Tag: mood swings

Why So Many Accidental Pregnancies Happen in Your 40s

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After she turned 42, Teesha Karr thought she was done having kids. Six, in her mind, was perfect. And besides, she was pretty sure she had started menopause. For the past six months she’d had all the same signs as her friends: hot flashes, mood swings, tender breasts. She and her husband decided they could probably safely do away with contraception. But less than a month later, Karr felt a familiar twinge of pain in her ovary—the same twinge she’d felt every time she’d been pregnant before.

Karr felt embarrassed. “Teenagers accidentally get pregnant. Forty-two-year-old women don’t usually accidentally get pregnant,” she told me. But, really, 42-year-old women accidentally getting pregnant is surprisingly common. Nearly 4 percent of all new babies are born to women 40 and older, according to the latest data from the National Center for Health Statistics. As many as 75 percent of pregnancies in this age range are unplanned. It’s a frequent enough occurrence that the plots of Downton Abbey, Sex Education, And Just Like That, Grey’s Anatomy, and Black-ish have depended on it.

Many women still believe that by their 40s, unintended pregnancy just isn’t something they have to worry about. After all, many of us are told our whole lives that our biological clock is ticking, that our fertility plummets after 35, and that if we wait too long we’ll likely need some form of reproductive technology to get pregnant—if we can get pregnant at all. If conceiving at this age is so hard, surely you wouldn’t get pregnant by accident, right?

To understand why pregnancy can, and does, happen at this age, it helps to consider the wacky in-between land that is perimenopause. This stage, which can last anywhere from a few months to about eight years, is typically assumed to be a smooth transition into menopause. In reality, it’s more like the hormonal chaos of puberty, when the ovaries first sputter to life, wreaking all sorts of bodily havoc as they try to figure out their new groove.

In perimenopause, the ovaries are once again trying to adapt to a new normal. Only now they’re in overdrive, sending out scattered spurts of estrogen to recruit a much scarcer pool of eggs to release during ovulation. During this time, you might ovulate twice in one cycle, miss a cycle altogether, or experience unpredictable flash periods. “Those ovaries are kind of going nuts,” Robin Noble, a gynecologist and menopause specialist in Maine, told me. That can have all sorts of weird consequences. For one, extreme hormone spikes can stimulate the ovary to release extra eggs, which is one reason why fraternal twins are more common in older pregnancies.

If your ovaries are still ovulating, however sporadically, then you can still get pregnant. The likelihood of getting pregnant does decline with age, particularly toward the tail end of your 30s. By 40, according to the American Society for Reproductive Medicine, the chance of getting pregnant during a single menstrual cycle is less than 5 percent. The problem starts when these low odds lead women to use less reliable contraception, such as the rhythm method or withdrawal. Thanks to hormone spikes and the menstrual cycle becoming less predictable, those methods become even riskier during perimenopause, and the odds can stack up.

Read: The secret power of menopause

“I hear it every day,” Rachel Pope, an OB/GYN and the head of female sexual health at University Hospitals, in Ohio, told me. “Many women really think that their reproductive potential doesn’t exist anymore, which is not true.” In reality, you can’t be sure you’re in menopause—and therefore really done worrying about pregnancy—until you haven’t had a period for at least a year. For this reason, the Menopause Society recommends keeping a hormonal IUD in or continuing hormonal birth-control pills for a year after your last period, just in case.

To add to the confusion, some symptoms of perimenopause—missed periods, fatigue, mood shifts—resemble early signs of pregnancy. Lisa Perriera, an OB/GYN and the chief medical director of the Women’s Centers, a group of abortion clinics across several states, sees women almost every month who are shocked to find that their body is still capable of getting pregnant. “I’ve definitely cared for my share of 47-year-olds that are like, ‘I just thought it was menopause,’” she told me.

Because women in their 40s may be expecting aging-related changes in their body but not looking out for signs of pregnancy, many don’t realize they’re pregnant until 16 or even 20 weeks along, Perriera said. That’s what happened to Anne Ruiz. In 2017, the 43-year-old mom wasn’t experiencing any signs of perimenopause but figured her window for pregnancy was closing fast. Her period had always been irregular, so she wasn’t overly concerned when it didn’t come for a month or two. By the time she started getting morning sickness and took a pregnancy test, she was almost four months pregnant.

Read: Capitalism has plans for menopause

Ruiz and her husband welcomed the news, but also felt overwhelmed. “It was probably maybe like 60 percent excited and 40 percent Oh my God, how are we going to start over?” she told me. She gave birth the next year and immediately got an IUD.

Facing a pregnancy at a time when you think it is no longer a possibility can be profoundly distressing. “I do see a lot of people shaken by it,” Pope said. “Having a pregnancy that’s not planned can be just so life-altering,” especially at a time when abortions are difficult or impossible to access in many states. A common first reaction is denial. After Christina Ficicchia started experiencing irregular periods, at 42, her gynecologist told her she was in perimenopause. So when she missed a period entirely, she assumed her menstrual cycle was on its way out. Then she started “feeling” pregnant—“after you’ve been pregnant a few times, you kind of know,” she told me. Yet even after a positive pregnancy test, she asked her doctor to take an in-office test to confirm the results. After planning her first two children, Ficicchia struggled to wrap her mind around the choice that she now faced: “It was one that I realistically never thought that I had to make.”

Many women face extra distress because they know that being pregnant over the age of 40 comes with greater risks. The chance of miscarriage above that age rises to one in three, if not much higher, according to the Mayo Clinic. Pregnant people over 40 are also at a greater risk for preeclampsia, gestational diabetes, placenta previa, preterm delivery, hypertension, pelvic-floor injuries—“basically everything that could go wrong,” Pope said. Risks for Down syndrome and other chromosomal abnormalities also rise.

Read: Please don’t call my cervix incompetent

After talking with her obstetrician, Ficicchia ultimately chose to continue her pregnancy. Despite her heightened anxiety, she delivered her fourth child, Emmerson, at age 43 with no complications. Karr wasn’t so lucky. After she and her husband adjusted to the news, Karr told her other children to expect a new sibling, and even told her colleagues. Then, at her eight-week ultrasound, the technician told her the fetus had no heartbeat.

After finally having allowed herself to imagine another baby in her future, Karr was crushed. “I was pretty set with where I was in life and then this all happened and turned everything upside down,” she said. She is still trying to make sense of the loss, and dreads the weekly emails she still receives from pregnancy websites, telling her what to expect at each stage of pregnancy and advertising breastfeeding products. “If I’d known what was happening in my body, then this would have never happened,” she told me. “I was not informed.”

Of course, bodies can be confusing even for the extremely well informed—for instance, doctors who spend their days explaining perimenopause to their patients. When Pope missed her period in July and started feeling tenderness in her breasts, she had a hunch that she knew what was going on: perimenopause. At 38, she was on the early side. Still, she thought, “this is probably it,” she said. A spontaneous pregnancy seemed unlikely, given that she and her husband had used IVF for their two children and were planning on using it again.

“Then my husband, who’s a family doctor, was like, ‘Maybe you should check a pregnancy test,’” she said. In fact, Pope wasn’t perimenopausal. She was five weeks pregnant.

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Rachel E. Gross

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November 14, 2023
Is This Premenstrual Condition a Mental Illness or Oppression?

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This article originally appeared in Undark Magazine.

For one week of every month, I have a very bad time. My back aches so badly I struggle to stand up straight. My mood swings from frantic to bleak. My concentration flags; it’s difficult to send an email. Then, my period starts, and the curse is lifted. I feel okay again.

Like some 1 to 7 percent of menstruating women, I meet the criteria for premenstrual dysphoric disorder, or PMDD. According to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), a person with PMDD experiences marked emotional changes—such as sadness, anger, or anxiety—and physical or behavioral changes—such as difficulty concentrating, fatigue, or joint pain—in the week before their period. PMDD can also affect trans men and nonbinary people who menstruate.

When I first heard of PMDD, it was a revelation. Here was a concrete explanation for the pain and stress I was feeling every month. Better yet, there was a simple, effective treatment: common antidepressant drugs called selective serotonin reuptake inhibitors, or SSRIs, which can be prescribed for people to take only in the two weeks before their period. Birth-control pills, cognitive behavioral therapy, and calcium supplements may also help.

Then I heard about the controversy surrounding the diagnosis. When the American Psychiatric Association added a form of PMDD as a proposed disorder to the diagnostic manual in the 1980s—DSM-III-R—some scholars pushed back. They saw the diagnosis as part of the historical oppression of women, done in the name of mental health. The controversy reared up again as PMDD remained in the 1994 DSM-IV, where it was also listed under “Depressive Disorder Not Otherwise Specified.” Many people who menstruate experience emotional changes during their cycles, so defining it as a mental illness could have serious personal and societal consequences, critics argued. A 2002 Monitor on Psychology article, “Is PMDD real?,” quoted the late psychologist and author Paula Caplan: “Women are supposed to be cheerleaders,” she said. “When a woman is anything but that, she and her family are quick to think something is wrong.”

In the end, the APA weighed these concerns and pushed ahead, adding PMDD to the DSM-5 as an official diagnosis in 2013. But I found the criticism disquieting. Had I embraced a modern hysteria diagnosis? Were the symptoms I experienced even real?

Read: Why are so many women being told their hormones are out of whack?

Researchers have looked for hormonal differences between people who experience severe premenstrual distress and people who don’t. In some cases, they’ve found them: A 2021 meta-analysis found that people with PMDD tend to have lower levels of estradiol, a form of estrogen, between ovulation and menstruation. But other studies have shown little to no difference in hormone levels. “There are no biomarkers. There’s no test that can be done which helps identify someone with PMDD,” says Lynsay Matthews, who researches PMDD at University of the West of Scotland.

Instead, to receive treatment, people experiencing premenstrual distress have to monitor their own mind and body. PMDD diagnosis is based on a symptom diary kept over the course of multiple menstrual cycles.

The symptoms recorded in those diaries can be severe. In a 2022 survey, 34 percent of people with PMDD reported a past suicide attempt. More than half reported self-harm. “If someone has suicidal ideation or self-harm, or suicide attempts every month for 30 years, that wouldn’t be described as a normal female response to the menstrual cycle,” Matthews says.

There is evidence that SSRIs work for people with PMDD, in ways researchers don’t fully understand. “In some cases, hours after taking an effective SSRI, people can feel a lot better,” Matthews says, referring to PMDD patients. In contrast, people with depression usually need to take SSRIs for weeks before feeling the effects. Researchers know the drugs’ mechanism of action is different for PMDD—they just don’t know why. “When people find that out, they find it quite validating that it is a medical condition,” Matthews says.

Tamara Kayali Browne, a bioethicist at Deakin University, in Australia, agrees that some people experience serious distress in the week before their period—but disagrees with calling it a mental illness.

“The crux of the problem seems to be that we are in a patriarchal society that treats women very differently and puts a lot of women under a lot of significant, disproportionate stress,” Browne says. That disproportionate stress begins early. Eighty-three percent of a sample of Australian PMDD patients reported trauma in early life. It continues in adulthood. A Swedish survey of 1,239 people with PMDD found that raising children was associated with higher rates of premenstrual distress.

Between ovulation and menstruation, many people experience higher physical and emotional sensitivity. They may feel unwilling or unable to deal with the stressors they tolerate the rest of the month: the screaming baby, the messy partner. “Is it the time of the month where the truth comes out?” Browne suggests. Seen in this light, irritability, anxiety, and low mood are understandable reactions to life stressors, not symptoms of mental illness.

There is a long history of doctors labeling women crazy. There is also a long history of doctors dismissing women’s pain. Debates about premenstrual distress are caught in the middle.

When critics question PMDD and the less severe premenstrual syndrome, it can feel invalidating. “It’s time to stop questioning whether women’s experiences are real and instead start making them real priorities,” the journalists Emily Crockett and Julia Belluz wrote in response to an article that suggested PMS is culturally constructed.

At the same time, when left unchecked, casual sexism can seep into the medical discourse around PMDD. Early pharmaceutical advertisements marketing SSRIs for PMDD show how this works in practice. In 2000, Eli Lilly packaged fluoxetine hydrochloride in a pink-and-purple capsule and branded it Sarafem. Advertisements for the drug featured incapable, unreasonable women; one fights a shopping cart, another bickers with her (male) partner. “Think it’s PMS? Think again. It could be PMDD.” (The Sarafem brand has since been discontinued.)

What if we can question the structural factors that make life harder for women while providing medical support for people who are suffering? Could the critiques lead us to more, not fewer, options for people with PMDD?

Medical interventions can be lifesaving for people with PMDD. But they don’t address a society that places a heavy burden on the shoulders of people assigned female at birth.

Read: Women aren’t just small men

Browne compares severe premenstrual distress to a broken leg. “If you have a broken leg, you really do need painkillers, because you’re experiencing pain,” she says. “But it’s not going to be helpful in the long term if you don’t deal with whatever the underlying cause is.” In the week before menstruation, the life stressors a person with PMDD deals with the rest of the month can feel unbearable. Those life stressors can and should be addressed alongside conventional medical treatment.

One common stressor is the caregiving load. “Parenting is not only a massive trigger, but it’s also the biggest burden or the biggest guilt that comes with having PMDD,” Matthews says. “Not only are you struggling yourself every month, but you also feel as though you’re failing your children every month.” The co-parent can help alleviate this burden. When fathers spend more time with their kids—and doing child-related chores—mothers tend to be less stressed about parenting.

Another stressor is relationship difficulties. The emotional changes that come with the premenstrual phase can make conflict with a partner more likely. They can also prompt the PMDD sufferer’s partner to dismiss those feelings. “Nowadays, a partner might still be inclined to say, ‘Wait a minute, I know it’s that time of your month again. You’re just being oversensitive,’” Browne points out. Women in relationships with women, who tend to be more understanding of premenstrual change than men, report a more positive experience of the week before their period.

Researchers have done great, necessary work to understand PMDD, work that should continue. How are people who experience premenstrual distress biologically different from people who don’t? Can we find new, more effective drugs to treat that distress?

In the meantime, we need to build a better world for people who experience premenstrual distress. Doctors can prescribe medicine, but managers can make accommodations in the workplace. Co-parents can take on more caregiving responsibility. And partners can provide love and support.

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Ciara McLaren

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September 4, 2023
Birth Control Isn’t the Only Thing That Just Went Over-the-Counter

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The FDA announced yesterday that it had for the first time approved a daily birth-control pill for over-the-counter sales. That’s a big change; once the product, called Opill, is on the market—which may be as soon as early 2024—Americans will be able to buy daily hormonal birth control without a prescription. That’s historic news, but hidden underneath it is another set of firsts: In the coming months, Americans will also be able to grab an over-the-counter treatment for their heavy periods, cramps, headaches, and even migraines; they’ll have prescription-free access to a drug for endometriosis and polycystic ovary syndrome; and they’ll be able to buy a medication that can mitigate the symptoms of menopause. It’s all in the same, progestin-based pill.

The FDA’s approval only covers Opill’s use as a form of birth control, but doctors have been prescribing pills that contain progestin for noncontraceptive needs for years. For the most part, the intervention works much better when the pills include both progestin and estrogen. Adding that second hormone to the mix amplifies all of progestin’s beneficial effects, plus helps control hormonal acne. It also leaves more wiggle room in terms of timing: Progestin-only pills—sometimes called a minipill—have a much shorter half-life in the body, so if you don’t take them during the same three-hour window each day, they’re much less reliable at preventing pregnancy, says Anne-Marie Amies Oelschlager, the chief of pediatric and adolescent gynecology at Seattle Children’s. (Some women are prescribed progestin-only pills because they are particularly susceptible to certain risks associated with estrogen.)

As a result, an over-the-counter progestin-only pill is far from the best way of treating these conditions, experts told me. “While I suppose that it could be used off-label, I would be hesitant to do that if someone was otherwise able to obtain a prescription for a combined oral contraceptive,” Erin Fleurant, a family-planning fellow at Northwestern Medicine, told me. And if progestin by itself really were the right approach, then an IUD, implant, or injection might be a more effective way to deliver the drug.

From July 1939: The responsibilities of birth control

Despite the fact that progestin on its own would not usually be a doctor’s first choice—“I generally don’t prescribe it,” Veronica Ades, the vice chair of ob/gyn at Jacobi Medical Center, told me—the drug can have meaningful benefits when taken on its own. Amies Oelschlager told me that she prescribes it to suppress patients’ periods, especially if they’re experiencing pain or heavy bleeding. Even low-dose pills (like Opill) can be helpful for controlling period- and perimenopause-related migraines, as well as mood swings from premenstrual syndrome or premenstrual dysphoric disorder.

Progestin pills can also be used to treat endometrial hyperplasia, an abnormal thickening of the uterine lining (a.k.a. the endometrium) that can develop into cancer. Same for endometriosis, a condition that may affect up to 11 percent of American women in which endometrial tissue grows outside the uterus. Patients with PCOS produce unusually high levels of male sex hormones and, Ades said, generally have too much estrogen in their body relative to progesterone (the naturally occurring analogue of progestin). Progestin pills can help strike a healthier balance.

Right now, patients have few options to get relief from any of those symptoms without a doctor’s help. Until Opill hits the market, the best non-prescription way to treat PCOS is with healthy eating and exercise, Amies Oelschlager told me. For heavy periods, the best option patients can buy without a prescription is an NSAID like ibuprofen. “As far as an over-the-counter, daily hormonal medication, this is the first in the United States,” she said.

Perhaps the best circumstances for off-label use of Opill will be as a stopgap. If someone starts having abnormal bleeding or period pain but can’t get an appointment or travel to a doctor for several weeks, they could buy themselves some progestin-only pills for the interim. Opill could also be a backup plan for patients who are already taking birth-control pills for a non-birth-control purpose but can’t make it to their doctor to renew their prescription, or can’t get their prescription filled at a pharmacy.

Read: A vaccine for birth control?

Still, Ades cautioned that even stopgap use might not be wise for endometriosis patients, for whom switching medications could disrupt a delicate balance of hormones and “create a cascade of problems.” Fleurant warned that some of the symptoms that progestin pills could help alleviate may also be associated with very serious conditions that need a different treatment plan. “Say someone was 45 years old and having irregular bleeding and also had a lot of other risk factors for uterine cancer. I wouldn’t want them to pick up this pill and think that that was going to cure everything,” she said. Instead, they should be seen by a health-care provider.

For most women who need to be on birth control, a single-hormone drug like Opill is not the most reliable option; but starting next year, it could well be the most convenient. That same trade-off, between effectiveness and access, affects other uses of progestin, too.

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Rachel Gutman-Wei

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July 14, 2023