The perimenopause, depressive disorders, and hormonal variability
Keywords:
Perimenopause, Depression, Review, Estrogen, TreatmentAbstract
CONTEXT: Several investigations have postulated that the perimenopause may represent a period of increased psychiatric vulnerability, particularly for mood disorders. This review characterizes the perimenopause, including biological changes, the influence of psychosocial factors and the most common clinical manifestations. Clinic-based studies and community-based surveys addressing the prevalence of depressive symptoms in perimenopausal women are critically reviewed. We also discuss the potential greater vulnerability to mood disturbance during the perimenopause in response to hormonal variability. A therapeutic algorithm for management of depressive symptoms in middle-aged perimenopausal women is also presented. The role of estrogen in the treatment of perimenopausal depressive symptoms is particularly discussed. In addition, we review the existing data regarding the potential efficacy of estrogen as an antidepressant agent (monotherapy, augmentation strategy or prophylaxis). DESIGN: Narrative review.
Downloads
References
World Health Organization. Research on the menopause in the 1990s: report of a WHO scientific group. Geneva: WHO Techni- cal Report Series number 866; 1996.
Teede H, Burger HG. The menopausal transition. In: Studd JWW, editor. The Management of Menopause - Annual Book Review. London, England: Parthenon Publishing Group; 1998:1-12.
Schmidt PJ, Roca CA, Bloch M, Rubinow DR. The perimenopause and affective disorders.Semin Reprod Endocrinol 1997;15(1):91-100.
The North American Menopause Society. Clinical challenges of perimenopause: consensus opinion of the North American Meno- pause Society. Menopause 2000;7:5-13.
Treolar AE. Menstrual cyclicity and the premenopause. Maturitas 1981;3:249-64.
McKinlay SM. The normal menopause transition: an overview. Maturitas 1996;23:137-45.
Midgette AS, Baron JA. Cigarette smoking and the risk of natural menopause. Epidemiology 1990;1:475-80.
Speroff L. The menopause: a signal for the future. In: Lobo RA, editor. Treatment of postmenopausal women. New York, NY: Raven Press Ltd.; 1994:1-10.
Harlow BL, Cramer DW, Annis KM. Association of medically treated depression and age at natural menopause. Am J Epidemiol 1995;141:1170-6.
Metcalf MG, Donald RA. Fluctuating ovarian function in perimenopausal women. N Z Med J 1979;89:45-7.
McKinlay SM, Jeffreys M. The menopausal syndrome. Br J Prev Soc Med 1974;28:108-15.
Swartzman LC, Edelberg R, Kemmann E. The menopausal hot flush: symptom reports and concomitant physiological changes. J Behav Med 1990;13:15-30.
Freedman RR. Hot flashes revisited. Menopause 2000;7:3-4.
Kronenberg F. Hot flashes: Phenomenology, quality of life, and search for treatment options. Exp Gerontol. 1994;29:319-36.
Campbell S, Whitehead M. Oestrogen therapy and the meno- pause syndrome. Clin Obstet Gynaecol. 1977;4:31-47.
Haas S, Walsh B, Evans S, Krache M, Ravnikar V, Schiff I. The effect of transdermal estradiol on hormone and metabolic dynamics over a six-week period. Obstet Gynecol 1988;71:671-6.
Guthrie JR, Dennerstein L, Hopper JL, Burger HG. Hot flushes, menstrual status, and hormone levels in a population-based sam- ple of midlife women. Obstet Gynecol 1996;88:437-42.
Mitchell ES, Woods NF. Symptom experiences of midlife women: observations from the Seattle Midlife Women’s Health Study. Maturitas 1996;25:1-10.
Jaszmann L, Van Lith ND, Zaat JC. The age of menopause in the Netherlands. The statistical analysis of a survey. Int J Fertil 1969;14:106-17.
Baram DA. Physiology and symptoms of menopause. In: Stewart DE, Robinson GE, editors. A clinician’s guide to menopause. Washington DC: American Psychiatric Press; 1997:9-27.
Woods NF. Menopause, models, medicine and midlife. San Fran- cisco, CA: North American Menopause Society; 1995.
Bart PB, Grossman M. Menopause. In: Notman MT, Nadelson CC, editors. The Woman Patient. New York: Plenum; 1978:337-54.
Glenn ND. Psychological wellbeing in the post-parental stage: some evidence from national surveys. J Marital Fam Ther 1975;32:105-10.
Lock M. Ambiguities of aging: Japanese experience and percep- tions of menopause. Cult Med Psychiatry 1986;10:23-46.
Lock M. Menopause in cultural context. Exp Gerontol 1994;29:307-17.
Nagata C, Takatsuka N, Inaba S, Kawakami N, Shimizu H. Asso- ciation of diet and other lifestyle with onset of menopause in Japa- nese women. Maturitas 1998;29:105-13.
Anderson E, Hamburger S, Liu JH, Rebar RW. Characteristics of menopausal women seeking assistance. Am J Obstet Gynecol 1987;156:428-33.
Hay AG, Bancroft J, Johnstone EC. Affective Symptoms in Women Attending a Menopause Clinic. Br J Psychiatry 1994;164:513-6.
Novaes C, Almeida OP. Premenstrual syndrome and psychiatric mor- bidity at the menopause. J Psychosom Obstet Gynaecol 1999;20:56-7.
Morse CA, Smith A, Dennerstein L, Green A, Hopper J, Burger H. The treatment-seeking woman at menopause. Maturitas 1994;18:161-73.
Avis NE, McKinlay SM. A longitudinal analysis of women’s atti- tudes toward the menopause: results from the Massachusetts Women’s Health Study. Maturitas 1991;13:65-79.
Burt VK, Altshuler LL, Rasgon N. Depressive symptoms in the perimenopause: prevalence, assessment, and guidelines for treat- ment. Harv Rev Psychiatry 1998;6:121-32.
Bungay GT, Vessey MP, McPherson CK. Study of symptoms in middle life with special reference to the menopause. Br Med J 1980;281:181-3.
Novaes C, Almeida OP, de Melo NR. Mental Health among perimenopausal women attending a menopause clinic: possible association with premenstrual syndrome? Climacteric 1998;1:264-70.
Ballinger CB. Psychiatric morbidity and the menopause: survey of a gynaecological outpatient clinic. Br J Psychiatry 1977;131:83-9.
Hunter M, Battersby R, Whitehead M. Relationships between psychological symptoms, somatic complaints and menopausal sta- tus. Maturitas 1986;8:217-28.
Collins A, Landgren BM. Reproductive health, use of estrogen and experience of symptoms in perimenopausal women: a popula- tion-based study. Maturitas 1994;20:101-11.
Kaufert PA, Gilbert P, Tate R. The Manitoba Project: a re-exami- nation of the link between menopause and depression. Maturitas 1992;14:143-55.
Harlow BL, Cohen LS, Otto MW, Spiegelman D, Cramer DW. Prevalence and predictors of depressive symptoms in older pre- menopausal women: the Harvard Study of Moods and Cycles. Arch Gen Psychiatry 1999;56:418-24.
Schmidt PJ, Rubinow DR. Menopause-related affective disorders: a justification for further study. Am J Psychiatry 1991;148(7):844-52.
Arpels JC. The female brain hypoestrogenic continuum from the premenstrual syndrome to menopause. A hypothesis and review of supporting data. J Reprod Med 1996;41:633-9.
Studd JWW. Oestrogens and depression in women. Br J Hosp Med 1992;48:211-3.
Joffe H, Cohen LS. Estrogen, serotonin, and mood disturbance: where is the therapeutic bridge? Biol Psychiatry 1998;4(9):798- 811.
Kessler RC, McGonagle KA, Swartz M, Blazer DG, Nelson CB. Sex and depression in the National Comorbidity Survey. I: Life- time prevalence, chronicity and recurrence. J Affect Disord 1993;29:85-96.
Morse CA, Dudley E, Guthrie J, Dennerstein L. Relationships between premenstrual complaints and perimenopausal experiences. J Psychosom Obstet Gynaecol 1998;19(4):182-91.
Larsson C, Hallman J. Is severity of premenstrual symptoms related to illness in the climacteric. J Psychosom Obstet Gynaecol 1997;18:234-43.
Roca CA. Estrogen and Mood in Perimenopausal Women. In: Mood & Psychotic Disorders in Women: An Update on Treat- ment. Washington DC: American Psychiatric Association Annual Meeting; 1999.
Guicheney P, Leger D, Barrat J, et al. Platelet serotonin content and plasma tryptophan in peri- and postmenopausal women: vari- ations with plasma oestrogen levels and depressive symptoms. Eur J Clin Invest. 1988;18:297-304.
Holte A. Menopause, mood and hormone replacement therapy: methodological issues. Maturitas 1998;29(1):5-18.
Soares CN, Almeida OP. Associação entre depressão na peri- menopausa e níveis séricos de estradiol (E2) e hormônio folículo- estimulante (FSH). Rev Bras Psiquiatr 2000;22(1):17-21.
Sarrel PM. Sexuality and menopause. Obstet Gynecol 1990;75(Suppl):26S-30S.
Jensen J, Nilas L, Christiansen C. Influence of menopause on se- rum lipids and lipoproteins. Maturitas 1990;12:321-31.
Tang MX, Jacobs D, Stern Y, et al. Effect of oestrogen during menopause on risk and age at onset of Alzheimer’s disease. Lancet 1996;348:429-32.
Smith RN, Studd JW, Zamblera D, Holland EF. A randomised comparison over 8 months of 100 micrograms and 200 micrograms twice weekly doses of transdermal oestradiol in the treatment of severe premenstrual syndrome. Br J Obstet Gynaecol. 1995;102:475-84.
Gregoire AJP, Kumar R, Everitt B, Henderson AF, Studd JWW. Transdermal oestrogen for treatment of severe postnatal depres- sion. Lancet 1996;347:930-3.
Wiklund G, Berg M, Hammar M, Karlberg J, Lindgren R, Sandik K. Long-term effect of transdermal hormonal therapy on aspects of quality of life in postmenopausal women. Maturitas 1992;14:225-36.
Karlberg J, Mattsson LA, Wiklund I. A quality of life perspective on who benefits from estradiol replacement therapy. Acta Obstet Gynecol Scand 1995;74:367-72.
Schneider MA, Brotherton PL, Hailes J. The effect of exogenous oestrogens on depression in menopausal women. Med J Aust 1977;2:162-3.
Pearce J, Hawton K, Blake F, et al. Psychological effects of con- tinuation versus discontinuation of hormone replacement therapy by estrogen implants: a placebo-controlled study. J Psychosom Res 1997;42:177-86.
Ditkoff EC, Crary WG, Cristo M, Lobo RA. Estrogen improves psychological function in asymptomatic postmenopausal women. Obstet Gynecol 1991;78:991-5.
Coope J. Is oestrogen therapy effective in the treatment of meno- pausal depression? J R Gen Pract 1981;31:134-40.
Thomson J. Double blind study on the effect of estrogen on sleep, anxiety and depression in perimenopausal women: preliminary results. Proc R Soc Med 1976;69:829-30.
Nickelsen T, Lufkin EG, Riggs BL, Cox DA, Crook TH. Raloxifene hydrochloride, a selective estrogen receptor modula- tor: safety assessment of effects on cognitive function and mood in postmenopausal women. Psychoneuroendocrinology 1999;24:115-28.
Shapira B, Oppenheim G, Zohar J. Lack of efficacy of estrogen supplementation to imipramine in resistant female depressive. Biol Psychiatry 1985;20:576-9.
Schneider LS, Small GW, Hamilton SH, et al. Estrogen replace- ment and response to fluoxetine in a multicenter geriatric depres- sion trial. Am J Psychiatry 1997;5:97-106.
Amsterdam J, Garcia-Espana F, Fawcett J, et al. Fluoxetine effi- cacy in menopausal women with and without estrogen replace- ment. J Affect Disord 1999;55:11-7.
Sichel DA, Cohen LS, Robertson LM, Ruttenberg A, Rosenbaum JF. Prophylactic estrogen in recurrent postpartum affective disor- der. Biol Psychiatry 1995;38:814-8.
Soares CN, Almeida OP, Joffe H, Cohen LS. Efficacy of estradiol for the treatment of depressive disorders in perimenopausal women: A Randomized, double-blind, placebo-controlled trial. Arch Gen Psychiatry 2001 (in press).
