriosis. Yale Medicine. https://www.yalemedicine.org/conditions/endometriosis
Major depression is a widespread chronic illness that significantly contributes to the global burden of disease. In 2010, depressive disorders were the second leading cause of years lived with disability in Canada, the United States, and across the globe. When considering deaths from suicide and stroke related to depression, it ranks third in the global burden of disease. The overall burden of major depression is increasing, and it is expected to be the leading cause of disease burden by 2030, already holding this position for women worldwide. Between 1990 and 2010, Canada saw a 75% increase in disability-adjusted life years due to major depression, second only to Alzheimer’s disease, while the increase in the U.S. was 43%. The female-to-male ratio of global disability from major depression has remained at 1.7:1. While socioeconomic factors such as abuse, education, and income may influence the higher rate of depression in women, this article focuses on biological contributors to this disparity.
The prevalence of major depression is higher in women than in men. In 2010, the global annual prevalence was 5.5% for women and 3.2% for men, a 1.7-fold difference. In Canada, the prevalence in 2002 was 5.0% for women and 2.9% for men, increasing to 5.8% and 3.6% respectively by 2012. These similar ratios across developed countries suggest that the differential risk is mainly due to biological sex differences rather than social or economic factors. The rate of depression does not appear higher in countries where women have significantly lower socioeconomic status than men. Depression is more than twice as prevalent in young women (ages 14–25) than in men, but this ratio decreases with age. Before puberty, boys and girls have similar depression rates, which decline after age 65, becoming similar between genders. This higher prevalence in women is also reflected in the prescription rates of antidepressants, with women in Canada being prescribed these medications more than twice as often as men. The delay in antidepressant treatment for young adults may contribute to higher depression rates in adolescence and young adulthood.
Depression triggers differ between genders, with women more often experiencing internalizing symptoms and men externalizing symptoms. Studies of dizygotic twins suggest women are more sensitive to interpersonal relationships while men are more sensitive to external career and goal-oriented factors. Women also face specific forms of depression-related illnesses linked to hormonal changes, such as premenstrual dysphoric disorder, postpartum depression, and postmenopausal depression and anxiety. This suggests that hormonal fluctuations, particularly estrogen, may trigger depression in women. However, most preclinical studies focus on males to avoid behavioural variability related to the menstrual cycle. Additionally research on primates has shown that social stress can lead to depression-like symptoms and changes in the serotonin system and hippocampal volume, more pronounced in postmenopausal than ovarian-intact monkeys. Furthermore, hormone replacement therapy during perimenopause has shown promise in preventing postmenopausal depression. Studies indicate that oral contraceptive use may reduce depression and anxiety, suggesting that moderating estrogen cycling could be protective.
Despite the lack of systemic estrogen, men have lower depression rates, possibly due to the conversion of testosterone to estrogen in the male brain, providing consistent protection. Men also have androgen receptors that may offer additional protection. These hormonal and developmental differences in brain circuitry contribute to the lower prevalence of depression in men.
The fundamental genetic differences between men and women, such as the presence of X and Y chromosomes, contribute to the differing depression rates. Societal factors likely have a biological basis, yet even with improving social equality, the female-to-male depression ratio remains unchanged. Biological factors, particularly fluctuations in ovarian hormones and decreases in estrogen, appear to significantly contribute to the higher prevalence of depression in women. Developing treatments that target these biological factors could help mitigate this disparity.
References
Whiteford, H. A., Degenhardt, L., Rehm, J., Baxter, A. J., Ferrari, A. J., Erskine, H. E., Charlson, F. J., Norman, R. E., Flaxman, A. D., Johns, N., Burstein, R., Murray, C. J., & Vos, T. (2013). Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet, 382(9904), 1575–1586. https://doi.org/10.1016/s0140-6736(13)61611-6
Ford, D. E., & Erlinger, T. P. (2004). Depression and C-Reactive protein in US adults. Archives of Internal Medicine, 164(9), 1010. https://doi.org/10.1001/archinte.164.9.1010
Nourishing the Journey: The Vital Role of Good Nutrition During Pregnancy
Pooja Bhavsar
June 2024
Pregnancy is a transformative period in a woman’s life. The excitement that comes with the journey is unparalleled, an astonishing experience for everyone involved. In the miscellany of all of these emotions, good nutrition can easily be overlooked. It has recently been discovered the vitality of good nutrition during this time and how a lack of nourishment can undermine the health of the baby.
In some underprivileged countries, women’s diets are lacking in main food groups, like dairy and legumes. Since the pandemic, malnutrition in adolescent girls and women has skyrocketed by twenty-five percent, from 5.5 million to 6.9 million.[1] Malnutrition has severe effects when only one individual is dependent on the body’s nourishment. When two are reliant, the response can be detrimental. Malnutrition can lead to an increased risk in neonatal death, which is defined by the death of a live-born infant within the first 28 completed days of life.[1] It can also impair fetal development with lifelong consequences for children’s nutrition and growth.[1] However, these are just the effects on the baby. The effects on the mother are just as dangerous.
Vitamins are key in any diet. From iron to calcium, these nutrients are building blocks for exceptional health. Poor diet during pregnancy is represented with reduced levels of necessary vitamins, like iodine, iron, folate, calcium and zinc.[2] This can often lead to anemia, preeclampsia, hypertension and more.[2] Disease is a less harsh repercussion of this loss. Malnourishment leads to double the chances of maternal mortality.[2] There are many elements when thinking about malnutrition in pregnant women like a lack of resources, prior health detriments and furthermore. These factors are out of one’s control and are not at all the fault of the mother . There are few and far between programs to help mothers sustain themselves and to aid with good maternal nutrition. It is vital for the health of children and women globally that there are more of these programs instituted as the malnourishment crisis continues to grow.
We see the harms of malnutrition. But what can a good diet do for mothers and their babies? A well-balanced diet, rich in legumes, proteins, grains and healthy fats aid the immune system and reduce inflammation.[4] Physiological changes and stressors can be a lot for women to bear during pregnancy, however this benefit makes it easier for them to cope with the adaptations. It also helps regulate blood glucose, weight fluctuations etc.[4] Good nutrition can aid a pregnancy tremendously, making the process easier and less stressful for mothers.
Maintaining good nutrition during pregnancy has a few requirements. Eating nutrient-dense foods, smaller meals, staying hydrated and limiting processed food can ensure mothers getting the key nutrients to keep them and their babies healthy.[3] If available, consulting with a healthcare provider or dietician is always a beneficial way of ensuring that your diet is in check.
By eating healthily, pregnant women can enhance the health of themselves and their children. Empowering expectant mothers with the knowledge and resources to make informed dietary choices goes hand in hand in promoting positive birth outcomes and ensuring a healthy start for both mother and baby.
References
[1] Malnutrition in mothers soars by 25 per cent in crisis-hit countries, putting women and newborn babies at risk. UNICEF. (n.d.). https://www.unicef.org/press-releases/malnutrition-mothers-soars-25-cent-crisis-hit-countries-putting-women-and-newborn
[2] Marshall, N. E., Abrams, B., Barbour, L. A., Catalano, P., Christian, P., Friedman, J. E., Hay, W. W., Hernandez, T. L., Krebs, N. F., Oken, E., Purnell, J. Q., Roberts, J. M., Soltani, H., Wallace, J., & Thornburg, K. L. (2022, May). The importance of nutrition in pregnancy and lactation: Lifelong consequences. American journal of obstetrics and gynecology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9182711/
[3] Nutrition during pregnancy. Johns Hopkins Medicine. (2019, November 19). https://www.hopkinsmedicine.org/health/wellness-and-prevention/nutrition-during-pregnancy [4] Shenoy, S., Sharma, P., Rao, A., Aparna, N., Adenikinju, D., Iloegbu, C., Pateña, J., Vieira, D., Gyamfi, J., & Peprah, E. (2023, October 25). Evidence-based interventions to reduce maternal malnutrition in low and middle-income countries: A systematic review. Frontiers in health services. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10634505/#:~:text=Shockingly%2C%20malnourished%20women%20face%20a,in%202020%20occurred%20within%20LMICs.
About every two minutes, a maternal death occurred in the year 2020, according to the World Health Organization (WHO).[5] Maternal mortality is a critical global health issue that takes away numerous women’s lives around the world. Data from 2020 reveals that around 95% of all maternal deaths happened in low and lower-middle-income countries, most of which could have been prevented.[5] Since maternal mortality causes so many deaths worldwide, it is important to unravel the intricacies and be aware of diverse outcomes, factors, and prevention strategies that can influence maternal mortality and save women’s lives.
Maternal mortality is an essential concern to be aware of not only because it takes away so many women’s lives, but it can also directly affect the life course of infants born to mothers who have passed away during and after childbirth. For instance, the infants may not be able to be breastfed and receive the health benefits of breastfeeding as well as lack a maternal figure in their lives. Moreover, the death of a woman during pregnancy or childbirth can drastically affect the lives of her other loved ones. For example, research has found that among previous children of mothers who have died during or after the subsequent pregnancy, their mental health and emotional well-being can be significantly impacted. This, in turn, can also make it more difficult for them to concentrate on academics,[6] especially when they mourn and grieve the loss of their mother. By the same token, some men who have lost their wives to maternal mortality can be at risk of developing post-traumatic stress disorder.[6] Maternal death can also bring up concerns about additional child caregiving responsibilities and financial worries[6] among men whose wives have passed away during pregnancy or childbirth. Therefore, along with posing a threat to women’s lives, maternal mortality can affect men and children to some degree, which is why it is such an important global health concern.
Throughout pregnancy and childbirth, several complications can arise, some of which can lead to maternal mortality. The most common complications leading to maternal mortality include severe bleeding, infections, high blood pressure, and complications from delivery, as well as unsafe abortions.[5]In order to effectively mitigate such complications as well as other biological and physical health factors leading to maternal mortality, proper medical facilities with trained healthcare workers, medical supplies, access to pharmaceutical drugs, and sanitary services are essential. Women’s lives can also be saved by addressing complications in a time-efficient manner. For example, although a woman experiencing severe bleeding after childbirth can die within hours, medical professionals can help reduce the risk by immediately administering oxytocics after childbirth.[5] Moreover, the WHO suggests that maternal deaths linked to unsafe abortion can be reduced by providing access to safe abortion services and post-abortion care. Additionally, ensuring access to contraception can help address maternal mortality, by preventing unintended pregnancies.[5] Furthermore, women who are pregnant[4] or planning on becoming pregnant[2] should maintain healthy lifestyles and regularly monitor their health and wellness. Women should be encouraged to continue positive health behaviors, such as eating nutritious food, and eliminate behaviors that can pose a threat to their or their infant’s life, such as substance use.[2]
Maternal mortality can be complex especially since along with the biological and physical health aspects that can lead to it, numerous and diverse socio-cultural factors can influence it. For instance, in societies where women are considered inferior to men, women’s dietary needs are often ignored. Interestingly, in some cultures, traditionally, the women in a family are able to start eating only after the men and children in the family have finished their meals, as opposed to all members of the family eating together at the same time. Some women cannot access adequate and nutritious food, which is necessary during pregnancy and after childbirth to safeguard their health and prevent complications.[3] Additionally, exposure to stress and traumatic experiences, including violence, can affect maternal health and well-being. For example, research has shown that intimate partner violence can significantly increase the risk of maternal mortality, especially since it can increase the risk of developing complications such as preterm labor.[1] Furthermore, since pregnancy and childbirth are so common and natural, women often get ignored or dismissed when they share concerns about them. Research found that especially in societies where pregnant women lack autonomy and mobility, their in-laws decide whether it is worth seeking healthcare, based on components such as the perceived severity of concern, the nature of the threat, and healthcare cost. Many families doubt why they should spend a lot of money on medical facilities when women have given birth in their own homes throughout generations.[3] As a result, oftentimes, pregnant women are brought to medical facilities when it is too late and they are nearing death due to complications.[3]
Although pregnancy and childbirth are natural processes that countless women have undergone throughout history for the creation of new lives, it is important to be aware of the diverse factors surrounding maternal mortality and continue advocating for maternal health. Researchers acknowledge that governmental efforts have been made to help provide access to healthcare and basic needs including food, as well as advocating for women’s education and economic empowerment. Nonetheless, awareness[3] of maternal health should be further raised to promote health literacy and prevent adverse outcomes associated with delays in seeking medical care and complications. Awareness of maternal health should be spread in comprehensive ways and include essential information about the significance of nutritious food, the importance of seeking timely medical care, and effectively caring for women before and after childbirth. The WHO also recognizes the importance of remembering that the health of a pregnant woman directly affects the health and life of both her and her newborn.[5] Therefore, pregnant women as well as women in the postpartum period should be attentively and responsibly monitored, supported, cared for, and empowered.
References
[1] Agarwal, S., Prasad, R., Mantri, S., Chandrakar, R., Gupta, S., Babhulkar, V., Srivastav, S., Jaiswal, A., & Wanjari, M. B. (2023). A Comprehensive Review of Intimate Partner Violence During Pregnancy and Its Adverse Effects on Maternal and Fetal Health. Cureus, 15(5), e39262. https://doi.org/10.7759/cureus.39262
[2] Centers for Disease Control and Prevention. (2023, April 26). Preventing Pregnancy-Related Deaths. Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/maternal-mortality/preventing-pregnancy-related-deaths .html#:~:text=Many%20factors%20influence%20pregnancy-related,health%20problems%20bef ore%20getting%20pregnant.
[4] Stickler, T. (2020, July 9). Maintaining a Healthy Pregnancy. Healthline. https://www.healthline.com/health/pregnancy/healthy-pregnancy
[5] World Health Organization. (2023, February 22). Maternal mortality. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
[6] Zhou, H., Zhang, L., Ye, F., Wang, H. J., Huntington, D., Huang, Y., Wang, A., Liu, S., & Wang, Y. (2016). The Effect of Maternal Death on the Health of the Husband and Children in a Rural Area of China: A Prospective Cohort Study. PloS one, 11(6), e0157122. https://doi.org/10.1371/journal.pone.0157122
Whether this is the first time you are hearing about polycystic ovary syndrome (PCOS) or not, the name of this disorder may mislead you into thinking that it is caused explicitly by having several ovarian cysts, but that is not entirely true[12]. The National Library of Medicine defines PCOS as an endocrine disorder that involves having two or more of these three determining factors: irregular menses, hyperandrogenism, and polycystic ovaries[3,6]. Currently, the cause of PCOS in women of reproductive ages (18-40 years old) is still unknown[3,4]. But, scientists believe that perhaps hereditary genes, environmental factors, hormonal imbalances, and/or insulin resistance may play a role in developing PCOS[3,4]. Since there is no known cure, the disorder is currently being managed via medications and lifestyle modifications in an attempt to alleviate its symptoms[3,14,15].
PCOS is accompanied by several unpleasant symptoms such as weight gain, pelvic pain, headaches, acne, edema, decreased libido, mood swings, etc [9,14,15]. PCOS significantly affects a woman’s quality of life as it is one of the leading causes of infertility[11,14,15]. Various combinations of the three previously mentioned PCOS factors can cause an overexpression of androgens, such as testosterone[4,15]. This can prohibit ovulation, and therefore fertilization, from occurring[4,15]. Infertility can also cause major psychological distress as becoming a mother is a future many women look forward to[15]. Not only does this affect the PCOS patient, but it can affect the relationship with their partner and/or family members[15]. This can cause feelings of unworthiness, guilt, and barrenness which may lead to anxiety and depression[11]. Couples battling PCOS-related infertility may try certain medications and/or fertility treatments in order to achieve stable hormone levels and increase their chances of egg fertilization. This can be a time-consuming and mentally draining process as one’s rate of success with these methods is not always guaranteed[10,11].
The aforementioned high levels of testosterone and other androgenic hormones frequently lead to hirsutism in women suffering with PCOS[4,15]. This condition causes excessive hair growth on parts of the body such as the face, chest, legs, back, or arms[4,15,16]. It can be a debilitating condition, especially for young women, who are often judged by others, and made to feel abnormal, ashamed, and less feminine[4,15,16]. Although there are hair reduction options, removing the hair professionally usually takes multiple sessions in order to see results and the process can be painful[16]. Not only does this require time and money, but keeping the condition hidden is stressful as well[15,16]. In summary, living with PCOS can cause women to feel social stigma, anxiety, and depression, they may also create a negative body image of themselves[13].
Diagnostic Dilemma
Despite PCOS being deemed a medical disorder over 100 years ago, up to 70% of affected women remain undiagnosed worldwide[1,2,7]. But, why is that? Physicians face a challenge when it comes to diagnosing PCOS because of one thing: the symptoms. PCOS can present itself through many symptoms that overlap and mimic what you would commonly find in other diseases such as pelvic inflammatory disease, thyroid disease, diabetes, etc[5,7,8]. Therefore, physicians request certain lab tests to be conducted and from their results, they eliminate other similar diseases; it could take several months or years for a true PCOS diagnosis to be reached[1]. This period of time where the patient is waiting to be diagnosed could potentially allow other harmful, long-term complications associated with PCOS to develop such as obesity, type 2 diabetes mellitus (DM-2), depression, endometrial cancer, and nonalcoholic fatty liver disease[1,8,15]. On a similar note, PCOS has also been found to increase one’s risk of heart disease and metabolic disorders. Recently, scientists have also discovered that it may also increase one’s risk of memory loss[2,5].
A New Study Relating Brain Health and PCOS, Results Discussed
An ongoing cohort study conducted by CARDIA Women’s health has collected new data that suggests PCOS may have negative impacts on the brain[5]. Approximately one thousand women participated in this study, with roughly 6% of those women having PCOS per the study’s definition of PCOS[5]. The participants partook in a variety of cognitive tests that measured brain memory, reaction time/attention capacity, and verbal fluency[5]. In addition, a subset of the participants had brain MRI’s conducted in order to observe any differences between PCOS vs. non-PCOS participants[5].
The results of the study show that the PCOS patients, in fact, did score lower on the cognitive tests compared to the participants without PCOS. In addition, PCOS patients exhibited decreased white matter density in their brains[5]. White matter is the portion of your brain that is responsible for memory retention and coordination[17]. However, this study is unable to conclusively state that there is a significant decrease in brain function directly caused by PCOS[5].
Most published PCOS studies focus on its relation to heart health and infertility, but this is the first study that has attempted to observe a direct correlation between brain health and PCOS in women of middle age; with these new findings come a few caveats[5]. One limitation from this experiment is that the group size is not very large; the number of participants for both the cognitive testing and the MRI testing was relatively small[5]. A larger group of participants would yield a more accurate dataset and give us a greater understanding of the toll this disorder can take on the brain. Regarding the brain MRI results, further research is needed to verify whether or not the decrease in cognitive performance is directly related to PCOS or simply a consequence of aging[5]. Scientists should consider looking into certain metabolic and hormonal factors that can affect the brain as well as the current mental state of the PCOS patients. For example, depression is a common PCOS symptom which is known to decrease brain function[5]. Although performing this study was a huge step in the right direction, more research must be conducted. If future research provides evidence to support this study, it should primarily focus on preventing or slowing the rate of memory loss for affected women[2]. This could greatly improve the quality of life for PCOS patients as it may allow us to gain more insight into the mysteriously complex inner workings of this disorder[2].
[3] John Hopkins Medicine.(n.d). Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-diseases/polycystic-ovary-syndrome-pcos#:~:text=Polycystic%20ovary%20syndrome%20(PCOS)%20is,that%20form%20in%20the%2 0ovaries.
[5] Huddleston, H.G., Jaswa, E.G., Casaletto, K.B., Neuhaus, J. , Kim, C. Wellons, etc. (2024). Associations of Polycystic Ovary Syndrome WithIndicators of Brain Health at Midlife in the CARDIA Cohort. Neurology 2024. https://www.neurology.org/doi/abs/10.1212/WNL.0000000000208104. doi:10.1212/WNL.0000000000208104
[6] Dennett, C. C., & Simon, J. (2015). The role of polycystic ovary syndrome in reproductive and metabolic health: overview and approaches for treatment. Diabetes spectrum : a publication of the American Diabetes Association, 28(2), 116–120. https://doi.org/10.2337/diaspect.28.2.116
[7] World Health Organization. (n.d.). Polycystic ovary syndrome.
[8] Sirmans, S. M., & Pate, K. A. (2013). Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clinical epidemiology, 6, 1–13. https://doi.org/10.2147/CLEP.S37559
[9] Bromberger, A. (2022). Why Women Face Difficulties Receiving PCOS Diagnosis. Duke University.https://dukecenterforglobalreproductivehealth.org/2022/12/26/why-women-face-diffic ulty-receiving-pcos-diagnoses/
[10] Melo, A. S., Ferriani, R. A., & Navarro, P. A. (2015). Treatment of infertility in women with polycystic ovary syndrome: approach to clinical practice. Clinics (Sao Paulo, Brazil), 70(11), 765–769. https://doi.org/10.6061/clinics/2015(11)09
[11] Sharma A, Shrivastava D. Psychological Problems Related to Infertility. Cureus. 2022 Oct 15;14(10):e30320. doi: 10.7759/cureus.30320. PMID: 36407201; PMCID: PMC9661871.
[12] Azziz R. Polycystic ovary syndrome: what’s in a name? J Clin Endocrinol Metab. 2014 Apr;99(4):1142-5. doi: 10.1210/jc.2013-3996. Epub 2014 Feb 3. PMID: 24491161; PMCID: PMC3973784.
[14] Divya, M., & Ranganathan, S. (2022). “PCOS is Like Having a Disease”: The Everyday Stress of Living with Polycystic Ovarian Syndrome (PCOS). Indian journal of communitymedicine : official publication of Indian Association of Preventive & Social Medicine, 47(4), 622–623. https://doi.org/10.4103/ijcm.ijcm_1374_21
[15] Brady, C., Mousa, S. S., & Mousa, S. A. (2009). Polycystic ovary syndrome and its impact on women’s quality of life: More than just an endocrine disorder. Drug, healthcare and patient safety, 1, 9–15. https://doi.org/10.2147/dhps.s4388
[17] University of North Carolina.(2021). White matter plays a complex role in brain health. https://sph.unc.edu/sph-news/white-matter-plays-a-complex-role-in-brain-health/#:~:text=While %20gray%20matter%20is%20a,and%20stay%20balanced%20when%20walking.
