Menopausal transition and increased depressive symptomatology: a community based prospective study

Predictors of psychological well-being and stress among Jordanian menopausal women

PURPOSE

The aim of this study was to investigate purpose in life, self-acceptance, perceived stress levels, and menopausal symptoms among Jordanian women.

METHODS

A descriptive, correlational design with a convenience sample of 193 women aged 40-55 years was employed.

RESULTS

The average age at menopause for the current sample was 47.4 years, and menopausal status did not significantly affect purpose in life, self-acceptance, or perceived stress levels. Negative correlations were found between purpose in life and perceived stress, and between self-acceptance and perceived stress (r = -0.49; p = 0.01 and r = -0.58; p = 0.01, respectively). Menopausal symptoms were found to be a strong negative predictor of purpose in life, self-acceptance, and perceived stress levels. In addition, higher health rating was significantly associated with higher psychological well-being and lower perceived stress levels. Perimenopause was found to be a vulnerable stage for severe menopausal symptoms particularly psychological complaints. However, vasomotor symptoms and loss of sexual interest became more intense among postmenopausal women. Although women in the current study had low psychological well-being and high perceived stress, these were not affected by their menopausal status.

CONCLUSION

The study showed the importance of including both physical and psychological symptoms during encounters with health professionals, besides considering women's expectations about menopause to help ease their menopausal transition and improve their well-being.

Depressive symptoms are increased in the early perimenopausal stage in ethnically diverse human immunodeficiency virus-infected and human immunodeficiency virus-uninfected women

OBJECTIVE

The risk of clinically significant depressive symptoms increases during perimenopause. With highly active antiretroviral treatment (HAART), more human immunodeficiency virus (HIV)-infected women survive to transition through menopause. In a cross-sectional analysis, we evaluated the association of menopausal stage and vasomotor symptoms with depressive symptoms in an ethnically diverse cohort of women with a high prevalence of HIV.

METHODS

Participants included 835 HIV-infected women and 335 HIV-uninfected controls from the Women's Interagency HIV Study (63% African American). The Center for Epidemiologic Studies Depression Scale was used to screen for elevated depressive symptoms. Menopausal stages were defined according to standard definitions. Logistic regression analysis was used to identify predictors of elevated depressive symptoms.

RESULTS

Compared with premenopausal women, early perimenopausal women (OR [odds ratio], 1.74; 95% CI, 1.17-2.60), but not late perimenopausal or postmenopausal women, were more likely to show elevated depressive symptoms in adjusted analyses. The odds were similar in HIV-infected and HIV-uninfected women. Persistent vasomotor symptoms also predicted elevated depressive symptoms in HIV-infected and HIV-uninfected women (OR, 1.45; 95% CI, 1.02-2.06). In HIV-infected women, menopausal stage interacted with antiretroviral use (P = 0.02); the likelihood of elevated depressive symptoms in early perimenopause compared with premenopause was especially high in HAART-untreated women (OR, 3.87; 95% CI, 1.57-9.55).

CONCLUSIONS

In HIV-infected and HIV-uninfected women, the odds of elevated depressive symptoms were significantly higher during early perimenopause. Elevated depressive symptoms were associated with nonadherence to HAART, underscoring the importance of screening and treating depressive symptoms in HIV-infected women who have experienced a change in the regularity of their menstrual cycles.

Histórico de transtornos disfóricos no período reprodutivo e a associação com sintomas sugestivos de depressão na pós-menopausa

Este estudo buscou verificar se existe associação entre o histórico de transtornos disfóricos no período reprodutivo e a presença de sintomas sugestivos de depressão na pós-menopausa. Trata-se de uma pesquisa do tipo transversal analítica. A população foram mulheres pós-menopausa, com idade entre 50 e 65 anos, com no mínimo 12 meses de amenorreia, residentes em um município do interior do Estado do Rio Grande do Sul. Atenderam aos critérios do estudo 112 mulheres. Os dados foram obtidos por meio de entrevista estruturada contendo informações sociodemográficas, anamnese para identificação da presença de transtornos disfóricos, sintomas relacionados a menopausa, tratamento de reposição hormonal e aplicada a escala de depressão de Hamilton para avaliar a presença de sintomas sugestivos de depressão. Os transtornos disfóricos mais relatados pelas mulheres foram o cansaço, as dores articulares ou musculares, cefaleia, nervosismo e irritabilidade. A maioria apresentava algum grau de sintoma depressivo e verificou-se associação entre esses sintomas e a presença de transtornos disfóricos. Embora não se tenha observado relação entre terapia de reposição hormonal e sintomas depressivos, expressivo número de mulheres apresentou este sintoma com o uso ou não de terapia de reposição hormonal. O estudo mostrou associação de transtornos disfóricos pré-menstruais e sintomas sugestivos de depressão em mulheres pós-menopausa.

Neurobiological Underpinnings of the Estrogen - Mood Relationship

Women are at a higher risk than men to develop mood disorders and depression. The increased risk is associated with fluctuating estrogen levels that occur during reproductive cycle events, particularly during the menopausal transition, a time characterized by drastic fluctuations in estrogen levels and increases in new onset and recurrent depression. Conversely, recent data show that hormone therapy, particularly transdermal estradiol formulations, may prevent mood disorders or even serve as a treatment regimen for women with diagnosed mood disturbances via estrogen regulation. While the exact mechanism is unknown, there is compelling scientific evidence indicating the neuromodulatory and neuroprotective effects of estrogen, which are directly relevant to mood symptomotology. Specifically, affective regulation has been linked to neural structures rich in estrogen receptors and estrogenic regulation of neurotransmitters. While a wealth of basic science, observational and clinical research support this rationale, potential mediating variables, such as estrogen formulation, proximity of administration to menopause, and the addition of progestins should be considered. Furthermore, the nature of postmenopausal exogenous hormone formulations in relation to premenopausal endogenous levels, as well as the ratio of estrone to estradiol warrant consideration.

Perimenstrual symptoms and symptoms at midlife in Puebla, Mexico

OBJECTIVES

To examine perimenstrual symptoms in relation to hot flushes and depressive symptoms among 755 pre- and postmenopausal women aged 40-60 years drawn from a general population in Puebla, Mexico.

METHODS

Hot flushes and depressed mood during the past 2 weeks were queried, along with cramps and other symptoms experienced during or before menstruation. Relationships among perimenstrual symptoms were examined by factor analyses. Logistic regression was used to assess determinants of hot flushes and determinants of depressed mood at midlife.

RESULTS

Fifty-four percent of the women reported abdominal cramping (cólicos) during menstruation; fewer reported irritability (8%) and depressed mood (9%). Gastrointestinal complaints were most frequently volunteered (12%), followed by breast tenderness (10%) and mid-back pain (9%). Emotional symptoms clustered separately from perimenstrual symptoms. In bivariate analyses, abdominal cramping and waist pain were associated with hot flushes at midlife (p <0.01) and remained significant determinants after controlling for potential confounders. Depressed mood with menstruation was associated with depressed mood at midlife (p <0.05). After controlling for education, socioeconomic status and parity, perimenstrual irritability and depressed mood raised the risk of midlife depressed mood, although significance was lost after adding current hot flushes and trouble sleeping.

CONCLUSIONS

The relationship between abdominal cramps and hot flushes may be hormonal or sociocultural. The lack of association between depressed mood with menstruation and depressed mood at midlife after controlling for current hot flushes and trouble sleeping suggests that concurrent difficulties were more important than past history of depression in this population.

Depression and midlife: are we overpathologising the menopause?

OBJECTIVE

Cross sectional and longitudinal studies have suggested that the menopausal transition is a period of vulnerability for the development of depressive symptoms in women. It has been proposed that depression at the time of transition to menopause is part of a distinct diagnostic group of 'reproductive-related depressive disorders'. Furthermore it is proposed that these disorders are so prevalent that that middle aged women should be routinely screened to improve detection. The aims of this paper were to explore key studies undertaken over the past three decades to examine what evidence exists to support the proposals that depression in midlife women occurs as a biological response to hormonal change and that it is so common that all middle aged women should be routinely screened for depression.

METHOD

A systematic search was carried out of electronic databases for original research using population-based studies examining the relationship between menopause and depression.

RESULTS

Longitudinal change in menopausal status over time is associated with an increased risk of elevated depressive symptoms, independent of relevant demographic, psychosocial, behavioural and health factors. However, depressive symptoms have non-specific diagnostic significance, and even when severe do not always reflect a depressive syndrome. There is no clear evidence that depressive disorders occur more commonly in association with the menopause. Rather, it appears that the true rate of disorder is similar to that at other times in a woman's reproductive life.

CONCLUSIONS

The studies identified here do not provide evidence for the delineation of depression at the menopausal transition as part of a distinctive diagnostic group of 'reproductive-related depressive disorders' which occur as a biological response to hormonal change. The most plausible explanation is a bio-psycho-socio-cultural model of the processes which might lead to a depressive disorder in midlife. Although depressive symptoms are common at this time, data do not support the call for screening of all women for depression at the time of the MT. Rather, given the frequency of depression in the general population, clinicians should be alert to the possibility of depression in every clinical encounter.

Mood and menopause: findings from the Study of Women's Health Across the Nation (SWAN) over 10 years

Women are twice as likely as men to suffer from depressive symptoms/disorder. Research has focused on physiologic and psychosocial differences between men and women; an important target of study has been periods of reproductive changes. Controversy has existed regarding the extent to which the menopausal transition or postmenopause increases the risk for depressive symptoms/disorders. This paper presents findings from analyses of data from the SWAN study and an ancillary study on mental health. We found that risk for high depressive symptoms and disorder is greater during and possibly after the menopausal transition. Other factors contribute to risk for depression.

Major depression during and after the menopausal transition: Study of Women's Health Across the Nation (SWAN)

BACKGROUND

It is unclear whether risk for major depression during the menopausal transition or immediately thereafter is increased relative to pre-menopause. We aimed to examine whether the odds of experiencing major depression were greater when women were peri- or post-menopausal compared to when they were pre-menopausal, independent of a history of major depression at study entry and annual measures of vasomotor symptoms (VMS), serum levels of, or changes in, estradiol (E2), follicular stimulating hormone (FSH) or testosterone (T) and relevant confounders.

METHOD

Participants included the 221 African American and Caucasian women, aged 42-52 years, who were pre-menopausal at entry into the Pittsburgh site of a community-based study of menopause, the Study of Women's Health Across the Nation (SWAN). We conducted the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) to assess diagnoses of lifetime, annual and current major depression at baseline and at annual follow-ups. Psychosocial and health factors, and blood samples for assay of reproductive hormones, were obtained annually.

RESULTS

Women were two to four times more likely to experience a major depressive episode (MDE) when they were peri-menopausal or early post-menopausal. Repeated-measures logistic regression analyses showed that the effect of menopausal status was independent of history of major depression and annually measured upsetting life events, psychotropic medication use, VMS and serum levels of or changes in reproductive hormones. History of major depression was a strong predictor of major depression throughout the study.

CONCLUSIONS

The risk of major depression is greater for women during and immediately after the menopausal transition than when they are pre-menopausal.

Depression or menopause? Presentation and management of major depressive disorder in perimenopausal and postmenopausal women

OBJECTIVE

The purpose of this review was to examine the risk of depression onset in perimenopausal and postmenopausal women, discuss the importance and rationale for screening for major depressive disorder (MDD) in women in the menopausal transition, and review therapeutic options for management of MDD in perimenopausal and postmenopausal women.

DATA SOURCES

PubMed was searched (1970 to 2008) using combinations of the following terms: major depressive disorder, perimenopause, postmenopause, mood disorder, risk factors, reproductive period, family practice, differential diagnosis, hormone, estrogen replacement therapy, reuptake inhibitors, and neurotransmitter.

STUDY SELECTION

All relevant articles identified via the search terms reporting original data and published in English were considered for inclusion. Twenty-two cross-sectional and longitudinal studies were utilized to evaluate the relationship between the menopausal transition and risk of mood disorders and to formulate recommendations for screening and management of MDD in perimenopausal and postmenopausal women.

DATA EXTRACTION

RESEARCH STUDIES UTILIZED THE FOLLOWING MEASURES: postal questionnaires, Women's Health Questionnaire, Beck Depression Inventory, Center for Epidemiologic Studies-Depression scale, Modified Menopause Symptom Inventory, 12-item symptom questionnaire, or Structured Clinical Interview for DSM-IV.

DATA SYNTHESIS

Menopause is a normal, and for most women largely uneventful, part of life. For some women, however, the menopausal transition is a period of biologic vulnerability with noticeable physiologic, psychological, and somatic symptoms. The perimenopausal period is associated with a higher vulnerability for depression, with risk rising from early to late perimenopause and decreasing during postmenopause. Women with a history of depression are up to 5 times more likely to have a MDD diagnosis during this time period.

CONCLUSIONS

Routine screening of this at-risk population followed by careful assessment for depressive symptoms can help identify the presence of MDD in the menopausal transition. Recognition of menopausal symptoms, with or without depression, is important given their potential impact on quality of life.

Neuromodulation by soy diets or equol: anti-depressive & anti-obesity-like influences, age- & hormone-dependent effects

BACKGROUND

Soy-derived isoflavones potentially protect against obesity and depression. In five different studies we examined the influence of soy-containing diets or equol injections on depression, serotonin levels, body weight gain (BW) and white adipose tissue (WAT) deposition in female Long-Evans rats at various stages of life [rats were intact, ovariectomized or experienced natural ovarian failure (NOF)].

RESULTS

In general, animals fed a soy-rich diet (Phyto-600) and/or administered equol (@ 5 mg/kg/day) displayed significant decreases in BW and WAT compared to a low-soy diet. When equol was injected alone (5 mg/kg/day), experiments 1, 4, and 5 demonstrated that body weight was significantly decreased. Equol has body weight control effects in females that are dependent on ovarian status and/or age of diet initiation. Experiments 1-4 all displayed no significant differences in depressive-related behavior as measured by the Prosolt forced swim test (PFST) when soy-rich (Phyto-600) or low-soy diets (Phyto-low) or equol treatments (5 mg/kg/day) were tested in female rats at various ages or hormonal status. Results of all the experiments are not presented here due to space limitations, but data from experiment 5 are presented. From conception female rats were exposed to either: a) a soy-rich (Phyto-600) or b) low-soy diet (Phyto-low). After 290 days all rats experienced NOF. At 330 days-old the animals were examined in the Porsolt forced swim test (PFST). One month later a second PFST was performed [after Phyto-low fed animals were injected with equol (5 mg/kg/day) for one week prior to the second PFST]. At the first PFST, serotonin and mobility levels were significantly decreased in the Phyto-low fed animals compared to animals that consumed the Phyto-600 diet. After equol injections at the second PFST, mobility and serotonin levels significantly increased in aged NOF rats fed the Phyto-low diet (to levels comparable to Phyto-600 fed animals).

CONCLUSIONS

Consumption of dietary isoflavones or equol exposure in rats has body weight controlling effects and equol specifically may have antidepressant potential dependent upon diet initiation and/or dosage of treatments. The current study demonstrates that equol is able to decrease body weight, abdominal WAT, and depressive-related behavior. While other factors and mechanisms may play a role, in part, the present results provide a greater understanding of how isoflavonoid molecules modulate the brain's influence on behavior.

Symptom clusters during the late menopausal transition stage: observations from the Seattle Midlife Women's Health Study

OBJECTIVE

The aims of this study were to identify groups of women in the late menopausal transition stage who experienced the same cluster of symptoms and to identify indicators that predicted membership in these distinct groups.

METHODS

The sample consisted of a subset of Seattle Midlife Women's Health Study participants who were in the late menopausal transition stage and provided self-report data on symptoms experienced between 1990 and 2005. Latent class analysis (LCA) was used to identify groups of women who experienced similar clusters of the following five symptoms: problem concentrating, hot flashes, joint ache, mood changes, and awakening at night. LCA with multivariate logistic regression was used to identify covariates that predicted membership in each group.

RESULTS

Four groups of women were identified: (1) low severity for all symptoms except for joint ache, which was moderate (65%); (2) high severity for all symptoms except for hot flashes, which was moderate (13%); (3) high severity for hot flashes, joint ache, and awakening at night (12%); and (4) high severity for problem concentrating and joint ache (10%). A clear delineation between groups based on individual characteristics was not fully elucidated.

CONCLUSIONS

This analysis demonstrates that LCA may be useful to identify women who may experience poorer outcomes related to a higher propensity for severe symptoms. Shifting the focus from single symptoms to symptom clusters will aid in the identification of phenotypic profiles, thus facilitating symptom management strategies that can be tailored to meet the needs of individual women.

Can depression be a menopause-associated risk?

There is little doubt that women experience a heightened psychiatric morbidity compared to men. A growing body of evidence suggests that, for some women, the menopausal transition and early postmenopausal years may represent a period of vulnerability associated with an increased risk of experiencing symptoms of depression, or for the development of an episode of major depressive disorder. Recent research has begun to shed some light on potential mechanisms that influence this vulnerability. At the same time, a number of studies and clinical trials conducted over the past decade have provided important data regarding efficacy and safety of preventative measures and treatment strategies for midlife women; some of these studies have caused a shift in the current thinking of how menopausal symptoms should be appropriately managed.Essentially, most women will progress from premenopausal into postmenopausal years without developing significant depressive symptoms. However, those with prior history of depression may face a re-emergence of depression during this transition while others may experience a first episode of depression in their lives. Here I provide an overview of what is known about risk factors for depression and the risk posed by the menopausal transition, its associated symptoms, and the underlying changes in the reproductive hormonal milieu, discussing the evidence for the occurrence of mood symptoms in midlife women and the challenges that face clinicians and health professionals who care for this population.

Associations of depression with the transition to menopause

OBJECTIVES

The aims of this study were to identify the risk of depression in the transition to menopause in women with and without a history of depression and to consider that the changing hormonal milieu is one of multiple risk factors for perimenopausal depression.

METHOD

A review of epidemiologic studies of depressed mood in the menopausal transition since the State-of-Science Report of the National Institutes of Health in 2005 was conducted.

RESULTS

Recent longitudinal cohort studies indicate that the likelihood of depressed mood in the menopausal transition is approximately 30% to three times greater compared with that during premenopause. Women with a history of depression are nearly five times more likely to have a diagnosis of major depression in the menopausal transition, whereas women with no history of depression are two to four times more likely to report depressed mood compared with premenopausal women. In some studies, the changing hormonal milieu is significantly associated with depressive symptoms in the menopausal transition. Other risk factors for depressed mood in perimenopausal women include poor sleep, hot flashes, stressful or negative life events, employment status, age, and race.

CONCLUSIONS

The findings support the concept that the menopausal transition is a "window of vulnerability" for some women and is framed by the changing hormonal milieu of ovarian aging.

Longitudinal change in reproductive hormones and depressive symptoms across the menopausal transition: results from the Study of Women's Health Across the Nation (SWAN)

CONTEXT

The contribution of reproductive hormones to mood has been the focus of considerable research. Results from clinical and epidemiological studies have been inconsistent. It remains unclear whether alterations in serum hormone levels across the menopausal transition are linked to depressive symptoms.

OBJECTIVES

To evaluate the relationship between serum hormone levels and high depressive symptoms and whether hormone levels or their change might explain the association of menopausal status with depressive symptoms previously reported in a national sample of midlife women.

DESIGN

A longitudinal, community-based, multisite study of menopause. Data were collected at baseline and annually from December 1995 to January 2008 on a range of factors. Early follicular phase serum samples were assayed for levels of estradiol, follicle-stimulating hormone, testosterone, and dehydroepiandrosterone sulfate.

SETTING

Seven communities nationwide.

PARTICIPANTS

A community-based sample of 3302 multiethnic women, aged 42 to 52 years, still menstruating and not using exogenous reproductive hormones. Main Outcome Measure Depressive symptoms assessed with the Center for Epidemiological Studies Depression Scale (CES-D). The primary outcome was a CES-D score of 16 or higher.

RESULTS

In multivariable random-effects logistic regression models, log-transformed testosterone level was significantly positively associated with higher odds of a CES-D score of 16 or higher (odds ratio = 1.15; 95% confidence interval, 1.01-1.31) across 8 years, and a larger increase in log-transformed testosterone from baseline to each annual visit was significantly associated with increased odds of a CES-D score of 16 or higher (odds ratio = 1.23; 95% confidence interval, 1.04-1.45). Less education, being Hispanic, and vasomotor symptoms, stressful life events, and low social support at each visit were each independently associated with a CES-D score of 16 or higher. No other hormones were associated with a CES-D score of 16 or higher. Being perimenopausal or postmenopausal compared with being premenopausal remained significantly associated with a CES-D score of 16 or higher in all analyses.

CONCLUSIONS

Higher testosterone levels may contribute to higher depressive symptoms during the menopausal transition. This association is independent of menopausal status, which remains an independent predictor of higher depressive symptoms.

Challenges and opportunities to manage depression during the menopausal transition and beyond

Women are at a higher risk than men of developing depression and anxiety and such increased risk might be particularly associated with reproductive cycle events. Recent evidence suggests that the transition to menopause may constitute a window of vulnerability for some women for the development of new onset and recurrent depression. Several biological and environmental factors seem to be independent predictors or modulating factors for the occurrence of depression in menopausal women; they include the presence and severity of hot flushes, sleep disturbances, history of severe premenstrual syndrome or postpartum blues, stressful life events, history of depression, socioeconomic status, and use of hormones and psychotropic agents. The regulation of monoaminergic systems by ovarian hormones might explain, at least in part, the emergence of depressive symptoms and/or anxiety in biologically predisposed subpopulations. The use of transdermal estradiol, as well as serotonergic and noradrenergic antidepressants, is an efficacious strategy in the treatment of depression and vasomotor symptoms in symptomatic women in midlife. In this review, the authors discuss the existing evidence of a greater risk for the development of depression during the menopausal transition and the putative underlying mechanisms contributing to this window of vulnerability. Hormonal and nonhormonal treatment strategies for depression and anxiety in this particular population are critically examined, although more tailored treatment options are still needed.

Association between depressive symptoms and reproductive variables in a group of perimenopausal women attending a menopause clinic in México City

The aim of this study was to explore the association between depressive symptoms and some variables related to the reproductive life, such as history of premenstrual dysphoric disorder, antecedent of postpartum depression, previous use of hormonal contraceptives, and current hot flushes, in a group of perimenopausal women attending a menopause clinic. Perimenopausal women, 45 to 55 years old, who had not received hormonal replacement therapy and/or psychotropic medication, were invited to participate in this study. 141 perimenopausal women were included; we obtained their psychiatric and gynecological data, and we evaluated their depressive symptomatology using the CES-D scale. There were a significantly higher number of cases of previous depressive episodes, PMDD and PPD history in depressed patients compared with non-depressed women; current hot flushes prevalence was similar between depressed and non-depressed women. Patients with a PMDD history were more likely to have experienced previous depressive episodes, a PPD history and high levels of depression. Variables associated with the level of depression were a previous history of PMDD, current hot flushes, and previous depressive episodes. The occurrence of perimenopausal depression is related to a previous history of PMDD, PPD, and depressive episodes; hot flushes only increase the severity of the depressive episode.

Depression is associated with worse objectively and subjectively measured sleep, but not more frequent awakenings, in women with vasomotor symptoms

OBJECTIVE

Depression occurs more commonly during the menopausal transition in women with vasomotor symptoms (VMS) than in those without, but most women with VMS do not develop depression. It has been hypothesized that VMS are associated with depression because VMS lead to repeated awakenings, which impair daytime well-being. We aimed to determine if objectively measured sleep and perceived sleep quality are worse in depressed women with VMS than in nondepressed women with VMS.

METHODS

Objectively and subjectively measured sleep parameters were compared between 52 depressed women with VMS and 51 nondepressed controls with VMS. Actigraphic measures of objective sleep conducted in the home environment and subjective measures of sleep quality (Pittsburgh Sleep Questionnaire Index) were compared using linear regression models.

RESULTS

On objective assessments, depressed women with VMS spent less time in bed (by 64.8 min; P < 0.001) and had shorter total sleep time (by 47.7 min; P = 0.008), longer sleep-onset latency (by 13.8 min; P = 0.03), and lower sleep efficiency (by 3.2 percentage points; P = 0.09), but did not awaken more or spend more time awake after sleep onset than nondepressed controls with VMS. Depressed women also reported worse sleep quality (mean Pittsburgh Sleep Questionnaire Index 12.0 vs 8.3; P < 0.001). Adjustment for VMS frequency and important demographic characteristics did not alter these associations.

CONCLUSIONS

Sleep quality and selected parameters of objectively measured sleep, but not sleep interruption, are worse in depressed than in nondepressed women with VMS. The type of sleep disturbance seen in depressed participants was not consistent with the etiology of depression secondary to VMS-associated awakenings.

Estradiol reduces anxiety- and depression-like behavior of aged female mice

Beneficial effects of the ovarian steroid, 17beta-estradiol (E(2)), for affective behavior have been reported in young individuals, but less is known about the effects of E(2) among older individuals, and the capacity of older individuals to respond to E(2) following its decline. In the present study, the effects of acute E(2) administration to aged mice for anxiety-like and depression-like behaviors were investigated. Intact female C57BL/6 mice (N=18) that were approximately 24 months old were administered vehicle (sesame oil, n=9) or E(2) (10 microg, n=9) subcutaneously 1h prior to behavioral testing. Mice were tested for anxiety-like behavior (open field, elevated plus maze, mirror chamber, light-dark transition task, Vogel conflict task) and depression-like behavior (forced swim task). To assess the role of general motor behavior and coordination in these aged mice, performance in an activity monitor and rotarod task, and total entries made in tasks (open field, elevated plus maze, light-dark transition task) were determined. Mice administered E(2), compared to vehicle, demonstrated anti-anxiety behavior in the open field, mirror chamber, and light-dark transition task, and anti-depressive-like behavior in the forced swim task. E(2) also tended to have anti-anxiety effects in the elevated plus maze and Vogel task compared to vehicle administration, but these effects did not reach statistical significance. E(2) did not alter motor behavior and/or coordination in the activity monitor, open field, or rotarod tasks. Thus, an acute E(2) regimen produced specific anti-anxiety and anti-depressant effects, independent of effects on motor behavior, when administered to aged female C57BL/6 mice.

Sex hormones and mood in the perimenopause

The focus of this chapter is the relationship between the onset of depression in women and the reproductive events of the menopause transition. Epidemiologic studies have documented that the majority of women do not become depressed during the menopause transition. However, recent longitudinal studies suggest that in some women, the reproductive events related to the menopause transition could play a role in the onset of depression. No abnormality of ovarian hormones has been identified that distinguishes women with depression from those who remain asymptomatic during the menopause transition. Nonetheless, several findings suggest a role of ovarian hormones in the onset of these depressions. First, episodes of depression cluster during the stage of the menopause transition that is accompanied by estradiol withdrawal. Second, randomized controlled trials have documented the short-term (3-6 weeks) antidepressant efficacy of estradiol in depressed perimenopausal women. Third, experimentally induced estradiol withdrawal triggers mood symptoms in some women. Thus, although depression is not a uniform accompaniment of the menopause transition, in some women, age-related changes in ovarian estrogen production may alter central nervous system function and predispose them to develop depression.

A prospective study of the association between endogenous hormones and depressive symptoms in postmenopausal women

OBJECTIVE

Across a woman's lifetime, variations in hormone levels are known to influence mood and well-being. Whether absolute or changes in hormone levels over time are associated with depression among postmenopausal women remains unclear.

METHODS

The Melbourne Women's Midlife Health Project is a longitudinal population-based study of women who were followed through the menopausal transition. This analysis is based on data collected from 138 postmenopausal women in years 11 and 13 of the study, who were assessed for the presence of depressive symptoms using the Center for Epidemiological Studies Depression Scale. Logistic regression models were developed to determine whether absolute or changes in hormone levels were associated with depression.

RESULTS

No significant associations were found between depressive symptoms and the absolute levels of sex hormone-binding globulin, testosterone, free androgen index, estradiol, free estradiol, or follicle-stimulating hormone (FSH). On the other hand, women with a decline in total serum estradiol over the 2-year period had a more than threefold increased risk of depressive symptoms (odds ratio, 3.5; 95% CI, 1.2-9.9). A large increase in FSH levels over this period was also associated with depressive symptoms (odds ratio, 2.6; 95% CI, 1.0-6.7). These associations remained even after adjustment for initial depression score, as well as a range of potential confounding factors.

CONCLUSIONS

Changes in estradiol and, to a lesser extent, in FSH levels are associated with an increased risk of depressive symptoms in postmenopausal women. These results further support a role for fluctuating rather than absolute hormone levels in depression in later life.

Depression and the menopause: why antidepressants are not enough?

Background

Gender differences, related to varying sexual hormone levels and hormone secretion patterns across the lifespan, contribute to women's vulnerability to mood disorders and major depression. Women are more prone than men to depression, from puberty onwards, with a specific exposure across the menopausal transition. However, controversy still exists in considering fluctuation/loss of estrogen as a specific aetiologic factor contributing to depression in perimenopause and beyond.

Aims

To briefly review the interaction between changes in menopausal hormone levels, mood disorders, associated neuropsychological co-morbidities and ageing, and to evaluate the currently available therapeutic options for perimenopausal mood disorders: (a) treatment of light to moderate mood disorders with hormonal therapy (HT); (b) treatment of major depression with antidepressants; (c) the synergistic effect between HT and antidepressants in treating menopausal depression.

Results

Depression across the menopause has a multifactorial aetiology. Predictive factors include: previous depressive episodes such as premenstrual syndrome and/or postpartum depression; co-morbidity with major menopausal symptoms, especially hot flashes, nocturnal sweating, insomnia; menopause not treated with HT; major existential stress; elevated body mass index; low socioeconomic level and ethnicity. Postmenopausal depression is more severe, has a more insidious course, is more resistant to conventional antidepressants in comparison with premenopausal women and has better outcomes when antidepressants are combined with HT.

Conclusion

The current evidence contributes to a re-reading of the relationship between menopause and depression. The combination of the antidepressant with HT seems to offer the best therapeutic potential in terms of efficacy, rapidity of improvement and consistency of remission in the follow-up.

Reproductive aging, sex steroids, and mood disorders

Epidemiologic studies have documented that the majority of women do not become depressed during the menopause transition. However, recent longitudinal studies suggest that in some women, the events related to the menopause transition could play a role in the onset of depression. In this article we review evidence suggesting a relationship between the menopause transition and depression. Additionally, we describe several findings that suggest a role of ovarian hormones in the onset of these depressions, including the clustering of episodes of depression during the stage of the menopause transition that is accompanied by estradiol withdrawal, and the therapeutic effects of short-term estradiol in depressed perimenopausal women. Finally, we discuss possible causes of affective disturbances during the menopause transition.

Depression during menopausal transition: a review of treatment strategies and pathophysiological correlates

It has long been recognized that women are at a higher risk than men to develop depression and that such risk is particularly associated with reproductive cycle events. Recent long-term, prospective studies have demonstrated that the transition to menopause is associated with higher risk for new onset and recurrent depression. A number of biological and environmental factors are independent predictors for depression in this population, including the presence of hot flushes, sleep disturbance, history of severe premenstrual syndrome or postpartum blues, ethnicity, history of stressful life events, past history of depression, body mass index, socioeconomic status and the use of hormones and antidepressants. Accumulated evidence suggests that ovarian hormones modulate serotonin and noradrenaline neurotransmission, a process that may be associated with underlying pathophysiological processes involved in the emergence of depressive symptoms during periods of hormonal fluctuation in biologically predisposed subpopulations. Transdermal estradiol and serotonergic and noradrenergic antidepressants are efficacious in the treatment of depression and vasomotor symptoms in symptomatic, midlife women. The identification of individuals whom might be at a higher risk for depression during menopausal transition could guide preventive strategies for this population.

Prevalence of depression and anxiety symptoms and their influence factors during menopausal transition and postmenopause in Beijing city

OBJECTIVE

To investigate the prevalence of depression and anxiety symptoms and their influence factors in women during menopausal transition and postmenopause.

METHODS

A cross-sectional investigation was conducted with a composed questionnaire on general conditions, social support scoring, the Zung self-evaluating depression and anxiety scoring. All of the parameters were input into a database and analyzed with t-test, chi(2) and logistic regression using SPSS.

RESULTS

A total of 1280 women aged 45-59 in Beijing city were interviewed with the questionnaire mentioned above. The prevalence of depression symptoms and anxiety in these women was 306 (23.9%) and 131 (10.2%), respectively. Risk factors associated with depression included strait financial status, social support, dyspareunia and dry vagina, hot flashes and sweating, satisfaction with family, children fail college or job and divorced or separated. Risk factors associated with anxiety included history of premenstrual dysphoric disorder (PMDD), hot flashes, vaginal dryness or dyspareunia and some negative life events.

CONCLUSIONS

Depression and anxiety were common symptoms in Chinese women during menopausal transition and postmenopause. Some psycho-social factors may play a role in the prevalence of them.

The unique challenges of managing depression in mid-life women

Throughout most of their lives, women are at a greater risk of becoming depressed than men. Some evidence suggests that this heightened risk is associated with increased sensitivity to the hormonal changes that occur across the female reproductive lifecycle. For some women, the peri-menopause and early post-menopausal years may constitute a "window of vulnerability" during which challenging physical and emotional discomforts could result in significant impairment in functioning and poorer quality of life. A number of biological and environmental factors are independent predictors for depression in this population, including the presence of hot flashes, sleep disturbance, history of severe premenstrual syndrome or postpartum blues, ethnicity, history of stressful live events, past history of depression, body mass index and socioeconomic status. This paper explores the current knowledge on the complex associations between mood changes and aging in women. More specifically, the biological aspects of reproductive aging and their impact on mood, psychosocial factors, lifestyle, and overall health are reviewed. In addition, evidence-based hormonal and non-hormonal therapies for the management of depression and other complaints in midlife women are discussed. Ultimately, this article should help clinicians and health professionals to address a challenging clinical scenario: a preventive and effective strategy for the management of depression in the context of the menopausal transition and beyond.

Bilateral oophorectomy and depressive symptoms 12 months after hysterectomy

OBJECTIVE

This study was performed to examine whether bilateral oophorectomy is related to depressive symptoms.

STUDY DESIGN

A secondary analysis of data collected from a cohort study of 1047 premenopausal women undergoing hysterectomy with or without concomitant oophorectomy for benign indications was performed. Data on depressive symptoms, based on the Profile of Mood States survey, were collected presurgically and 12 months postoperatively.

RESULTS

The effect of bilateral oophorectomy on postoperative depressive symptoms varied, depending on the presence of baseline depressive symptoms. Bilateral oophorectomy was associated with a decrease in risk of depressive symptoms in women without baseline depressive symptoms (risk ratio [RR] 0.36 [95% confidence interval (CI), 0.17, 0.78]) and did not change significantly in those with baseline depressive symptoms (RR 1.21 [95% CI, 0.73, 2.00]).

CONCLUSIONS

Bilateral oophorectomy, in comparison with unilateral or no oophorectomy, is associated with less risk of postoperative depressive symptoms in women without baseline depressive symptoms undergoing hysterectomy.

Menopause

Menopause is the time of life when menstrual cycles cease, and is caused by reduced secretion of the ovarian hormones oestrogen and progesterone. Although menopause is a normal event for women, individual experiences vary, and some women seek medical advice for the management of symptoms. Many symptoms have been attributed to menopause, but only vasomotor dysfunction and vaginal dryness are consistently associated with this time of life in epidemiological studies. Other common symptoms such as mood changes, sleep disturbances, urinary incontinence, cognitive changes, somatic complaints, sexual dysfunction, and reduced quality of life may be secondary to other symptoms, or related to other causes. Trials of therapies for vasomotor dysfunction have shown improvements with oestrogen, gabapentin, paroxetine, and clonidine, but little or no benefit with other agents; adverse effects of these treatments must also be considered. Many questions about menopausal transition and its effects on health have not been adequately addressed.

Neurobehavioral impact of menopause on mood

The menopausal transition is a time of risk for mood change ranging from distress to minor depression to major depressive disorder in a vulnerable subpopulation of women in the menopausal transition. Somatic symptoms have been implicated as a risk factor for mood problems, although these mood problems have also been shown to occur independently of somatic symptoms. Mood problems have been found to increase in those with a history of mood continuum disorders, but can also occur de novo as a consequence of the transition. Stress has been implicated in the etiology and the exacerbation of these mood problems. Estrogen and add-back testosterone have both been shown to positively affect mood and well-being. In most cases, the period of vulnerability to mood problems subsides when the woman's hormonal levels stabilize and she enters full menopause.

The impact of extroversion or menopause status on depressive symptoms among climacteric women in Taiwan

OBJECTIVE

The study was designed to test whether neuroticism moderated the effect of extroversion and mediated the impact of menopause status on depressive symptoms among women in Taiwan during their menopausal transition.

DESIGN

A sample of 197 women, aged 40 to 60 years, were recruited from the community. We used Ko's Depression Inventory, the Five-Factor Inventory-Chinese version, the Menopausal Symptoms Scale, and the Chinese version of the Modified Schedule of Affective Disorders and Schizophrenia-Lifetime to gather data. Moreover, each woman underwent a semistructured diagnostic interview in person to obtain her lifetime psychiatric history.

RESULTS

The hierarchy regression analyses showed that the interaction between neuroticism and extroversion was statistically significant. Further analyses indicated that in the high neuroticism group, extroversion was negatively associated with depressive symptoms; however, in the low neuroticism group, extroversion was not correlated with depressive symptoms. Menopause status was correlated with depressive symptoms, but after adding neuroticism and extroversion, the main effect of menopause status became insignificant. Results of the Sobel test showed that depressive symptoms of women during the menopause transition largely represented neuroticism.

CONCLUSIONS

The present study revealed that the lower levels of extroversion are associated with depression among all stages of menopausal women with high levels of neuroticism; moreover, all stages of menopausal women who have high levels of neuroticism are more vulnerable to depression. The results support that personality may play an important role in women's depression during the transition of menopausal status.

Attitudes toward menopause in HIV-infected and at-risk women

OBJECTIVE

To study attitudes toward menopause in women with or at risk of human immunodeficiency virus (HIV) aged 35 to 60 in New York City, NY, USA.

DESIGN

Data were obtained at the baseline interview in a cohort study of menopause. Of 502 participating women, 92 were postmenopausal and 162 were perimenopausal.

RESULTS

Overall, 37.5% of women had a relatively favorable attitude toward menopause. African Americans had a 72% greater odds of a positive attitude (OR = 1.72, 95% CI 1.16-2.57) than all other groups after adjusting for covariates. Hispanic women had the least favorable view of menopause. Experience of > 3 menopausal symptoms and negative life events-being a witness to a murder, and the death ofa child-were significantly associated with negative attitudes towards menopause (OR = 0.62, 95% CI 0.42-0.93 and OR = 0.64, 95% CI 0.43-0.93, respectively). Depressive symptoms, street drug use, and having a domestic partner, which is significant in single variable analyses, did not remain independent predictors in multivariate results. HIV status, menopause status, and age at interview were not associated with menopause attitudes.

CONCLUSIONS

HIV-infected, drug-using, low-income women showed generally unfavorable attitudes towards menopause. High stress life events coupled with a high prevalence of depressive symptoms indicate this population has special needs marked by the menopause transition into older age.

Escitalopram versus ethinyl estradiol and norethindrone acetate for symptomatic peri- and postmenopausal women: impact on depression, vasomotor symptoms, sleep, and quality of life

OBJECTIVE

To examine the efficacy and tolerability of escitalopram (ESCIT) compared to estrogen and progestogen therapy (EPT) for the treatment of symptomatic peri- and postmenopausal women.

DESIGN

Forty women (aged 40-60 years) with depressive disorders and menopause-related symptoms were randomly assigned to an 8-week open trial with ESCIT (flexible dose, 10-20 mg/day; fixed dose, 10 mg/day for the first 4 weeks) or estrogen plus progestogen therapy (ethinyl estradiol 5 microg/day plus norethindrone acetate 1 mg/day). Primary outcome measures included Montgomery-Asberg Depression Rating Scale and the Greene Climacteric Scale at week 8. Secondary outcome measures included the Clinical Global Impressions as well as sleep and quality of life assessments.

RESULTS

Thirty-two women (16 on EPT, 16 on ESCIT) were included in the analyses. Full remission of depression (score of <10 on the Montgomery-Asberg Depression Rating Scale) was observed in 75% (12/16) of subjects treated with ESCIT, compared to 25% (4/16) treated with EPT (P = 0.01, Fisher's exact tests). Remission of menopause-related symptoms (>50% decrease in Greene Climacteric Scale scores) was noted in 56% (9/16) of women treated with ESCIT compared to 31.2% (5/16) on EPT (P = 0.03, Pearson's chi2 tests). Improvement in sleep, hot flashes, and quality of life was observed with both treatments.

CONCLUSIONS

ESCIT is more efficacious than EPT for the treatment of depression and has a positive impact on other menopause-related symptoms. ESCIT may constitute a treatment option for symptomatic menopausal women who are unable or unwilling to use hormone therapy.

Hot flashes and estrogen therapy do not influence cognition in early menopausal women

OBJECTIVE

To examine how menopausal symptoms and estrogen therapy (ET)-induced symptom relief affect cognition in early menopause.

DESIGN

There were two components. Part 1 was a cross-sectional study of 37 healthy, recently postmenopausal women with diverse menopausal symptoms. Women were categorized as having low (n=20) or high symptoms (n=17) based on a validated symptom questionnaire. Women completed mood and sleep questionnaires and underwent cognitive testing, which included verbal memory, visual memory, emotional memory, and verbal fluency. Thirty-two of these women went on to part 2 of the study. Fourteen were randomly assigned to receive ET and 18 to receive placebo for 8 weeks. Before treatment and at 4 and 8 weeks, women completed the same measures as in part 1 of the study.

RESULTS

High symptom women had more negative mood (P=0.01) and lower quality sleep (P<0.001) than low symptom women. Despite suffering from more menopausal symptoms, worse mood, and poorer sleep, women in the high symptom group performed the same on cognitive testing as women in the low symptom group. Women receiving ET had greater improvements in menopausal symptoms and sleep compared with those receiving the placebo (P<or=0.05). ET did not improve mood compared with placebo. Women receiving ET did not have any improvement in cognitive performance compared with those receiving the placebo.

CONCLUSIONS

Menopausal symptoms do not impair cognition. ET does not improve cognition despite alleviating symptoms and improving sleep in recently naturally menopausal women with diverse menopausal symptoms.

Hormonal therapy and depression: are we overlooking an important therapeutic alternative?

OBJECTIVE

This review aimed to examine evidence for the role of hormonal changes in the onset and course of depressive symptomatology and to assess the possible future role of hormonal therapies in the treatment of depression.

METHODS

A Medline and PsycINFO search of the literature published between 1965 and 2006 was made of studies of depressive symptoms and hormonal treatment in women at all stages of reproductive life.

RESULTS

The cyclic fluctuation of gonadal steroids at menarche coincides with the beginning of gender-based differences in depression rates, which continue throughout reproductive life until menopause. Modifications in hormonal status, whether related to endogenous or exogenous exposure or to hormone deprivation, appear to be associated with affective disorder in a subgroup of women. For these women, a growing body of evidence indicates a biological pattern of vulnerability to mood disorders in response to hormonal fluctuations. This could have three major implications: that women vary in vulnerability to mood disorder when abrupt change in steroid levels occur, that these effects could be cumulative across the female life span, and that women do not arrive at menopause with equal risk of mood disorders or equal susceptibility to the effects of hormonal replacement therapy as has been assumed by current clinical research and practice.

CONCLUSION

While hormonal therapies could have positive effects in the treatment and prevention of depressive disorders, further research is required to differentiate hormone-responsive subgroups of women for whom specific hormonal treatments may be most beneficial. To this end, we suggest that a multifactorial model of cumulative vulnerability, which takes into account hormonal exposure throughout life, genetic vulnerability, and environmental factors, may provide better prediction of treatment response.

Perimenopause and depression: strength of association, causal mechanisms and treatment recommendations

Perimenopause represents a significant transition in a woman's life. The evidence to support an association between perimenopause and depression is mixed, yet recent prospective studies have provided stronger evidence to support such an association. Interpretation of study data are complicated by methodological issues, such as a lack of standard definition for perimenopause or depression, reducing comparability. A variety of causal factors, including psychological, genetic and physiological, have been implicated in depression during perimenopause, which lends weight to a multifactorial model. Physicians should consider initiating dialogue about menopause and symptom relief at age 40 and screening perimenopausal women for depressive symptoms. Selective serotonin reuptake inhibitors are a first line of treatment for depression, but hormone therapy could be considered for women experiencing menopausal symptoms unless there are contraindications. Future research should focus on establishing temporality and studying these potential relationships among women of different ethnicities.

Sleep disorders in women: clinical evidence and treatment strategies

Sleep disorders are more prevalent in women than in men. Sex hormones modulate sleep-wake behaviors and mood and may contribute to heightened risk across the life cycle of women. Sleep disorders may have a unique expression in women, emerging throughout their reproductive life cycle. These conditions require careful treatment strategy to manage medical, hormonal, and behavioral contributing factors to poor sleep efficiency and impaired quality of life. This review focuses on clinical evidence for sleep disorders in women and discusses existing evidence of risk factors and treatment options for insomnia and sleep-disordered breathing in women.

Medial frontal cortex perfusion abnormalities as evaluated by positron emission tomography in women with climacteric symptoms

OBJECTIVE

To identify functional changes in the brains of women with climacteric symptoms. Images of regional cerebral blood flow (rCBF) were compared statistically between women with and women without symptoms to identify changes in rCBF. Results may provide a better understanding of the neural basis of the symptoms, which are divided into three symptom clusters: vasomotor, psychological, and somatic.

DESIGN

The study participants consisted of 12 women with moderate to severe climacteric symptoms (age 47.5 +/- 5.9 years, mean +/- SD) and 7 women with no symptoms (control group; age 49.6 +/- 4.2 years, mean +/- SD). The study participants were patients at a menopause clinic, and the latter were healthy volunteer nurses and hospital staff. Climacteric symptoms were evaluated by an assessment of the severity of 17 symptoms immediately before positron emission tomography examination of rCBF. The symptoms had been used previously to generate the Kupperman Kohnenki Shogai Index, a modified Kupperman Menopausal Index adapted to Japanese women. rCBF was measured by positron emission tomography with the CO2 dynamic inhalation method.

RESULTS

Reductions in relative rCBF in the patient group were observed in the bilateral rectal gyrus and in the left subcallosal gyrus on a voxel-by-voxel basis as compared with the control group.

CONCLUSIONS

The present study revealed reductions in relative rCBF of the prefrontal cortex of Japanese women with moderate to severe climacteric symptoms. This area is close to that previously addressed in studies of familial bipolar depression and familial unipolar depression, although our participants did not satisfy criteria for depression. This reduction of rCBF may be related to the three climacteric symptom clusters, but further studies are needed for evaluation of its significance. Our results should stimulate investigations into the positron emission tomography rCBF change of these women as to the integration of multiple entities in climacteric symptoms.

Prevalência de transtornos depressivos e ansiosos em uma amostra ambulatorial brasileira de mulheres na menopausa

OBJETIVO: Determinar a prevalência dos transtornos depressivo-ansiosos entre mulheres atendidas em um ambulatório de menopausa. METODOLOGIA: Avaliamos, através da entrevista semi-estruturada Mini International Neuropsychiatric Interview, 86 mulheres que encontravam-se em tratamento no ambulatório de menopausa do Instituto de Ginecologia da Universidade Federal do Rio de Janeiro. RESULTADOS: A maioria das mulheres apresentava algum diagnóstico psiquiátrico (57%) sendo mais prevalentes o transtorno de ansiedade generalizada (34,9%) e a depressão maior (31,4%). O grupo com algum diagnóstico foi representado por mulheres mais jovens, casadas, com menor escolaridade e história familiar para transtornos psiquiátricos. CONCLUSÃO: Observamos uma grande prevalência de transtornos mentais entre mulheres em atendimento ambulatorial na menopausa em nosso estudo, em relação às mulheres em atendimento em outros ambulatórios segundo a literatura. Há também uma alta taxa de prevalência de comorbidades (55,5% dos pacientes com algum transtorno) complicadoras do transtorno primário, o que pode representar a evolução para pior prognóstico pela ausência de tratamento precoce e específico.

Depressão no climatério: indicadores biopsicossociais

OBJETIVO: Identificar a presença de sintomas depressivos em mulheres no climatério, analisando os indicadores biopsicossociais relacionados. MÉTODOS: Aplicaram-se o Questionário de Identificação e Contexto da Mulher no Climatério (ICMC) e o inventário de Beck a 30 mulheres em primeiro atendimento no Ambulatório Multidisciplinar do Climatério do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCRP/FMRP/USP). Os dados foram estatisticamente trabalhados por análise bivariada e multivariada. RESULTADOS: Observa-se que, de acordo com o inventário de Beck, foi identificada depressão em 14 das 30 mulheres atendidas no ambulatório no período de novembro de 2003 a dezembro de 2004. CONCLUSÃO: Os resultados mostraram que os sintomas depressivos estavam aumentados em mulheres na faixa dos 40 aos 49 anos, não-brancas, que tinham companheiro pertencente ao grupo biológico B ou C, que tinham problemas com o cônjuge, que vivenciaram hábito de beber, situação de óbito recentemente e/ou desemprego na família.

The association of perimenopausal mood disorders with other reproductive-related disorders

Data regarding the increased incidence of psychiatric illness during midlife in women are still conflicting. However, there is a growing consensus that certain groups of women may in fact be at higher risk for mood symptoms and psychiatric disorders during the perimenopausal transition. Mood symptoms during the perimenopause may be related to mood disorders during other periods of hormonal fluctuation throughout a woman's reproductive lifecycle. Elucidating these associations may advance the understanding of mood disorders during the perimenopausal transition. The epidemiology and treatment of perimenopausal mood symptoms compared with the epidemiology and treatment of mood disorders during the late luteal phase of the menstrual cycle, pregnancy, and postpartum. Common risk factors associated with mood disorders during these periods of hormonal changes or instability include poor lifestyle habits, a history of hormonally related mood disorders, stress and negative life events, ethnicity, and comorbidity. Reproductive-related mood disorders also are subject to an improvement in symptoms in response to treatment with selective serotonin reuptake inhibitors. As the morbidity associated with mood disorders during midlife may be quite significant, and as life expectancy continues to increase, recognition, prevention, and treatment of perimenopausal affective illness is becoming increasingly essential.

Citalopram and fluoxetine in the treatment of postmenopausal symptoms: a prospective, randomized, 9-month, placebo-controlled, double-blind study

OBJECTIVE

Nonhormonal treatment of postmenopausal symptoms is a subject of great interest today. The results of studies on selective serotonin reuptake inhibitors (SSRIs) are promising, but long-term results do not exist. The objective of this study was to evaluate the efficacy of citalopram and fluoxetine in the treatment of physical and psychological menopausal symptoms and their effects on psychosocial and sexual well being in symptomatic postmenopausal women.

DESIGN

One hundred fifty healthy women suffering from menopausal symptoms were recruited to this placebo-controlled double-blind study with a follow-up period of 9 months. They were randomized into three groups receiving placebo, fluoxetine, or citalopram. The initial dose was 10 mg of both fluoxetine and citalopram, and it was increased to 20 mg at 1 month and to 30 mg at the 6-month visit. The main outcome measures were hot flushes and Kupperman index. The RAND-36 Quality of Life questionnaire, Beck's Depression Scale, and the McCoy Female Sexuality Questionnaire were used at every control visit.

RESULTS

There were no statistically significant differences between the groups in respect to number of hot flushes, Kupperman index, or Beck's Depression Scale, although there was a tendency in all these parameters in favor of SSRIs versus placebo. Insomnia improved significantly in the citalopram group versus placebo. Discontinuation rates at nine months were 40% in the placebo group, 34% in the fluoxetine group and 34% in the citalopram group.

CONCLUSIONS

Compared with placebo, citalopram and fluoxetine have little effect on hot flushes and cannot therefore be recommended for the treatment of menopausal symptoms, if vasomotor symptoms are the main complaint. Whether the improvement of insomnia by means of citalopram affects the quality of sleep needs further investigation.

Acute consequences of the menopausal transition: the rise of common menopausal symptoms

More than 80% of women experience psychologic or physical symptoms in the late reproductive years, with varying degrees of severity and disruption in their lives. Patients and clinicians have misconceptions about what changes are considered "normal" or"abnormal" during this period. Of importance to clinicians, large-scale longitudinal studies recently have been conducted to better characterize and explore changes during this period. This article re-views the current evidence regarding the acute symptoms of the menopausal transition, including vasomotor symptoms, mood changes, sleep problems, and changes in sexual functioning.