The role of hormone therapy in the management of severe postpartum depression in patients with Turner syndrome

OBJECTIVE: Premature ovarian failure associated with Turner syndrome presents clinicians with a vast range of health concerns, including infertility, cardiovascular disease, and decreased bone mineral density, in addition to psychological sequelae. Hormone therapy is paramount in managing these complications, but the additional needs in the postpartum period for those who are able to carry out a successful pregnancy have not been described. METHODS: We present a case of severe postpartum depression (PPD) with psychotic features in a patient with Turner syndrome, which presented at 4 weeks after the birth of her first child via egg donation RESULTS:: We describe the case of a previously well 32-year-old patient with an 46 X, i(Xq) karyotype, who went through a 4-week intensive inpatient treatment course for PPD, requiring electroconvulsant therapy for persistent infanticidal and suicidal ideation. It was hypothesized that an estrogen-depleted state secondary to premature ovarian insufficiency and lactation may have been more pronounced during her postpartum course when hormone levels dramatically decrease. To buffer the dramatic drop in sex steroid levels postpartum for her second pregnancy, she was immediately started on estrogen and progesterone replacement, and did not experience any change in mood or similar psychiatric disturbance during this postpartum course. Four years after the PPD episode, her mood remains stable. CONCLUSION: This case highlights the complex interplay between ovarian steroids, depletion of their levels, and psychiatric sequelae. The postpartum period represents a particularly vulnerable time for patients with premature ovarian insufficiency, which requires very close monitoring and early replacement of depleted hormone levels.