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Keywords: Background: Postpartum depression is one of the major causes of disability among women who are on their
Postpartum depression childbearing years. Identifying people at risk of postpartum depression may improve its management. The
Gynecological morbidities objective of this study was to determine the probable association between postpartum depression and some
The JECS preconception gynecological morbidities.
Methods: Data from a nationwide birth cohort study, the Japan Environment and Children's study (JECS), up to
one month of postpartum were analyzed. To assess postpartum depression, the Edinburgh Postnatal Depression
Scale (EPDS) was used; 11 preconception gynecological morbidities were considered as risk factors. Covariates
included psychiatric illness history, psychosocial factors, some pregnancy adverse outcomes, birth outcomes,
socio-demographic and health behavioral factors.
Results: Except for the prevalence of previous miscarriage, leiomyoma and polycystic ovarian syndrome,
depressive women had more gynecological morbidities compared to non-depressive ones.
In logistic regression model, endometriosis (OR, 1.27; 95%CI: 1.15–1.41), dysmenorrhea (OR, 1.13; 95%CI:
1.06–1.21) and abnormal uterine bleeding (OR, 1.21; 95%CI: 1.15–1.29) were associated with postpartum
depression.
Limitations:
• We could not specify in detail which type of gynecological morbidity was associated with postpartum
depression, because the current design was not exclusively oriented by the JECS research question.
• A part of gynecological morbidities were self-reported.
Conclusion: Women with endometriosis and menstrual problems were at risk of developing postpartum
depression.
This study suggests a perinatal mental health screening for predisposed women.
⁎
Correspondence to: Department of Environmental Medicine, Kochi Medical School, Kochi University, Oko-cho Kohasu, Nankoku, Kochi 783-8505, Japan.
E-mail address: nsuganuma@kochi-u.ac.jp (N. Suganuma).
1
The complete membership of the author group can be found in the Acknowledgments.
http://dx.doi.org/10.1016/j.jad.2017.03.049
Received 12 January 2017; Received in revised form 17 March 2017; Accepted 24 March 2017
Available online 30 March 2017
0165-0327/ © 2017 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
S.M.J. Muchanga et al. Journal of Affective Disorders 217 (2017) 34–41
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S.M.J. Muchanga et al. Journal of Affective Disorders 217 (2017) 34–41
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S.M.J. Muchanga et al. Journal of Affective Disorders 217 (2017) 34–41
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S.M.J. Muchanga et al. Journal of Affective Disorders 217 (2017) 34–41
Table 1c Table 2
Obstetrical and birth outcomes characteristics of the study population according to the Unadjusted and adjusted association between gynecological morbidities and PPD.
presence or absence of PPD.
Risk factors OR (CI) aOR (CI)
Risk factor PPD (N=11,341) No PPD (N=71,148) P (p value)
% % Endometriosis 1.39(1.26–1.52)*** 1.31(1.19–1.45)***
Dysmenorrhea 1.26(1.18–1.34)*** 1.20(1.12–1.27)***
Obstetrical factors AUB 1.42(1.34–1.51)*** 1.38(1.31–1.46)***
Parity < 0.001 Uterine deformation 1.38(0.99–1.93) 1.32(0.94–1.84)
Primiparous 37.7 28.2 Miscarriage 0.87(0.82–0.91)*** 0.87(0.82–0.91)***
Multiparous 60.9 70.9 Adenomyosis 1.52(1.12–2.05)** 1.29(0.95–1.75)
Missing 1.3 0.9 Gynecological cancer 1.22(1.00–1.49)* 1.20 (0.99–1.47)
Mode of conception PCOS 0.85(0.67–1.08) 0.73(0.58–0.94)*
Natural 93.1 92.9 Leiomyoma 0.98(0.90–1.06) 0.97(0.89–1.05)
Oviduct flashing 2.5 2.6 Urogenital anomalies 1.26(0.48–3.28) 1.25(0.48–3.26)
AIH 1.0 1.0 Ovarian tumor 1.05(0.95–1.17) 0.99(0.89–1.11)
IVF 1.7 1.6
ICSI 0.7 0.8 CI: confidence interval; aOR: adjusted odds ratio; OR: odds ratio; PCOS: polycystic ovary
Fresh ET 0.0 0.1 syndrome.
Frozen ET 0.5 0.6 * p < 0.05.
Blastocyst T 0.1 0.1 ** p < 0.01.
Missing 0.5 0.5 *** p < 0.001.
Mode of delivery < 0.001
Normal 54.4 58.0
Induction 18.8 17.4 tion of steroid hormones. In addition to the steroid fall, the new mother
Suction 6.4 5.4 is also exposed to the hypogonadal state until the return of ovulation
Forceps 0.3 0.2 (Bloch et al., 2003). The result of the hormonal deficiency states could
Cesarean section 19.7 18.6 be contributing factors to the occurrence of PPD on the endometriosis
Missing 0.5 0.4
pre-existing background.
Threatened abortion 13.2 11.7 < 0.001
Missing 0.2 0.2 Furthermore, the association between dysmenorrhea and PPD could
Delivery 48.8 44.6 < 0.001 be attributable to the hormonal variation seen during menstrual cycles.
complications In fact, the drop of progesterone during the late luteal phase is
Missing 2.0 1.9
associated with an imbalanced production of prostaglandins implicated
Preterm labor 21.3 18.9 < 0.001
Missing 0.2 0.2
in the genesis of menstrual pain (Dawood, 2006). On the other hand,
PROM 9.3 8.0 < 0.001 dysmenorrhea coexists with premenstrual symptoms in many women
Missing 0.2 0.2 (Kitamura et al., 2012). Although the etiology of premenstrual symp-
Hypertension 2.8 2.1 < 0.001 toms remains unclear, it is considered to be resulted from multiples
Missing 0.2 0.2
interactions between ovarian hormones changes of the menstrual cycle
Gestational diabetes 1.2 1.1
Missing 0.2 0.2 and various neurotransmitters including GABA and serotonin (Ismaili
et al., 2016). It is widely reported that fluctuations of ovarian hormones
Birth outcome factors
Infant sex during premenstrual, postnatal and perimenopausal periods are asso-
Male 51.7 51.0 ciated with depression (Lokuge et al., 2011; Studd, 2015). Both
Female 48.3 49.1 estrogen and progesterone have their receptors localized in brain
Missing 0.0 0.0 region implicated in emotional and cognitive regulation (Brinton
Fetal distress 2.7 2.4
Missing 0.2 0.2
et al., 2008; Wharton et al., 2012). Indeed, the estrogen fluctuation of
SGA 2.3 1.9 < 0.01 these vulnerable periods may cause an alteration in serotonin neuro-
Missing 0.2 0.2 transmission, which then can lead to mood disorders (Lokuge et al.,
ICU admission 0.1 0.1 2011). It has also been reported that progesterone plays a mediating
Missing 0.2 0.2
role on mood disturbances (Wharton et al., 2012). Thus, women with
Birth defect 6.9 5.9 < 0.001
Missing 2.2 2.2 history of dysmenorrhea are more sensitive to the post-delivery
Apgar < 7 at 5 min 0.7 0.5 < 0.05 hormone withdrawal. Our result is in accordance with previous studies
Missing 5.0 5.0 which found an association between premenstrual symptoms and
postpartum depression (Buttner et al., 2013; Lee et al., 2015). Unlike
AIH: artificial insemination by husband; Blastocyst T: blastocyst transfer; Fresh ET: fresh
other authors who have examined dysmenorrhea in the context of
embryo transfer, Frozen ET: frozen embryo transfer, ICSI: intracytoplasmic sperm
injection; ICU: intensive care unit; IVF: in vitro fertilization; PPD: Postpartum depression;
premenstrual syndrome, in our case, dysmenorrhea was an independent
PROM: premature rupture of membranes; SD: standard deviation; SGA: small for predictor of PPD.
gestational age. The imbalanced hormonal state found in abnormal uterine bleeding
(AUB) could explain its association with PPD. Evidence shows that the
imbalance innervations of endometriosis (Liang and Yao, 2016). onset of depressive symptoms temporally coincides with the abrupt fall
Depression is a consequence of endometriosis and/or its association of steroids hormones at delivery, leading to assign the change in
with dysmenorrhea; whether the infertility, or the inflammation play a hormones as a promoting factor in susceptible women (Schiller et al.,
certain role remains to be clearly described (Pope et al., 2015). The 2015). In fact, AUB has different etiologies, structural or not (Munro
pelvic pain (Facchin et al., 2015; Lorencatto et al., 2006) and/or only et al., 2012), and most of them are hormone-related disorders. Thus,
the fact of being diagnosed with endometriosis (Denny, 2009)could be women suffering from AUB prior to the conception are more sensitive to
the causal factor. Studies conducted in non-pregnant women had the sudden post-delivery hormonal changes. However, a study con-
demonstrated an association between endometriosis and depression ducted in non parturient women, found a strong correlation between
(Lorencatto et al., 2006; Sepulcri Rde and do Amaral, 2009) and the AUB, mood and anxiety disorders (Kayhan et al., 2016).
abrupt fall of steroids hormones during the parturition contributes to We found a negative association between previous miscarriage and
the PPD (Brummelte and Galea, 2016). This hypothesis suggests that PPD in the model 1 and 2; this relationship did not maintain
women with endometriosis may be more affected by the large fluctua- significance after adjustment for obstetrics and birth outcome con-
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S.M.J. Muchanga et al. Journal of Affective Disorders 217 (2017) 34–41
Table 3
Adjusted final model for the association between gynecological morbidities, others covariates and PPD.
Risk factors Model 1 OR (CI) Model 2 OR (CI) Model3 OR (CI)) Model 4 OR (CI)
founders in the model 3. Indeed, some reports had shown the previous PPD, found in this study, could not be affected.
miscarriage as risk factors of PPD at one month and even in the late
postpartum (Blackmore et al., 2011; Giannandrea et al., 2013), while 4.3. Clinical implications
others did not show any association (Bicking Kinsey et al., 2015;
Hughes et al., 1999). It is possible that the apparent protection of Currently, implicated gynecological morbidities are not routinely
previous miscarriage on the onset of PPD may not be of clinical considered as risk factor for postpartum depression same as, for
significance; cultural and psychosocial factors having an important instance, past psychiatric illnesses or psychosocial factors. Our findings
role on the difference between populations. Thus, obstetrical and birth suggest that a succinct assessment of those gynecological morbidities
outcome factors should be taken into account for the assessment of the would be valuable as predictor of PPD and as possible markers for
concerned relationship. intervention. As most of risk factors were hormone-related, we en-
courage a possible use of hormone therapy in addition to usual
4.1. Strengths treatment of PPD for predisposed women.
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S.M.J. Muchanga et al. Journal of Affective Disorders 217 (2017) 34–41
Regional Center for JECS, Hyogo College of Medicine, Nishinomiya, women. J. Psychosom. Res. 71, 264–269.
Ismaili, E., Walsh, S., O'Brien, P.M., Backstrom, T., Brown, C., Dennerstein, L., Eriksson,
Japan), Yasuaki Kawai (Tottori Regional Center for JECS, Tottori E., Freeman, E.W., Ismail, K.M., Panay, N., Pearlstein, T., Rapkin, A., Steiner, M.,
University, Yonago, Japan), Narufumi Suganuma (Kochi Regional Studd, J., Sundstrom-Paromma, I., Endicott, J., Epperson, C.N., Halbreich, U., Reid,
Center for JECS, Kochi University, Nankoku, Japan), Koichi Kusuhara R., Rubinow, D., Schmidt, P., Yonkers, K., 2016. Fourth consensus of the International
Society for Premenstrual Disorders (ISPMD): auditable standards for diagnosis and
(Fukuoka Regional Center for JECS, University of Occupational and management of premenstrual disorder. Arch. Women's Ment. Health 19, 953–958.
Environmental Health, Kitakyushu, Japan), and Takahiko Katoh (South Iwata, H., Mori, E., Sakajo, A., Aoki, K., Maehara, K., Tamakoshi, K., 2016. Prevalence of
Kyushu/Okinawa Regional Center for JECS, Kumamoto University, postpartum depressive symptoms during the first 6 months postpartum: association
with maternal age and parity. J. Affect. Disord. 203, 227–232.
Kumamoto, Japan). Kawamoto, T., Nitta, H., Murata, K., Toda, E., Tsukamoto, N., Hasegawa, M., Yamagata,
We also acknowledge all members of Environmental Medicine Z., Kayama, F., Kishi, R., Ohya, Y., Saito, H., Sago, H., Okuyama, M., Ogata, T.,
Department of Kochi University for their support. Yokoya, S., Koresawa, Y., Shibata, Y., Nakayama, S., Michikawa, T., Takeuchi, A.,
Satoh, H., 2014. Rationale and study design of the Japan environment and children's
study (JECS). BMC Public Health 14, 25.
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