Academy of Psychosomatic Medicine

Many psychiatric disorders are more prevalent in women during their reproductive years and at stages of life associated with changes in the hormonal milieu. The neuroendocrine system, including central brain circuits, gonadal functions, and other target organs, has been implicated in the development of psychiatric conditions, such as mood, anxiety, and cognitive disorders. The hypothalamic-pituitary-gonadal (HPG) axis coordinates a tightly regulated feedback loop that consists of gonadotropin-releasing hormone (GnRH) produced by the hypothalamus; follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary; and the sex steroids estrogen, progesterone, and androgens, produced primarily by the ovary, corpus luteum, and adrenals (

). Cyclic and episodic alterations in the HPG axis across the menstrual cycle and during important reproductive health events, such as pregnancy and menopause, are hypothesized to alter the sensitivity of neurotransmitter systems and the function of neural circuits in ways that increase vulnerability to psychiatric symptoms for some women.

This article reviews basic neuroendocrine function and discusses the evidence base of hormonal contribution to psychiatric symptoms in polycystic ovary syndrome (PCOS), premenstrual dysphoric disorder (PMDD), and perimenopause. Strategies for psychiatrists for both clinical assessment and management of female patients with neuroendocrine dysfunction are provided, and the role of hormonal therapies in exacerbating or alleviating neuropsychiatric symptoms in these conditions is explored (

PCOS is one of the most common endocrine disorders in women of childbearing age and is a leading cause of menstrual irregularity and anovulatory infertility. In the US prevalence is 6% to 15%, depending on the criteria used for diagnosis.

 The core features of PCOS include hyperandrogenemia, menstrual irregularities/oligovulation or anovulation, and polycystic ovaries. Women with PCOS also commonly have metabolic disturbances such as reduced insulin sensitivity and obesity.

The characteristic problems of PCOS can be separated into reproductive/menstrual abnormalities, hyperandrogenemia, and metabolic dysfunction. Hyperandrogenemia is identified clinically by hirsutism, acne, and male-pattern alopecia; or biochemically, with elevated levels of testosterone, dehydroepiandrosterone sulfate, or androstenedione. Irregular or absent ovulation leads to the menstrual abnormalities typical of PCOS, including oligomenorrhea/amenorrhea and dysfunctional uterine bleeding (breakthrough bleeding and menorrhagia).

Infertility is common, and ovulation induction is often necessary for conception. There are increased rates of spontaneous abortion, premature delivery, pregnancy-induced hypertension, and gestational diabetes -independent of weight. Women with PCOS have an elevated risk of endometrial cancer because of less frequent exposure to ovulatory surges of progesterone and menstrual bleeding. They are also more likely to be obese, with rates varying according to environmental and cultural factors.

Insulin resistance affects more than three-quarters of women with PCOS, even those who are lean. Rates of type 2 diabetes and gestational diabetes are higher in those with PCOS, as is metabolic syndrome.

 The menstrual irregularities of PCOS may improve as women age and androgen levels decrease. Women with a history of PCOS may have persistent hyperandrogenemia and metabolic disturbances after menopause, and they may experience less severe vasomotor symptoms during the menopausal transition.

PCOS appears to be a multifactorial disorder, with genetic and environmental contributions.

 Excessive androgen production in the ovary leads to hyperandrogenemia, as well as the maturation and premature arrest of maturing follicles, which creates the characteristic polycystic ovary morphology. Insulin resistance and hyperinsulinemia further aggravate ovarian androgen production by stimulating the ovarian theca cells to produce androgens in response to LH and disrupting central control of gonadotropins. Circulating androgens may negatively and positively modulate the gamma-aminobutyric acid (GABA) and 

-methyl d-aspartate (NMDA) systems, respectively.

Disturbances of mental health are prevalent in PCOS.

 Hirsutism and obesity may have a negative impact on body image and feelings of attractiveness; menstrual dysfunction and anovulation may raise concerns about female identity; and challenges with fertility may cause emotional suffering and relationship disruption. Higher rates of depression and anxiety appear to be associated with features of PCOS, including obesity and signs of hyperandrogenemia. PCOS has also been associated with lower quality of life and higher distress scores. Disordered eating, particularly binge eating, appears to be more common in women with PCOS than in controls.

Associations have been found between bipolar disorder and PCOS, and this appears to be most closely linked to the use of valproate. There is limited convincing evidence that women with bipolar disorder are more likely to have PCOS than women without bipolar disorder, when they are not treated with valproate.

 A study that evaluated menstrual abnormalities and hyperandrogenemia in women with bipolar disorder did not find either measure to be significantly higher in patients with bipolar disorder than in a control group.

 On the other hand, bipolar disorder may be more common among women with PCOS than in the general population. A screening study of women with PCOS found higher rates of bipolar disorder than in women without PCOS, independent of valproate treatment, although the findings are limited by sample size, lack of a control group, and non-standardized diagnostic criteria for PCOS.

The moderating effect of valproate on the risk of PCOS is clearer, although the same limitations of inconsistent PCOS diagnostic criteria and methodological differences among studies exist. Valproate appears to increase the risk of PCOS in women with epilepsy, a population with high baseline rates of PCOS and reproductive abnormalities, thought to be related to the effect of epileptic activity on hypothalamic function.

The association between valproate on the incidence and prevalence of PCOS in women with bipolar disorder has been studied. Rates of PCOS are higher in women who take valproate than in those who take other antimanic agents.

 Valproate may contribute to PCOS via the alteration of androgen production and insulin metabolism and functioning, and is less likely to be a direct effect of weight gain.

While there remains uncertainty about the specific relationship between valproate and PCOS, and its clinical significance, prescribers should be mindful of this potential risk when making treatment decisions. In the context of other negative or undesirable effects such as weight gain, hair loss, and teratogenicity in the case of pregnancy, alternate treatments should be strongly considered before recommending valproate in women of reproductive age.

Treatment must address the common features of PCOS: menstrual dysfunction, infertility, acne and hirsutism, metabolic disorder, and mental health disturbances. The reproductive, dermatologic, and metabolic aspects of the syndrome should be managed by a primary care provider or relevant specialist. Weight loss is recommended for overweight or obese women with PCOS; it may be associated with direct improvement of reproductive functioning, metabolic health, and cosmetic appearance. For women who are not actively pursuing pregnancy, hormonal contraception is a first-line treatment. Estrogen in oral contraceptive pills suppresses hyperandrogenemia, and cyclic progestin exposure prevents endometrial hyperproliferation.

Metformin has demonstrated benefit on menstrual functioning as well as weight and insulin sensitivity. Antiandrogens, such as spironolactone and flutamide, may improve cutaneous features of hyperandrogenemia as well as menstrual function.

 Cosmetic treatments can be used to ameliorate acne and hirsutism. In refractory cases, pituitary suppression of gonadal hormones, or surgery, may be recommended by the medical provider. Ovulation induction and other fertility treatments are commonly needed for those who seek pregnancy. Psychiatric disorders, including anxiety, depression and eating disorders, should be actively screened for and addressed.

The psychiatrist plays a pivotal role in the management of patients with PCOS and should be knowledgeable about the condition, because of its prevalence in women of reproductive age. In addition to identification and management of the co-occurring mental health conditions in women with established PCOS, the mental health provider should assess for the features of PCOS such as menstrual abnormalities and dermatologic features in women who present with depression, anxiety, bipolar disorder, and eating disorders. Facilitating appropriate referral to a primary care provider for further evaluation, treatment, and specialist involvement allows for more women with PCOS to receive a diagnosis as well as needed attention -with significant implications for reproductive, metabolic, and mental health.

Psychological and physical symptoms that present in the second half of the menstrual cycle comprise premenstrual syndrome (PMS) and the more severe PMDD. Common symptoms include bloating, mood swings, lethargy, irritability, breast tenderness, anxiety or tension, and rejection sensitivity.

The American College of Obstetricians and Gynecologists defines PMS as the presence in the 5 days prior to menses of at least one physical or emotional symptom causing impairment in social or occupational functioning that must recur for a minimum of 3 consecutive cycles.

 A diagnosis of PMDD, as described in DSM-5, requires at least 5 symptoms from a list of psychological, physical, and behavioral symptoms, confirmed by the use of prospective daily ratings (eg, The Daily Record of Severity of Problems) over a minimum of 2 cycles. The symptoms, which should occur in the week leading up to menses and be largely absent following menses, must be present in the majority of cycles, cause impairment, and be distinct from an exacerbation of another mental disorder or a medical condition. Women who do not menstruate because of hysterectomy or an intrauterine device may still be ovulating, and they can have PMDD if their symptoms follow a pattern consistent with a menstrual cycle.

Although up to 85% of menstruating women may experience at least one menstrual-related symptom, conservative estimates indicate a prevalence of 5% for clinically significant premenstrual disorders.

 PMDD affects women across different cultures and ethnicities. Factors associated with a diagnosis of PMS and PMDD include increased weight, a history of sexual abuse or trauma, and additional psychiatric disorders including other depressive disorders, anxiety disorders, and substance use disorders. Women with a history of PMS/PMDD may be at elevated risk for postpartum depression and for depression during perimenopause. Moreover, there appears to be a genetic contribution to susceptibility to PMDD.

PMDD occurs exclusively in ovulating women and is thought to require fluctuating gonadal hormones. No studies have demonstrated significant differences in any specific hormone in women with PMDD; therefore, leading theories posit that the clinical expression of PMDD is related to increased sensitivity to changes in gonadal hormones, and their modulation of neurotransmitter systems, predominantly serotonin and GABA.

Differences in serotonin activity, improvement of symptoms in response to serotonin agonists and serotonin-reuptake inhibitors (SRIs), and worsening of symptoms in response to serotonin antagonists and depletion of the serotonin precursor tryptophan have been seen in women with premenstrual mood changes.

 Differences in sensitivity to and regulation of the progesterone metabolite allopregnanolone -a stress-responsive GABA receptor agonist -have also been implicated in the symptoms of PMDD.

Despite a lack of strong evidence, first-line management of PMDD is with lifestyle modifications (ie, sleep hygiene, exercise, stress management).

 Psychotherapy such as CBT may help women avoid stressors and better tolerate distress during symptomatic days. For moderate to severe symptoms, SRIs (including SSRIs and SNRIs) are recommended, with a response rate of up to 70%. Doses can be effective at the low end of therapeutic doses for depression, but moderate doses are often required. SRIs can be dosed during the luteal phase or at the start of symptoms, or they can be dosed continually throughout the month. Factors such as cycle and symptom regularity, adverse-effect profile, and personal preference may guide the dosing schedule.

In contrast to depression, the benefits of SRIs for PMDD are observed soon after the first dose, and patients on luteal-phase dosing do not appear to experience withdrawal symptoms when dosing stops each month.

If symptoms persist following an adequate trial of SRIs, hormonal therapy with an oral combination of ethinyl estradiol and the progestin drospirenone is indicated for ovulation suppression. Drospirenone may be particularly effective for PMDD because of its antiandrogenic effects; however, the risk of venous thromboembolism appears to be higher than that of other progestins.

There is evidence that continual dosing of oral contraceptive pills, skipping placebo pill days for several consecutive months, provides symptom relief, likely because of better suppression of ovulation. Antiandrogenic agents, such as spironolactone, finasteride, and flutamide, may be useful for women who cannot take SRIs or hormonal therapies. Brief use of alprazolam during the symptomatic period may also benefit some women. The GnRH antagonist leuprolide, with add-back estrogen and progesterone, or surgical removal of the ovaries may be required for refractory cases.

The menopausal transition occurs in the setting of reduced numbers of ovarian follicles, lower levels of follicle-derived inhibin B, and increased production of FSH from the anterior pituitary gland. Menstrual cycles become longer and more variable in duration, and non-ovulatory cycles are more prevalent. Progesterone levels drop, and levels of physiologic estrogen (estradiol [E2]) become more variable than with premenopausal cycles. Subsequently, menstrual cycles cease, and ovarian E2 and progesterone production fall to minimal levels, characterizing the postmenopausal state. The perimenopausal period can be associated with vasomotor symptoms, alterations in sexual functioning, and mood and cognitive changes.

Depressive disorders are twice as common in women, with rates diverging at puberty and aligning again in the postmenopausal period. Some women appear to be more prone to depressive symptoms and disorders at particular points of the reproductive cycle, such as during the luteal phase of the menstrual cycle, the postpartum period, and the perimenopause. In addition to such epidemiological data, basic and translational studies have elucidated connections between gonadal steroids and neurotransmitters, neurotrophic factors and inflammation, the hypothalamic-pituitary-adrenal (HPA) axis, and systems of the brain related to emotional processing.

 Together, the available research suggests that changes in ovarian hormones play a key role in the development of depressive syndromes in at least a subset of women.

While most women do not experience significant depression during the perimenopause, there may be a 2-fold risk of depression during this period. Women with a history of depression may be at greater risk for recurrence during the menopausal transition. The degree of fluctuations in levels of E2 and FSH and the severity of self-reported vasomotor symptoms have been associated with a higher risk of perimenopausal-onset depression.

 Such findings suggest that mood symptoms may develop in response to highly variable hormone levels, and depend on the ability of the brain to adapt to those fluctuating levels. The finding that perimenopausal women with depression benefit from estrogen therapy, while exogenous estrogen does not appear to improve depression later in the postmenopausal period, further supports the premise that it is the instability of gonadal steroids and trophic factors that drives the depressive symptoms, rather than a primary hormone deficiency.

Ovarian hormones may contribute to perimenopausal-onset depression in several ways. E2 raises levels of available serotonin and norepinephrine through reduced degradation and increased synthesis, modulates the serotonin reuptake transporter and receptors, and may affect levels of neurotrophins, such as brain-derived neurotrophic factor. E2 appears to be implicated in reward circuitry.

 E2 and progesterone are active in areas of the brain associated with mood and emotional processing, such as the prefrontal cortex, hippocampus, and brainstem. Perimenopausal depression may be related to dysfunction of the GABA system and the HPA axis in response to stress in the presence of changing ovarian hormone and neurosteroid levels.

Options for pharmacologic management of perimenopausal depression include antidepressants and hormone therapy. Despite some inconsistencies in the literature, there appears to be a benefit of E2 replacement in women within the perimenopausal period, whereas there was no improvement seen in women who have transitioned into menopause, which suggests a “critical window” for E2 replacement in depressive disorders.

The efficacy of E2 may be related to stabilization of circulating estrogen and FSH levels. Transdermal E2 may be more effective than oral formulations, although the literature is discrepant. Exogenous progestins, indicated if the patient has an intact uterus, may reduce the antidepressant benefit of E2 therapy. Menopausal hormone therapy carries an increased risk of adverse cardiovascular outcomes and cancer -among other risks -although evidence for short-term use (ie, 5 years) during the perimenopausal period and early menopause may be considered after discussion of individual risks and benefits with the patient’s medical provider.

SRIs have demonstrated efficacy in women with perimenopausal depression and may have the added benefit of improving vasomotor symptoms. Head-to-head studies of hormone therapy versus antidepressants for perimenopausal depression are lacking.

Uncertainties exist about the effect of the menopausal transition on neurocognitive functioning, although there is an emerging literature on the effect of ovarian hormones and neurosteroids on the aging brain. While women may report changes such as impaired memory and concentration, there is a dearth of studies that demonstrate specific changes in neurocognitive profiles. Estrogen depletion, either in the natural menopausal period or due to oophorectomy before menopause, appears to be associated with cognitive decline. This finding is supported by compelling human and animal studies and has led to interest in estrogen therapy after menopause to prevent or ameliorate age-related cognitive decline.

Estrogen’s potential benefits on cognition may be mediated through effects on the acetylcholine system, prefrontal cortex functioning, and dendritic spine density. Early studies of postmenopausal exogenous estrogen use suggested reduced risk of cognitive disorders, which was later questioned by results of the Women’s Health Initiative that suggested no cognitive benefit or an increased risk of cognitive impairment in some groups.

Current theories suggest that -as with depression -there may be a critical period for estrogen treatment during perimenopause or early postmenopause (ages 50 to 60) that may lead to improved cognition and/or prevention of age-related cognitive decline, perhaps with sustained benefit well beyond the cessation of hormone therapy. By comparison, initiation of estrogen treatment in the late postmenopausal stage (ages 65 to 79) may be associated with an increased risk of neurocognitive disorders.

While there is no approved indication for perimenopausal use of hormone treatment for cognition, women who undergo early surgical menopause or experience premature menopause should be considered for hormonal treatment until the average age of natural menopause. There are insufficient data at this time to make recommendations for hormone therapy in women who experience natural menopause at the expected age. If a woman chooses to begin treatment because of menopausal symptoms such as vasomotor symptoms, vaginal dryness, or mood instability, it is suggested that short-term use may have added benefit for her neuorocognitive health.

Women experience higher rates of several common psychiatric disorders, and they appear to be at elevated risk during their reproductive years and at specific reproductive transitional points. Pituitary and ovarian hormones have been implicated in these sex- and phase-specific differences. The mental health provider should be knowledgeable about prevalent psychiatric presentations related to reproductive functioning, including those reviewed in this article. Gaining appreciation for the effect of the HPG axis on neurobiology and mental health, as well as learning to recognize, assess, and manage or refer to the appropriate specialist, will enhance the mental health clinician’s capacity to serve the needs of women across the reproductive life cycle -as provider, liaison, and advocate.

The authors acknowledge the Academy of Psychosomatic Medicine (APM) for helping to bring this article to fruition. The APM is the professional home for psychiatrists providing collaborative care bridging physical and mental health. Over 1200 members offer psychiatric treatment in general medical hospitals, primary care, and outpatient medical settings for patients with comorbid medical conditions.

Dr. Gordon-Elliott is Assistant Professor of Clinical Psychiatry, New York-Presbyterian/Weill Cornell Medicine; Dr. Ernst is Associate Professor of Psychiatry, Icahn School of Medicine at Mount Sinai Hospital, New York; Dr. Fersh is Assistant Professor of Psychiatry, Long Island Jewish Medical Center/Hofstra Northwell School of Medicine, Hempstead, NY; Dr. Albertini is Assistant Professor of Psychiatry, Icahn School of Medicine at Mount Sinai Hospital; Dr. Lusskin is Clinical Professor of Psychiatry, Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai Hospital; Dr. Altemus is Associate Professor of Psychiatry, Yale School of Medicine, New Haven, CT.

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Articles

The authors review basic neuroendocrine function and the evidence base of hormonal contribution to psychiatric symptoms in PCOS, PMDD, and perimenopause. They also offer strategies for psychiatrists for both clinical assessment and management of women with neuroendocrine dysfunction.

The Hypothalamic-Pituitary-Gonadal Axis and Women’s Mental Health: PCOS, Premenstrual Dysphoric Disorder, and Perimenopause

Strategies have been developed to prevent HIV transmission and to improve adherence to risk reduction and medical care. These include the National AIDS Strategy for the United States Updated to 2020, the 2015 Blueprint on Ending AIDS in New York State by 2020, and the World Health Organization Guidelines.

 For any HIV prevention strategies to be implemented, physicians in all specialties need to be aware of them. An article in a previous issue of 

 have described the role of psychiatrists in a comprehensive approach to HIV prevention.

This article provides a brief overview of the comprehensive approach and delineates the specific role of psychiatrists in the prevention of HIV transmission both before and after HIV exposure through pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). 

 provides suggestions for a multidimensional approach to HIV prevention.

Many physicians do not know that transmission can be prevented both before and after exposure to HIV. Psychiatrists can refer HIV-negative persons at substantial risk for infection for PrEP before exposure and PEP after exposure to HIV.

The unique role of psychiatrists and mental health clinicians in HIV prevention

In the US, 1.2 million people are living with HIV, and 1 in 8 does not know that he or she is infected.

 The annual rate of new infections in the US has remained relatively stable over the past decade at a rate of 40,000 to 50,000 new infections each year. The prevalence of HIV infection is higher among persons with mental illness than in the general population, and the prevalence of psychiatric disorders and emotional distress among persons with HIV infection is also higher than in the general population.

HIV is transmitted sexually as well as by injection drug use. However, any substance misuse can play an important role in HIV transmission, since alcohol, stimulants, and other drugs may cause intoxication, impair judgment, and lead to risky behaviors such as unprotected or coerced sexual encounters.

Psychiatrists and other mental health clinicians can play an important role in a comprehensive approach to HIV prevention and engagement in care. Psychiatrists in every subspecialty from child and adolescent to geriatric, addiction, or psychosomatic medicine will encounter opportunities for HIV prevention in every setting from emergency departments and general care to inpatient and ambulatory care. Mental health clinicians in every discipline from addiction counselors to social workers, psychiatric nurse clinicians and practitioners, and psychologists will encounter opportunities for HIV prevention in every setting from emergency departments to drug rehabilitation, methadone maintenance, general care, and inpatient and ambulatory psychiatry. Psychiatrists can prevent HIV transmission by:

• Including HIV testing as part of every routine initial evaluation

• Evaluating for substance use and misuse

• Assessing sexuality and sexual function

• Determining whether a person is HIV negative and at substantial risk for HIV infection

• Making a recommendation and referral for PEP or PrEP that can be lifesaving and has public health implications

What psychiatrists need to know about PrEP

Psychiatrists can make a recommendation for PrEP for persons who are not infected with HIV but who are at substantial risk for infection. Psychiatrists can refer persons at risk to HIV clinicians for PrEP but need to know enough about it to make the referral. PrEP comprises continual daily oral antiretroviral medication that is initiated before potential exposure to HIV as a means of reducing the risk of infection among HIV-negative persons at high risk. Persons who are at ongoing and substantial risk of HIV infection include HIV-negative partners of HIV-positive persons and persons who inject drugs (

PrEP allows people who are at substantial risk for HIV infection to reduce their risk by taking antiretroviral medications on an ongoing basis. The medications for healthy adults and adolescents are tenofovir disoproxil fumarate (tenofovir DF or TDF) 300 mg with emtricitabine 200 mg formulated in a single pill to be taken once daily for HIV prevention on a continual basis.

In both sexual transmission and parenteral transmission in injection drug use, there is strong evidence that PrEP can help stop the virus from establishing a permanent infection when used consistently.

 Consistent use of PrEP can decrease HIV transmission by 92%.

The evidence for the effectiveness of PrEP is strong. When PrEP is used consistently and in combination with other preventive measures, the risk of HIV transmission may be not only reduced, but may be eliminated.

What psychiatrists need to know about PEP

There is evidence of a high prevalence of unprotected sex in the US. The prevalence of rape and sexual molestation is high throughout the US, as is the incidence of unintended pregnancy (

While rape is a crime and unintended pregnancy is an accident, both entail a lack of or incorrect use of barrier contraception. Both events can result in the transmission of HIV and other sexually transmitted diseases as well as hepatitis C.

Psychiatrists can prevent HIV infection before exposure by many measures, and they can prevent infection after exposure by recommending PEP. PEP differs from PrEP in the indications for use, medications used, duration of treatment, and lack of a very strong evidence base for treatment (

Despite the lack of strong evidence, PEP is useful for reducing HIV transmission when it is started as rapidly as possible following an isolated exposure. According to the CDC

The most effective methods for preventing human immunodeficiency virus (HIV) infection are those that protect against exposure. Antiretroviral therapy cannot replace behaviors that help avoid HIV exposure (eg, sexual abstinence, sex only in a mutually monogamous relationship with an HIV-uninfected partner, consistent and correct condom use, abstinence from injection drug use, consistent use of sterile equipment by persons unable to cease injection drug use). Provision of antiretroviral medication after isolated sexual, injection drug use, or other non-occupational HIV exposure, known as non-occupational PEP, is less effective at preventing HIV infection than avoiding exposure.

For persons who have isolated inadvertent or forced exposure to blood or body fluids by sexual contact or inadvertent injection drug use with a contaminated needle, non-occupational PEP may be used to prevent infection. (Occupational PEP-when PEP is used after accidental occupational exposure-is not addressed in this article.) Indications for non-occupational PEP are provided in 

Psychiatrists should evaluate and refer persons rapidly for non-occupational PEP when a patient presents for care. A potentially high-risk exposure typically involves direct contact with potentially infectious body fluids or secretions, either through sex or sharing injection equipment with someone who has or might have HIV infection. Exposure to HIV is a medical emergency. HIV establishes infection very quickly, often within 24 to 36 hours after exposure.

 Ideally, referral should be as early as possible but must be within 72 hours after a non-occupational exposure that poses substantial risk for HIV transmission.

All persons considered for non-occupational PEP should have determination of their HIV infection status by HIV testing, preferably by using rapid combined Ag/Ab or antibody blood tests.

If rapid HIV blood test results are unavailable, and non-occupational PEP is otherwise indicated, it should be initiated without delay. It can be discontinued if the patient is later determined to have HIV infection already or the source is determined not to have HIV infection.

Non-occupational PEP is recommended when the source of the body fluids is known to be HIV-positive and the reported exposure presents a substantial risk of transmission.

Non-occupational PEP is not recommended when the reported exposure presents no substantial risk of HIV transmission.

Non-occupational PEP is not recommended when care is sought more than 72 hours after potential exposure.

A case-by-case determination about non-occupational PEP is recommended when the HIV status of the source of the body fluids is unknown and the reported exposure presents a substantial risk of transmission if the source did have HIV infection.

The PEP medication regimen differs from that of the PrEP regimen. It consists of the following for healthy adults and adolescents: tenofovir disoproxil fumarate (tenofovir DF or TDF) 300 mg with emtricitabine 200 mg once daily plus raltegravir (RAL) 400 mg twice daily or dolutegravir (DTG) 50 mg daily. PEP also differs from PrEP in duration of use. PEP is recommended for 28 days after exposure while PrEP is prescribed on an ongoing basis for as long as an HIV-negative individual is at substantial risk for infection.

Through a basic understanding of PrEP and PEP, psychiatrists can play an important role in HIV prevention. Psychiatrists are uniquely poised to use their skills not only to treat psychiatric disorders but also to provide HIV treatment recommendations that protect their patients and the community from HIV transmission.

Dr. Cohen acknowledges the Academy of Psychosomatic Medicine (APM) for helping to bring this article to fruition. The APM is the professional home for psychiatrists providing collaborative care bridging physical and mental health. Over 1200 members offer psychiatric treatment in general medical hospitals, primary care, and outpatient medical settings for patients with comorbid medical conditions.

Dr. Cohen is Chair and Founder of the Academy of Psychosomatic Medicine HIV/AIDS Psychiatry Special Interest Group; she is a Member, APA Office of HIV Psychiatry Steering Committee; and she is Clinical Professor of Psychiatry, Icahn School of Medicine, Mount Sinai, NYC.

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 Choopanya K, Martin M, Suntharasamai P, et al; Bangkok Tenofovir Study Group. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand: a randomised, double-blind, placebo-controlled phase 3 trial. 

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 Basile KC, DeGue S, Jones K, et al. STOP SV: A Technical Package to Prevent Sexual Violence. 

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This article delineates the role of psychiatrists in preventing HIV transmission before and after HIV exposure through pre- and post-exposure prophylaxis. 

How Psychiatrists Can Prevent HIV Transmission With Pre- and Post-Exposure Prophylaxis

This article will briefly review the definition of sexual harassment, its prevalence among physicians and medical students, and its potential impact on physicians and trainees. It will also provide some guidance about its management.

Public awareness about the topic has increased since the 1990s when Attorney Anita Hill made allegations of sexual harassment about Supreme Court Justice Clarence Thomas. The authors became interested in this topic after a third-year medical student approached her Clerkship Coordinator to report she was confused about what to do because a male patient had brushed his hand on her backside on the inpatient psychiatric unit. When she reported the incident to her female supervisor, she was told, “Don’t make a big deal about it, it happens.”

For purposes of this article, we use the Equal Employment Opportunity Commission (EEOC) definition of sexual harassment. In 1980, the EEOC defined sexual harassment as unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature.

The US Merit Systems Protection Board conducted surveys in 1980, 1987, and 1994, and each of the surveys yielded similar results.

 In the first survey, 42% of women and 15% of men reported sexual harassment on the job; in the second survey, the same percentage of women and 14% of men reported sexual harassment; and in the third survey, 44% of women and 19% of men reported sexual harassment.

Sexual harassment appears to be common during medical training. A meta-analysis of data on the topic reported that 59.4% of medical trainees, including medical students, interns, and residents in all specialties, had experienced some form of harassment.

 Another study of emergency medicine residents found that 68.9% of women and 41.9% of men responders reported sexual harassment.

A 1994 survey of interns and residents in an internal medicine residency program showed that a total of 83 episodes of sexual harassment had occurred.

 Of these, 41 occurred during medical school and 42 during residency. About 77% of women did not report the harassment because they were not confident it would help, and 82% of men felt they could deal with the problem with no outside help. Women also reported fear of retaliation and feelings of shame and guilt. Other reasons were fear of not being believed, embarrassment, lack of trust in authority figures, and lack of familiarity with available resources.

A New Zealand study in 2001 that included trainees from all specialties showed that 20% of them had been sexually harassed: women were more likely to report the harassment than men were.

 Most harassers of women in hospitals tend to be male-whether attending physicians or others-and most episodes are likely to happen during medical school. Harassers of men were reported to be mostly nurses; these incidents tended to occur during residency and were found to be mostly non-physical in nature.

A British survey of 100 male and female psychiatric trainees showed that 86% reported unwanted sexual contacts such as deliberate touching, leaning over or cornering, letters, telephone calls, and exposure to sexual material. Most of the offenses were perpetrated by patients.

Findings indicate that female doctors are mostly harassed in their offices by their patients, but also in high-risk areas such as inpatient wards or walk-in clinics.

 Harassment also occurs in emergency departments, where there is a large proportion of previously unknown patients, as well as patients under the influence of alcohol or drugs.

In the New Zealand study, more than half of all trainees reported some form of threat by patients, and one-fifth had been sexually harassed. Psychiatric trainees were identified as being more at risk than other trainees in medicine, obstetrics and gynecology, and surgery (

Harassment is not limited to medical trainees. A 1995 cross-sectional survey showed that 52% of women compared with 5% of men on US academic medical faculties reported having been harassed.

 The hospital environment might foster such behaviors because doctors and trainees spend long hours working in a very stressful environment, doing physical examinations as well as discussing contraception, marital infidelities, sexual abuse, and other “sexual” topics.

A 2014 study that looked at both sexual harassment and gender discrimination among academic medicine faculty showed that 30% of women and 4% of men reported sexual harassment; 47% of the women noted that these experiences negatively affected their professional advancement, although no specifics were provided.

 In the same study, 66% of women and 56% of men reported experiencing gender bias in professional advancement.

 found a higher prevalence of sexual harassment in psychiatric practices than in primary family medicine practices. Many incidents were reported but dismissed as “part of the job.” In addition, when harassers were patients, their psychiatric diagnoses often altered the perception of their behavior. For example, delirium and psychoses were protective of accusations of sexual harassment. Other diagnoses such as dementia, mania, schizophrenia, depression, substance use disorders, and personality disorders were also perceived as protective of patients, even when they exhibited unwanted sexual behaviors. These findings suggest that psychiatrists may be at an increased risk for violence and sexual victimization by psychiatric patients.

A survey of medical residents revealed types of sexual harassment: sexual remarks, offensive comments about one’s body, unwanted sexual attention and flirtation, verbal advances or inquiries, offensive displays of sexual videos/pictures, repeated leering, standing too close, rubbing, fondling, brushing, pinching, patting, threats of punishment for refusal of sexual favors or offering better grades or promotion in return for sexual favors and, finally, attempted rape and rape. 

 compares sexual harassment behaviors reported by men and women using data from a survey conducted by Komaromy and colleagues

Harassment by patients of female doctors often includes suggestive looks and gestures, sexual remarks, inappropriate gifts and phone calls, exposure of body parts, inappropriate touching and requests for unwarranted physical examinations, attempted rape, and rape. Male doctors also are not exempt from harassment by patients, although it is less common.

The sequelae associated with sexual harassment are psychological, somatic, and work-related. Psychological effects include isolation, depression, guilt, anger, fear, low self-esteem, and helplessness. Somatic complaints are disrupted sleep, nightmares, headaches, fatigue, poor appetite, gastrointestinal disturbances, and weight loss. Work-related consequences include absenteeism, poor work evaluation, and poor work performance. An increased likelihood of depression, drug use, or suicidal thoughts has been reported as a consequence of being harassed or belittled by superiors.

Common psychiatric diagnoses associated with victims of sexual harassment include adjustment disorder; major depression; and anxiety disorders, such as panic disorder, generalized anxiety disorder, and PTSD. The estimated percentage of victims who suffer emotional distress as a result of these offending behaviors is as high as 90%.

 However, there is no single diagnosis associated per se with sexual harassment; additional studies are needed to address the relationship between the severity of the aggression and the psychological impact on victims.

Given the prevalence of sexual harassment in the medical field, a clinician may seek treatment from a psychiatrist for the above-mentioned conditions. The psychiatrist may also have to treat a harasser as a patient and might be asked to serve as an expert witness in a court of law. Because of bias, the psychiatrist is precluded from treating and testifying in a case of the same patient. Furthermore, the dual role of the psychiatrist may ruin the patient-doctor relationship and even worsen the patient’s condition. Therefore, an understanding of the legal issues related to sexual harassment is important.

 A “quid pro quo” when the employer enters into a relationship with the employee to obtain or retain employment, which is considered sexual bribery.

 When the employer creates a hostile, intimidating environment for the employee.

Of course, simple words can also be misinterpreted, and a man’s perspective for judging a hostile environment may be different than a woman’s. This was notable in a 1991 California court ruling that “the appropriate perspective for judging a hostile environment claim” (when a woman is a victim) is that of “a reasonable woman.” Words can often be taken out of context: telling a woman “you look attractive today” can be meant as a compliment and taken as such, while saying to a woman “this skirt shows your great legs, wear it more often” can be seen differently.

Recommendations and management of sexual harassment

Litigation is frequently not the answer to harassment-it can lead to resentment, shame, and defensiveness. The main goal in dealing with sexual harassment is prevention and education. The following are some recommendations when interacting with patients:

• In an office setting, consider installing a reliable alarm system

• As much as possible, avoid booking new patients at the end of the day because his or her history of previous violence is unknown until evaluated

• Avoid performing physical examinations on your own

• Inpatient psychiatric wards should be equipped with security systems, panic buttons, and other warning systems in appropriate locations such as interview and treatment rooms

• High-risk patients and those with repetitive disruptive behaviors should be readily identified by incident report analysis

Training programs should take into account the long-term psychological consequences of sexual harassment and ensure that rapid responses are available. Hospital staff and medical trainees need to be educated about sexual harassment. Moreover, institution of a zero-tolerance policy and elimination of the code of silence are highly recommended. It is crucial that easy methods are used to help victims file grievances, keep complaints confidential, and appoint neutral individuals to investigate complaints.

 When harassment has occurred, employers need to take immediate and appropriate action. An unbiased approach will not only demonstrate a commitment to establishing a comfortable working and training environment, but it will also help reinforce the importance of the issue and prevent further harassment.

All medical professionals should learn to recognize sexual harassment behavior and not tolerate it. Victims need to quickly respond to the harasser rather than standing by meekly or stoically. If the harassment persists, it is recommended that the victim compile a written report of the occurrences. Trainees should not feel ashamed or guilty, nor feel compelled to leave their training. Such attitudes may have a serious impact not only on their education but also prevent them from reaching further professional goals.

Harassment of trainees should be reported to general medical education Deans, Chairs of departments, and residency training and clerkship Directors. Volunteer peer crisis intervention, debriefing, counseling, or psychotherapy should be made available to victims. Procedures for both investigations and disciplinary actions should be prioritized when necessary.

The authors express their gratitude to Jacques Vital-Herne, MD, for his contribution to this article. The authors acknowledge the Academy of Psychosomatic Medicine (APM) for helping to bring this article to fruition. The APM is the professional home for psychiatrists providing collaborative care bridging physical and mental health. Over 1200 members offer psychiatric treatment in general medical hospitals, primary care, and outpatient medical settings for patients with comorbid medical conditions.

Dr. St. Victor is Board Certified in Psychiatry and Psychosomatic Medicine, a Fellow of the American Psychiatric Association, and a Fellow of the Academy of Psychosomatic Medicine. She works as the Assistant Clinical Director of Psychosomatic Medicine and the Clerkship Director for Medical Students at the Nassau University Medical Center, East Meadow, NY. Dr. Wichman is Associate Professor of Psychiatry and Obstetrics and Gynecology; Director of Women’s Mental Health, Director of the Inpatient Psychiatry Consultation Service at Froedtert Hospital; and Program Director of Psychosomatic Medicine Fellowship at the Medical College of Wisconsin in Milwaukee, WI. Ms. Malakkla is currently a third-year medical student at the American University of the Caribbean, doing her clerkship at Nassau University Medical Center, East Meadow, NY.

Dr. St. Victor and Dr. Wichman report no conflicts of interest concerning the subject matter of this article.

 Phillips SP, Schneider MS. Sexual harassment of female doctors by patients. 

 Jorgenson LM. Workplace sexual harassment: incidence, legal analysis, and the role of the psychiatrist. 

 Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training. 

 Schnapp B, Slovis B, Shah A, et al. Workplace violence and harassment against emergency medicine residents. 

 Komaromy M, Bindman AB, Haber RJ, et al. Sexual harassment in medical training. 

 Coverdale J, Gale C, Weeks S, et al. A survey of threats and violent acts by patients against training physicians. 

 Morgan JF, Porter S. Sexual harassment of psychiatric trainees: experiences and attitudes. 

 Carr PL. Faculty perceptions of gender discrimination and sexual harassment in academic medicine. 

Here: a review of the definition of sexual harassment, its prevalence among physicians and medical students, its potential impact on physicians and trainees, and guidance about its management. 

Author | Academy of Psychosomatic Medicine

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