Questions and Answers
Q: I've been taking antidepressant medication for years. Now, I'm trying to get pregnant. Should I stop taking my medication?
A: That's a complex question that only you and your doctor can decide. I can, however, tell you what we know about depression during pregnancy, and about women who have been diagnosed with depression before becoming pregnant. One study of 201 women with major depressive disorder found that 68 percent of those who stopped taking their medication when they got pregnant relapsed, compared to just 26 percent of those who continued their medication.
Depression during pregnancy is a serious issue. It has been linked with preterm delivery, low birthweight babies, preeclampsia, postpartum depression and even miscarriage. Plus, women who are depressed during pregnancy are less likely to see their health care providers often enough and may not gain enough weight. They are also more likely to smoke, drink alcohol or use cocaine. And, just as with women who aren't pregnant but who are depressed, they are likely to become withdrawn and may attempt suicide.
Decades of use of antidepressants during pregnancy has provided us with some fairly good information on the safety of some medications during this time. However, this information is retrospective. It looks back at women's experiences, rather than prospectively and randomly assigning women to different groups to test the effects of these drugs. Nonetheless, here's what we know:
- Selective serotonin reuptake inhibitors (SSRI). This class of drugs includes fluoxetine (Prozac) and paroxetine (Paxil). Most are considered generally safe with the exception of paroxetine, which may increase the risk of certain birth defects in the infants of women who take the drug during the first trimester. There is also some evidence that babies born to women who took SSRIs throughout pregnancy were more likely to be born early. We have the most evidence on the safety of fluoxetine during pregnancy.
- Venlafaxine (Effexor). Only one study has been published so far on the use of venlafaxine during pregnancy, and it showed no increased risk in birth defects.
- Mirtazapine (Remeron). Again, just one trial has been published about the effects of mirtazapine during pregnancy; it showed a higher rate of miscarriage and preterm births in women taking the drug than in those not taking it.
- Bupropion (Wellbutrin). In the one published study of bupropion use during pregnancy, women taking it during the first trimester for either depression or to help them quit smoking were compared with women taking other antidepressants or women not using any antidepressants. There was no major difference in birth defects, although there was a significant difference in the number of miscarriages in the bupropion group.
- Tricyclic antidepressants. This class of drugs includes nortriptyline and desipramine. Long-term data show little association between these medications and any birth defects, although there are some reports of withdrawal symptoms in infants.
There are nonpharmacological options for treating depression in pregnancy, including psychotherapy and bright-light therapy.
You and your health care providers need to carefully consider the pros and cons of continuing on your medication as you become pregnant, keeping in mind the impact of your overall health on your baby, as well as any effects of medication.
Posted 9/20/2007
Q: What is the difference between a Pap smear and an HPV test? Do I need both?
A: A Pap smear is a test that evaluates a sample of cells from your cervix. This very quick, painless test is responsible for an 80 percent drop in the number of women diagnosed with cervical cancer in the past 50 years. This year, about 10,800 cervical cancers will be diagnosed, far fewer than the 50,000 that would have occurred without screening. That's because the Pap smear can identify very early cellular changes called dysplasia. Dysplasia is not cancer, but, depending on the type of dysplasia, could signify an increased risk of cancer. Removing these abnormal cells and following up with frequent Pap smears can help prevent cancer from occurring.
Today most medical organizations, including the American College of Obstetrics and Gynecology (ACOG), the American Cancer Society (ACS) and the United States Preventive Services Task Force, recommend that women begin receiving Pap smears at age 21 or within three years of becoming sexually active. After that, you should have an annual Pap smear if your doctor uses the conventional Pap smear with a glass slide, or every two years if your doctor uses the newer, liquid-based Pap smear, which studies find is better at picking up cellular abnormalities.
After age 30, if your past three consecutive Paps were normal, you can talk to your health care professional about screening every two to three years. At age 70, if you've had three normal Pap smears and no abnormalities in the past 10 years, you can stop getting Pap smears. Also, you can stop having Pap smears if your uterus and cervix were removed for noncancerous reasons; but if they were removed because of cancer, you still need the test.
However, Pap smears aren't foolproof. Studies find that up to half of all women diagnosed with cervical cancer have had screenings, some with normal Pap smears. That's why the ACS and ACOG also recommend that women with abnormal cells on a Pap test, or women 30 and older (regardless of their Pap results) receive a high-risk HPV DNA test (Hybrid Capture 2) to identify any HPV infection. HPV, or human papillomavirus, is a sexually transmitted virus responsible for more than 90 percent of all cases of cervical cancer. The results of the Pap smear plus the HPV test help your doctor determine the next course of action. For instance, if you have abnormal results on both tests, your doctor may want to do a colposcopy to get a better look at your cervix and, possibly, take a sample of cervical tissue for a biopsy.
If you receive the HPV DNA test, ask your health care professional to use the high-risk HPV test, which tests for the viruses known to cause cervical cancer. About six to 10 percent of women older than 30 test positive for these high-risk viruses.
Posted 5/4/2007
Q: I've been hearing about the new HPV vaccine for girls. I don't know whether I should have my 13-year-old daughter vaccinated or not. What do you think?
A: The human papilloma virus (HPV) vaccine, called Gardasil, marks a major milestone in the fight against cancer and sexually transmitted infections. The vaccine is designed to protect against four HPV viruses that are found in 70 percent of cervical cancers and 90 percent of genital warts. It is the first FDA-approved cancer vaccine.
There are more than 100 strains of HPV, about 40 of which cause sexually related infections as well as cervical, vulvar and anal cancers. The virus often infects women during their very first sexual experience and is very difficult to avoid, even with condoms. Within the first two years of the first incidence of intercourse, more than half of all women have acquired HPV. Overall, an estimated 20 million men and women in the United States are infected with HPV, and about 6.2 million become infected each year.
Gardasil is administered through three injections, with the second and third doses given two and six months, respectively, after the first. The vaccine has been shown to be safe in tests involving more than 11,000 girls and women ages 9 to 26 throughout the world, including the U.S. The main side effect is some pain at the injection site.
The U.S. Centers for Disease Control (CDC) recommends the vaccine for girls and women ages 11 to 26, although it can be administered to girls as young as 9. Ideally, the vaccine should be administered before girls become sexually active. However, even those who are sexually active may benefit from vaccination since few young women are infected with all four HPV types that the vaccine covers.
So, my recommendation is that you have your daughter vaccinated with Gardasil.
Posted 5/4/2007
Q: My PMS symptoms are getting worse as I get older. When I talked to my health care provider about them, she told me that fluoxetine (Prozac) might help. What other medications are available, and how do they work?
A: It's not surprising your PMS symptoms are getting worse as you get older. This often happens, particularly with the more severe form of PMS called PMDD, or premenstrual dysphoric disorder. If you think of PMS as a continuum, at the far left is mild PMS—bloating, headaches, some irritability, maybe some other symptoms. They're annoying and a pain, but you can deal with them. As you continue toward the right end of the continuum, however, the symptoms become much more severe, until by the time you reach the far right you may not be able to continue with your normal activities in the week before your period.
At this point, there are several medications available that can help. Your doctor is right about fluoxetine, which was the first medication approved to treat PMDD. The brand name of the fluoxetine approved for PMDD is Sarafem. Unlike Prozac, which is taken every day, Sarafem is only taken once a day for the two weeks before your period.
Two other antidepressants, sertraline (Zoloft) and paroxetine (Paxil), have also been approved for the treatment of PMDD. You can take these either all month or just during the two weeks before your period. A fourth antidepressant, venlafaxine (Effexor), has also shown good results in women with PMDD, although it is not specifically approved for this use.
Finally, the fourth medication approved to treat PMDD is an oral contraceptive called Yaz. It contains a low dose of estrogen and the synthetic progesterone drospirenone, which mimics the body's own progesterone more closely than other synthetic progesterone. Unlike a similar oral contraceptive, Yasmin, which is taken for 21 days a month with a seven-day break, Yaz is taken 24 days a month with a four-day break.
I strongly recommend you talk to your doctor about which medication might be most helpful. There is no reason to suffer for a week a month with severe PMS or PMDD symptoms.
Posted 4/4/2007
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