Hormone Pellet Implantation for the Menopause and Premenstrual Syndrome

A guide to the treatment of depression in women by estrogens

Premenstrual depression, postnatal depression and climacteric depression are related to changes in ovarian hormone levels and can be effectively treated by hormones. It is unfortunate that psychiatrists have not accepted this form of treatment and this paper is an attempt to simplify this treatment, which should include transdermal estrogens, possibly testosterone and, if the woman has a uterus, also progestogen. A balance is often necessary between these three hormones. Transdermal estrogens in the appropriate dose will suppress ovulation and suppress the cyclical hormonal changes that produce premenstrual depression. Estrogens also have a mood-enhancing effect in postnatal depression and the depression in the transitional phase of the menopause. It is possible to add transdermal testosterone which will improve mood, energy and libido. The problem is the progestogen as these women are often progestogen-intolerant. Progestogen should be used in the lowest dose and for the shortest duration necessary to prevent endometrial hyperplasia or the return of premenstrual syndrome-type symptoms if the women are progestogen-intolerant. The use of estrogens for depression in these women does not exclude the use of antidepressants. Hormone-responsive depression cannot be diagnosed by measuring hormone levels but can only be diagnosed by a careful history relating depression to the menstrual cycle, pregnancies and the perimenopausal years. These appropriate questions should prevent the endocrine condition of premenstrual depression being misdiagnosed as bipolar disorder and the woman given inappropriate treatment.

Bioidentical Hormone Therapy: A Review of the Evidence

Bioidentical hormone therapy (BHT) uses bioidentical hormones (BHs), derivatives of plant extracts chemically modified to be structurally indistinguishable from human endogenous hormones. BHTs are available commercially or can be compounded into different dosages and for different routes of administration. Typically, compounded preparations of BHs may include estriol, estrone, estradiol, testosterone, micronized progesterone, and occasionally dehydroepiandrosterone (DHEA). It is generally accepted that estrogen-based hormone therapies share similar efficacies as well as risks. Many FDA-approved and regulated pharmaceutically manufactured and branded conventional hormone therapies (CHTs) employ BHs. Since the publication of the Women's Health Initiative (WHI) trial results publicizing an increased risk of stroke, venous thrombosis, and breast cancer and no beneficial effect on coronary heart disease (CHD), use of CHT has declined, and there has been increased interest in alternative approaches. This review of the literature related to compounded BHT and the practices of its advocates is to determine if sufficient scientific evidence supports claims of greater efficacy and safety and any additional risks and uncertainties not generally associated with CHTs. Compounded BHTs have been promoted by some as natural, safer, and in some cases more efficacious than conventional hormone therapies, but there is a dearth of scientific evidence to support these claims. Compounded BHTs lack well controlled studies examining route of administration, pharmacokinetics, safety, and a critical, science-based rationale for the mixture and ratios of bioidentical estrogens employed in many preparations. Many advocates of compounded BHTs customize prescriptions based on saliva tests or blood sera levels in direct contradiction to evidence-based guidelines, which support tailoring HT individually according to symptoms. Currently, scientific uncertainties associated with compounded BHTs make their use less preferable to that of CHTs, as CHTs have been and continue to be assessed by clinical trials regarding both benefits and risks and are indicated for use according to evidence-based guidelines.

Sex hormones and headache

A variety of evidence suggests a link between migraine and the female sex hormones. Women with migraine outnumber men by at least a 2:1 ratio and definite patterns of development and attacks are noted at menarche and throughout the period of menses, related to trimester of pregnancy, and again at menopause, although it may also regress. Hormonal replacement with estrogen can exacerbate migraine; oral contraceptives can change the character and frequency of migraine headache. This article will cover approaches to the therapy of hormone-related headaches associated with the menstrual cycle, menopause, and oral contraceptives.

Hormone implants and tachyphylaxis

The serum oestradiol levels of 1388 women treated with hormone implants at a menopause clinic were reviewed in 1988. Thirty-eight (3%) were found to be above 1750 pmol/l. Of these 38 women with supraphysiological oestradiol levels 23 had started therapy for menopausal symptoms and 15 for the premenstrual syndrome (PMS). Of the 23 women treated for menopausal symptoms 11 had a history of psychiatric referral for depression and nine had undergone a surgical menopause. Nine of the 15 women with PMS had a history of psychiatric referral for depressive symptoms. We conclude that the women who attain supraphysiological levels of oestradiol on implant therapy have a high frequency of psychopathology or surgical menopause and may require higher oestradiol levels for adequate control of symptoms.

The long-term effects of estradiol implant therapy for the treatment of premenstrual syndrome

Fifty patients receiving estradiol implants for long-term treatment of premenstrual syndrome were studied over 5.6 years (range 2-8 years). There was a continued beneficial response to treatment in all symptoms, varying between 74% for bloating and 96% for depression. Menstrual cycle control improved in 31 patients and periods were less painful in 30 patients. Cyclical progestogenic symptoms occurred in 58% of patients. These were partially relieved by alterations in dose, type and duration of progestogen treatment but in 7 patients the symptoms remained severe. Eight patients had a hysterectomy during treatment; 5 for continuing progestogenic symptoms, 1 for prolapse and 2 for prolonged menstrual bleeding despite adequate progestogen therapy. Attempts to reduce the dose of progestogen led to cystic hyperplasia in 4 patients. This was treated by hysterectomy in 2 patients and corrected with two 21-day courses of progestogen in the other 2. Uterine enlargement with a mean weight of 133 g (125-145 g) associated with myometrial hypertrophy occurred in all 8 hysterectomy patients. There were no complications form venous thrombosis, pulmonary embolus, breast disease or atypical endometrial hyperplasia.

Skeletal effects of oral oestrogen compared with subcutaneous oestrogen and testosterone in postmenopausal women

STUDY OBJECTIVE

To compare oral and implanted oestrogens for their effects in preventing postmenopausal osteoporosis.

DESIGN

Non-randomised cohort study of postmenopausal women treated with oral or depot oestrogens and postmenopausal controls.

SETTING

Gynaecological endocrine clinic in tertiary referral centre.

PATIENTS

Oral treatment group of 37 postmenopausal women (mean age 57.5 years, median 8.75 years from last menstrual period), compared with 41 women given oestrogen implants (mean age 56.2 years, median 9.5 years from last menstrual period) and 36 controls (mean age 51.8 years, median 2.0 years from last menstrual period). Weight was not significantly different among the groups.

INTERVENTIONS

Oral treatment group was given continuous treatment with cyclic oestrogen and progesterone preparations (Prempak C or Cycloprogynova) for a median of 8.0 years. Implant group was given subcutaneous implants of oestradiol 50 mg combined with testosterone 100 mg, on average six monthly for a median of 8.5 years. Controls were not treated.

END POINT

Significant increase in bone density.

MEASUREMENTS AND MAIN RESULTS

Bone density measured by dual beam photon absorptiometry was 1.02 (SD 0.13) g hydroxyapatite/cm2 in implant group versus 0.89 (0.11) in oral group (p less than 0.01) and 0.87 (0.14) in controls (p less than 0.01). Serum oestradiol concentration in implant group was (median) 725 pmol/l versus 170 pmol/l in oral group (p less than 0.01) and 99 pmol/l in controls (p less than 0.01). Serum follicular stimulating hormone was median 1 IU/l (range 1-11) in implant group (equivalent to premenopausal values) versus 43 (4-94) IU/l in oral group (p less than 0.01) and 72 (28-99) IU/l in controls (p less than 0.01).

CONCLUSIONS

Subcutaneous oestrogen is more effective than oral oestrogen in preventing osteoporosis, probably owing to the more physiological (premenopausal) serum oestradiol concentrations achieved. It also avoids problems of compliance that occur with oral treatment.