Premenstrual Syndrome as a Predictor of Menopausal Symptoms

The intersection between menopause and depression: overview of research using animal models

Menopausal women may experience symptoms of depression, sometimes even progressing clinical depression requiring treatment to improve quality of life. While varying levels of estrogen in perimenopause may contribute to an increased biological vulnerability to mood disturbances, the effectiveness of estrogen replacement therapy (ERT) in the relief of depressive symptoms remains controversial. Menopausal depression has a complex, multifactorial etiology, that has limited the identification of optimal treatment strategies for the management of this psychiatric complaint. Nevertheless, clinical evidence increasingly supports the notion that estrogen exerts neuroprotective effects on brain structures related to mood regulation. Indeed, research using preclinical animal models continues to improve our understanding of menopause and the effectiveness of ERT and other substances at treating depression-like behaviors. However, questions regarding the efficacy of ERT in perimenopause have been raised. These questions may be answered by further investigation using specific animal models of reduced ovarian function. This review compares and discusses the advantages and pitfalls of different models emulating the menopausal stages and their relationship with the onset of depressive-like signs, as well as the efficacy and mechanisms of conventional and novel ERTs in treating depressive-like behavior. Ovariectomized young rats, middle-to-old aged intact rats, and females treated with reprotoxics have all been used as models of menopause, with stages ranging from surgical menopause to perimenopause. Additionally, this manuscript discusses the impact of organistic and therapeutic variables that may improve or reduce the antidepressant response of females to ERT. Findings from these models have revealed the complexity of the dynamic changes occurring in brain function during menopausal transition, reinforcing the idea that the best approach is timely intervention considering the opportunity window, in addition to the careful selection of treatment according to the presence or absence of reproductive tissue. Additionally, data from animal models has yielded evidence to support new promising estrogens that could be considered as ERTs with antidepressant properties and actions in endocrine situations in which traditional ERTs are not effective.

[Premenstrual syndrome and premenstrual dysphoric disorder-Overview on pathophysiology, diagnostics and treatment]

Premenstrual syndrome and premenstrual dysphoric disorder become episodically manifest during the second half of the female menstrual cycle and are characterized by psychological and physical symptoms causing relevant functional and social impairments. Mood swings, depression and dysphoria are associated depressive symptoms. Therefore, affective disorders should be considered as a differential diagnosis. Of women in reproductive age 3-8% suffer from premenstrual syndrome and 2% of women are affected by premenstrual dysphoric disorder. Genetic and sociobiographical risk factors are discussed. Furthermore, genetic polymorphisms of specific hormone receptors are considered to be genetic risk factors. From a pathophysiological perspective premenstrual syndrome and premenstrual dysphoric disorder are caused by a complex interaction between cyclic changes of ovarian steroids and central neurotransmitters. An imbalance of estrogen and progesterone in the luteal phase is believed to cause the symptoms. Therefore, the first treatment approach consists of regulation of the menstrual cycle or luteal support with progesterone or synthetic progestins even if their effectiveness has not yet been proven in randomized controlled studies and meta-analyses. The administration of combined oral contraceptives is also an option. Especially treatment with selective serotonin reuptake inhibitors (SSRI) represent an evidence-based approach. In severe cases the administration of gonadotropin releasing hormone (GnRH) agonists with add back treatment can also be considered. In the field of affective disorders premenstrual syndromes represent clinically relevant differential diagnoses and comorbidities, which confront the treating physician with particular clinical challenges. Therefore, this literature review gives the readership a clinical orientation for dealing with these disorders.

Obstetric and psychiatric history as predictors for psychosomatic symptoms among Korean perimenopausal women

OBJECTIVES

Menopause presents various physical and psychological disturbances for women and comes at a high financial cost. Therefore, this study aimed to identify factors influencing menopause symptoms.

STUDY DESIGN

Data of Korean perimenopausal women aged 40-60 (n = 1060; mean age, 46.03 ± 4.08) were collected by a research company. Participants were classified into a "functional" group (n = 716) or a "dysfunctional" group (n = 344) according to the severity of their perimenopausal psychosomatic symptoms. To investigate the association of obstetric and psychiatric history with membership of the "dysfunctional" group, a hierarchical logistic regression analysis was conducted.

RESULTS

The outcomes of all three hierarchical logistic regression models presented significant overall model fit. Among the independent variables, family history of menopausal symptoms, menarcheal age, number of pregnancies, history of postpartum depression, postpartum psychosis, and other psychiatric disorders were positively associated with being in the "dysfunctional" group, whereas age and number of deliveries were negatively associated with being in the "dysfunctional" group.

CONCLUSION

A short reproductive period and short exposure to estrogen due to late menarche and early menopausal transition may be related to severe perimenopausal symptoms. The relationship between the history of postpartum mental illness and severe perimenopausal symptoms may be associated with heightened sensitivity to hormonal triggers when a woman is exposed to fluctuating ovarian sex steroid levels. The relationship between parity or gravidity and the severity of menopausal symptoms in Korean women differed from that in studies conducted in other countries, possibly due to the low birth rate in Korea.

Characterization of pathogenic factors for premenstrual dysphoric disorder using machine learning algorithms in rats

We established a methodology using machine learning algorithms for determining the pathogenic factors for premenstrual dysphoric disorder (PMDD). PMDD is a disease characterized by emotional and physical symptoms that occurs before menstruation in women of childbearing age. Owing to the diverse manifestations and various pathogenic factors associated with this disease, the diagnosis of PMDD is time-consuming and challenging. In the present study, we aimed to establish a methodology for diagnosing PMDD. Using an unsupervised machine-learning algorithm, we divided pseudopregnant rats into three clusters (C1 to C3), depending on the level of anxiety- and depression-like behaviors. From the results of RNA-seq and subsequent qPCR of the hippocampus in each cluster, we identified 17 key genes for building a PMDD diagnostic model using our original two-step feature selection with supervised machine learning. By inputting the expression levels of these 17 genes into the machine learning classifier, the PMDD symptoms of another group of rats were successfully classified as C1-C3 with an accuracy of 96%, corresponding to the classification by behavior. The present methodology would be applicable for the clinical diagnosis of PMDD using blood samples instead of samples from the hippocampus in the future.

Premenstrual Disorders, Timing of Menopause, and Severity of Vasomotor Symptoms

Importance

Although premenstrual disorders (PMDs) end at menopause, it is unclear whether they are associated with the timing and symptom severity of menopause.

Objective

To prospectively examine whether women with PMDs have increased risks of early menopause and menopause-related vasomotor symptoms (VMS).

Design, Setting, and Participants

This population-based cohort study was nested in the Nurses' Health Study II (data collected from questionnaire sent between June 1991 and June 2017). Analysis of menopause timing included participants who did not have natural or surgical menopause before study entry, while the analysis of VMS was restricted to women who provided information on VMS. Data were analyzed from August 2022 to March 2023.

Exposures

PMDs were identified by self-reported diagnosis and confirmed with symptom questionnaires from 1991 to 2005. Participants were age-matched to women without PMD diagnoses and confirmed absence of or minimal premenstrual symptoms.

Main Outcomes and Measures

During follow-up through 2017, timing of natural menopause was assessed biennially, and VMS were assessed in 2009, 2013, and 2017. The association of PMDs with early menopause was assessed by Cox proportional hazards models and with VMS by logistic regression models.

Results

Of 1220 included women with PMDs, the median (IQR) age was 40.7 (37.3-43.8) years; of 2415 included women without PMDs, the median (IQR) age was 41.7 (38.3-44.8) years. The median (IQR) follow-up in this study was 20.3 (17.8-22-2) years. Early natural menopause (menopause before age 45 years) was reported by 17 women with PMDs (7.1 per 1000 person-years) and 12 women without PMDs (2.7 per 1000 person-years; adjusted hazard ratio, 2.67; 95% CI, 1.27-5.59). In addition, 795 women with PMDs (68.3%) and 1313 women without PMDs (55.3%) reported moderate or severe VMS (adjusted odds ratio, 1.68; 95% CI, 1.32-2.14). There was no observed association between PMDs and mild VMS (adjusted odds ratio, 0.99; 95% CI, 0.76-1.28).

Conclusions and Relevance

In this cohort study of US women, PMDs were associated with increased risks of early menopause and moderate or severe VMS. PMDs may be indicative of underlying physiology linked to early menopause and VMS, suggesting a phenotype observable during the reproductive years that may allow clinicians to target women at risk of earlier menopause and subsequent health risks later in the life course.

Trauma and female reproductive health across the lifecourse: motivating a research agenda for the future of women's health

The aetiology behind many female reproductive disorders is poorly studied and incompletely understood despite the prevalence of such conditions and substantial burden they impose on women's lives. In light of evidence demonstrating a higher incidence of trauma exposure in women with many such disorders, we present a set of interlinked working hypotheses proposing relationships between traumatic events and reproductive and mental health that can define a research agenda to better understand reproductive outcomes from a trauma-informed perspective across the lifecourse. Additionally, we note the potential for racism to act as a traumatic experience, highlight the importance of considering the interaction between mental and reproductive health concerns, and propose several neuroendocrinological mechanisms by which traumatic experiences might increase the risk of adverse health outcomes in these domains. Finally, we emphasize the need for future primary research investigating the proposed pathways between traumatic experiences and adverse female reproductive outcomes.

The role of ovarian hormones in the pathophysiology of perimenopausal sleep disturbances: A systematic review

Sleep disturbance is a common clinical concern throughout the menopausal transition. However, the pathophysiology and causes of these sleep disturbances remain poorly understood, making it challenging to provide appropriate therapy. Our goal was to i) review the literature about the influence of ovarian hormones on sleep in perimenopausal women, ii) summarize the potential underlying pathophysiology of menopausal sleep disturbances and iii) evaluate the implications of these findings for the therapeutic approach to sleep disturbances in the context of menopause. A systematic literature search using the databases Embase, MEDLINE and Cochrane Library was conducted. Keywords relating to ovarian hormones, sleep disturbances and menopause were used. Ultimately, 86 studies were included. Study Quality Assessment Tools of the National Institutes of Health were used for quality assessment. Results from good-quality studies demonstrated that the postmenopausal decline in estrogen and progesterone contributes to sleep disturbances in women and that timely treatment with estrogen and/or progesterone therapy improved overall sleep quality. Direct and indirect effects of both hormones acting in the central nervous system and periphery, as well as via secondary effects (e.g. reduction in vasomotor symptoms), can contribute to improvements in sleep. To strengthen external validity, studies examining neurobiological pathways are needed.

Menstrual cycle phase, menopausal transition stage, self-reports of premenstrual syndrome and symptom severity: observations from the Seattle Midlife Women's Health Study

OBJECTIVE

The aim of this study was to determine the effects of menstrual cycle phases (postmenses and premenses), self-report of premenstrual syndrome (PMS), late reproductive stages (LRS1 and LRS2), and early menopausal transition (EMT) stage (Stages of Reproductive Aging Workshop [STRAW]) on severity of five symptom groups.

METHODS

A subset of Seattle Midlife Women's Health Study participants (n = 290) in either LRS1 or LRS2 or EMT (STRAW+10 criteria) provided daily symptom data for at least one full menstrual cycle during the first year of the study and reported current PMS. Symptom severity was rated (1-4, least to most severe) in the daily diary for five symptom groups (dysphoric mood, neuromuscular, somatic, vasomotor, and insomnia) identified earlier with the same sample ( Maturitas 1996;25:1-10). A three-way analysis of variance was used to test for within- and between-participants effects on symptom severity.

RESULTS

Stage had no effect on severity for any of the five symptom groups. Dysphoric mood and neuromuscular and somatic symptom severity (but not vasomotor or insomnia severity) differed significantly across menstrual cycle phases, increasing from postmenses to premenses. Current PMS and premenses cycle phase had significant interactive effects on dysphoric mood and neuromuscular symptoms, but there were no significant interaction effects on somatic, vasomotor, or insomnia symptom severity.

CONCLUSIONS

Dysphoric mood, neuromuscular, and somatic symptoms exhibit cyclicity and are influenced by current PMS. Late reproductive stages and EMT stage do not have significant effects on the five symptom groups. Vasomotor or insomnia symptoms do not exhibit significant cyclicity from postmenses to premenses and are not affected by current PMS. Future studies of symptom cyclicity and reproductive aging including daily symptom data across an entire menstrual cycle in samples including women in late menopausal transition stage are essential to capture the effects of both cyclicity and self-reported PMS to capture symptom severity reports at their peak.

Premenstrual symptoms across the lifespan in an international sample: data from a mobile application

Premenstrual symptoms, including physical and mood symptoms, affect a large proportion of women worldwide. Data on premenstrual symptoms across nations and age groups is limited. In the present study, we leveraged a large international dataset to explore patterns in premenstrual symptom frequency with age. A survey was administered to users of the Flo mobile application (app), aged 18 to 55. The survey queried app users about a range of premenstrual symptoms. Respondents were asked whether they experienced each symptom every menstrual cycle, some cycles, or never. Age was also captured and categorized as 18-27, 28-37, 38-47, 48-55. Data was summarized and Pearson's chi square test for count data assessed differences in symptom frequency by age group. A sample of 238,114 app users from 140 countries responded to the survey. The most common symptoms reported were food cravings (85.28%), mood swings or anxiety (64.18%), and fatigue (57.3%). Absentmindedness, low libido, sleep changes, gastrointestinal symptoms, weight gain, headaches, sweating or hot flashes, fatigue, hair changes, rashes, and swelling were significantly more frequent with increasing age (p's < 0.001). Mood swings and anxiety did not vary by age group. Of the respondents, 28.61% reported that premenstrual symptoms interfered with their everyday life each menstrual cycle. In a large international sample, the majority of women reported premenstrual food cravings, mood changes, and fatigue every menstrual cycle. Mood symptoms did not vary by age group, suggesting that premenstrual mood changes are a persistent issue among women of reproductive age.

Mindfulness Training Intervention With the Persian Version of the Mindfulness Training Mobile App for Premenstrual Syndrome: A Randomized Controlled Trial

Premenstrual syndrome (PMS) is a common problem for women of reproductive age, affecting various aspects of their lives. While various in-person psychotherapeutic interventions, including Mindfulness therapy, have yielded promising results in reducing PMS symptoms, due to the COVID-19 Pandemic, psychotherapists are providing their services via online methods. Therefore, the present study is the first one worldwide to examine whether smartphone-based Mindfulness training can reduce symptoms of PMS and improve the quality of life in women with PMS. We recruited 80 Iranian women (aged 25-45) with PMS through online advertising who were randomly allocated into two groups of 40. The intervention group underwent two online introductory group sessions followed by 8 weeks of Mindfulness practice, while the control group received no intervention. Before and after the intervention, participants completed the 12-Item Short-Form Health Survey and the Premenstrual Symptoms Screening (PSST) questionnaires. Data were analyzed using the Analysis of Covariance (ANCOVA). Following the intervention, the mean scores of PMS symptoms were significantly lower in the intervention group than in the control group (p < 0.001; η² = 0.18). Likewise, the quality of life score was significantly higher in the intervention group (p < 0.001; η² = 0.14). Our results indicated that the smartphone-based Mindfulness training intervention could be an effective treatment modality for women with PMS symptoms, especially during the COVID-19 Pandemic, which has posed limitations for in-person therapies.

CLINICAL TRIAL REGISTRATION

https://fa.irct.ir/trial/59924, identifier: IRCT20180607040000N2.

The role of estradiol fluctuation in the pathophysiology of perimenopausal depression: A hypothesis paper

The menopause transition, which constitutes the five or so years surrounding the final menstrual period, has been established as a time of increased risk for depressive symptoms. While mounting research suggests that exposure to more extreme and fluctuating levels of estradiol (E2) plays a role, it remains unclear which specific trigger is most strongly implicated in the development of depressive mood: acute E2 withdrawal or extreme increases in E2. The current review summarises the literature supporting the role of each, considering research pertaining to perimenopausal depression as well as other reproductive mood disorders in which ovarian hormone change is believed to play a key role, namely premenstrual dysphoric disorder and postpartum depression. Taking together the available research pertaining to the various reproductive mood disorders, we propose that women may exhibit one of four E2 sensitivity profiles, each of which may have important implications for the expected timing and severity of depressive mood during the menopause transition: the E2-increase sensitive profile, developing depressive mood in response to elevations in E2, the E2-decrease sensitive profile, for whom E2 withdrawal triggers negative mood, the E2-change sensitive profile, characterised by mood sensitivity to E2 change in either direction, and the E2 insensitive profile for whom changes in E2 have negligible psychological effects. The evidence supporting the existence of such profiles are summarised, potential biological mechanisms are briefly highlighted, and implications for future research are discussed.

Premenstrual Mood Symptoms in the Perimenopause

PURPOSE OF REVIEW

This review considers how reproductive aging may impact the trajectory of menstrually related mood disorders (MRMDs) such as premenstrual dysphoric disorder and considers how the treatment of MRMDs might require adjustment as patients approach midlife.

RECENT FINDINGS

The early menopause transition is accompanied by important hormonal changes that may exacerbate existing MRMDs. Indeed, recent research confirms that an important subset of women experiences depressive mood in response to perimenopausal elevations in ovarian hormones. In addition, a subset of women with an MRMD may exhibit an increased mood sensitivity to the ovarian hormone withdrawal that accompanies the late menopause transition and early postmenopausal phase. Though additional research is needed to clarify the trajectory of premenstrual dysphoria in the menopause transition, there is reason to believe that health care providers should be vigilant for a potential worsening of symptoms in perimenopause for women with past or current premenstrual dysphoric disorder.

Steroid stress hormone changes throughout the menstrual cycle: A rise in evening aldosterone concentration in early luteal phase precedes the symptoms of premenstrual syndrome

There is still a lack of consistent evidence on dysregulation of steroid stress hormones cortisol and aldosterone in premenstrual syndrome (PMS). We aimed to test the hypothesis that, in healthy women, salivary aldosterone concentrations are higher in those with PMS compared to controls, particularly during the luteal phase of the menstrual cycle. In total, 99 female subjects (49 women with and 50 women without PMS) participated in a prospective non-interventional case-control study. Saliva sampling was performed in the follicular (day 8), early luteal (day 20) and late luteal phase (2 days before expected onset of bleeding) of the menstrual cycle in the morning and the evening. The results confirmed the hypothesis that salivary aldosterone concentrations are higher in women with PMS during the early luteal phase compared to controls (p < .01) in the evening. Early luteal phase aldosterone concentrations positively correlated with the frequency of premenstrual symptoms. Women with PMS exhibited a flatter morning to evening aldosterone slope compared to controls (p < .05). Morning and evening salivary cortisol concentrations were unchanged throughout the menstrual cycle in both groups of women. In conclusion, evening salivary aldosterone, but not cortisol concentrations, are increased in women with PMS during the early luteal phase compared to controls. Cortisol does not appear to be involved in the mechanisms contributing to the course of PMS. High evening salivary aldosterone in the early luteal phase may represent an important risk factor and could be of predictive value for the occurrence of premenstrual symptoms.

Development of an Assessment Tool of Menstrual-Cycle-Related Signs and Symptoms Based on Thai Traditional Medicine Principles for Evaluation of Women's Health

Background

Utilization of Thai traditional medicine (TTM) was considered in menstrual-cycle-related signs and symptoms (MCSs) to evaluate women's health. TTM clinicians diagnosed the MCSs by signs, symptoms, and associated factors of patients including a physical examination to find patterns of imbalance elements and the origin of the disorder to optimize treatment. Thus, the purpose of this study was to develop a new assessment tool, the menstrual-cycle-related signs and symptoms questionnaire (MCSQ) based on TTM principles for evaluation of women's menstrual health.

Methods

The items and components of the MCSQ were adjusted by TTM expert consensus using the Delphi technique. The content validity of the MCSQ was quantified by the content validity index (CVI). MCSQ were examined by construct validity and internal consistency reliability using exploratory factor analysis (EFA) and Cronbach's α coefficient, respectively.

Results

: All 19 experts (100%) responded to the questionnaires in the three rounds of the Delphi technique. The MCSQ showed high content validity of individual items (I-CVI = 0.83-1.00) and high overall content validity of the questionnaire (S-CVI/AVE = 0.98). Overall, 429 of 432 participants completed the questionnaire (99.31%). After factor analysis, the final MCSQ was divided into two sections, which consisted of 49 items. The first had 23 items focusing on the MCSs. And, the second had 14 items of personal and medical data including 12 items of associated factors. Cronbach's α coefficient of the final MCSQ was 0.87, and that of each component was between 0.32 and 0.82.

Conclusions

This study reports a new MCS questionnaire tool, which was developed from TTM knowledge to evaluate women's health. This questionnaire showed an acceptable level of validity and reliability. Thus, it is also expected to be useful in clinical practice and ongoing research on evaluation of women's health.

Exploring the Relationship between Depression on Menopausal Symptoms and Personality Trails

The aim of the present study was to explore the potential relationships between menopausal symptoms, sleep quality, hot flash, and depressive symptoms in postmenopausal women. A cross-sectional study was designed with 150 healthy postmenopausal women (45-60 years of age) who had referred to the menopausal clinic in Babol. The participants completed the following instruments throughout the study: the Beck Depression Inventory for depressive symptoms, the Modified Blatt-Kupperman Menopausal Index for measuring menopausal symptoms, and the NEO-FFI for identifying the personality traits. After controlling all the covariates, high depressive symptoms were found to be associated with moderate/sever menopausal symptoms, poor sleep quality, and the average and high level of neuroticism. The results also demonstrated that the risk of depressive symptoms was lower in menopausal women with high level extroversion, high level agreeableness, and the average and high level of conscientiousness. The findings of the present study indicated that personality traits, menopausal symptoms, and poor sleep quality in particular can partially account for depression in Iranian menopausal women. It is highly imperative that effective health education or implement appropriate strategies to improve the quality of life for these women.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility.

METHODS

Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg²⁰²⁰) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care.

CONCLUSION

The MDcpg²⁰²⁰ builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.

Clinical Characteristics of PMS Co-Morbid with MDD and Effectiveness of SSRIs in its Treatment

Background: Data on the clinical characteristics of premenstrual syndrome (PMS) with co-morbid major depressive disorder (MDD) are scarce. Although selective serotonin re-uptake inhibitors (SSRIs) are widely used to treat both PMS and MDD there is little information on their efficacy in PMS in patients with co-morbid MDD.

Objective: To describe the clinical picture of PMS co-morbid with current depressive episode (DE) and evaluate its dynamics under a 6-month course of SSRIs treatment.

Materials and methods: We present a longitudinal observational study, conducted in out- and inpatient conditions. Thirty-one women eligible to antidepressant treatment for a current DE in the course of MDD were evaluated for PMS and those of them suffering from both conditions were re-evaluated twice during a 6-month medication intake period.

Results: The pre-treatment clinical picture of PMS co-morbid with MDD was dominated by moderately to severely expressed mood swings, anxiety, fatigue, breast tenderness, palpitations, abdominal bloating, and headache. After six months of SSRIs intake the syndrome was characterised by nearly the same symptoms (with the addition of irritability and appetite changes) but mildly expressed.

Conclusion: Untreated PMS co-morbid with MDD is characterised by mainly moderately severe psychological and around three times less commonly – somatic symptoms. SSRIs treatment alleviate both symptom types at month three and even further, although less pronouncedly at month six.

Symptoms assessed in studies on perimenopausal depression: A narrative review

The menopausal transition constitutes a phase of major biopsychosocial changes associated with an elevated risk for the development of depression. Perimenopausal depression is highly prevalent and usually characterized by core symptoms of a major depressive disorder combined with menopausal complaints such as vasomotor symptoms or other physical complaints. However, a distinct definition of the condition is lacking. The aim of this review is to portray the symptoms assessed in studies on perimenopausal depression in order to provide relevant information on the current understanding of this condition. A literature search was conducted using the databases PubMed, Cochrane Library, and PsycINFO. A total of 37 studies were included. Various assessment tools have been used to measure symptoms related to perimenopausal depression. Fifteen symptoms were identified. Depressed mood was assessed across all studies. Low energy or sleep disturbances, as acknowledged symptoms of a major depressive disorder, were surveyed in most studies. However, the assessment of menopausal complaints was rather heterogeneous. While vasomotor symptoms were often measured, other menopausal symptoms such as mood swings or pain were investigated less frequently. Sexual problems were only rarely assessed. Studies on perimenopausal depression regularly include the assessment of core symptoms of a major depressive disorder, but the assessment of menopausal complaints is inconsistent. While certain symptoms are commonly measured, others are not assessed. Such inconsistencies underline an ambiguous understanding of perimenopausal depression, which in turn affects the evaluation and treatment of the condition. Thus, the use of the existing guidelines on perimenopausal depression is recommended.

Pharmacological sex hormone manipulation as a risk model for depression

Sex hormone transition may trigger severe depressive episodes in some women. In order to map mechanisms related to such phenomena we developed a pharmacological preclinical human model using sex hormone manipulation with gonadotropin releasing hormone agonist (GnRHa) in a placebo‐controlled design. Here the findings from this model is synthesized and discussed in the context of related literature on hormonal contributions to reproductive mental health disorders. The GnRha model work points to an estradiol‐dependent depressive response in healthy women undergoing short‐term sex hormone manipulation with GnRHa, which is linked to serotonin transporter changes (a key regulator of synaptic serotonin), a disengagement of hippocampus, and overengagement of brain networks recruited when processing emotional salient information. Further, the GnRHa model suggest that key brain regions in the reward circuit are less engaged in positive stimuli when undergoing sex hormone manipulation, which may underlie anhedonia. Also, the work supports that enhanced sensitivity to estrogen signaling at the level of gene expression may drive increased risk for depressive symptoms when exposed to sex steroid hormone fluctuations. In conclusion, the GnRHa model work highlights the brain signatures of rapid and profound changes in sex steroid hormone milieu, which reflect plausible mechanisms by which risk for mood disorders works. This model points to the role of estrogen dynamics and sensitivity, and offers a rationale for personalized prevention in hormonal transition phases, for example pregnancy to postpartum transition, perimenopause, and hormone treatments, which now can move into clinical translation and ideally pave the way for protecting mental and cognitive health.

Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations

There is a new appreciation of the perimenopause - defined as the early and late menopause transition stages as well as the early postmenopause - as a window of vulnerability for the development of both depressive symptoms and major depressive episodes. However, clinical recommendations on how to identify, characterize and treat clinical depression are lacking. To address this gap, an expert panel was convened to systematically review the published literature and develop guidelines on the evaluation and management of perimenopausal depression. The areas addressed included: 1) epidemiology; 2) clinical presentation; 3) therapeutic effects of antidepressants; 4) effects of hormone therapy; and 5) efficacy of other therapies (eg, psychotherapy, exercise, and natural health products). Overall, evidence generally suggests that most midlife women who experience a major depressive episode during the perimenopause have experienced a prior episode of depression. Midlife depression presents with classic depressive symptoms commonly in combination with menopause symptoms (ie, vasomotor symptoms, sleep disturbance), and psychosocial challenges. Menopause symptoms complicate, co-occur, and overlap with the presentation of depression. Diagnosis involves identification of menopausal stage, assessment of co-occurring psychiatric and menopause symptoms, appreciation of the psychosocial factors common in midlife, differential diagnoses, and the use of validated screening instruments. Proven therapeutic options for depression (ie, antidepressants, psychotherapy) are the front-line treatments for perimenopausal depression. Although estrogen therapy is not approved to treat perimenopausal depression, there is evidence that it has antidepressant effects in perimenopausal women, particularly those with concomitant vasomotor symptoms. Data on estrogen plus progestin are sparse and inconclusive.

SLCO1B1 genetic variation and hormone therapy in menopausal women

Objective:

Response to menopausal hormone therapy (MHT) shows individual variation. SLCO1B1 encodes the OATP1B1 transporter expressed in the liver that transports many endogenous substances, including estrone sulfate, from the blood into hepatocytes. This study evaluated the relationship between genetic variation in SLCO1B1 and response to MHT in women enrolled in the Kronos Early Estrogen Prevention Study (KEEPS) at Mayo Clinic, Rochester, MN.

Methods:

KEEPS participants were randomized to oral conjugated equine estrogen (n = 33, oCEE), transdermal 17β-estradiol (n = 33, tE₂), or placebo (n = 34) for 48 months. Menopausal symptoms (hot flashes, night sweats, insomnia, palpitations) were self-reported before treatment and at 48 months. Estrone (E₁), E₂, and sulfated conjugates (E₁S, E₂S) were measured using high-performance liquid chromatography-tandem mass spectrometry. SLCO1B1 rs4149056 (c.521T>C, p.Val174Ala) was genotyped using a TaqMan assay.

Results:

After adjusting for treatment, there was a significant association between the SLCO1B1 rs4149056 TT genotype (encoding normal function transporter) and lower E₁S, E₁S/E₁, and E₂S (P = 0.032, 0.010, and 0.008, respectively) compared with women who were heterozygous (TC) or homozygous (CC) for the reduced function allele. The interactions between genotype, treatment, and E₂S concentration were stronger in women assigned to tE₂ (P = 0.013) than the women taking oCEE (P = 0.056). Among women assigned to active treatment, women with the CT genotype showed a significantly greater decrease in night sweats (P = 0.041) than those with the TT genotype.

Conclusions:

Individual variation in sulfated estrogens is explained, in part, by genetic variation in SLCO1B1. Bioavailability of sulfated estrogens may contribute to relief of night sweats.

Assessment of perimenopausal depression: A review

BACKGROUND

Within the female life cycle, the perimenopause is considered as a critical period for the development of depression. Prevalence rates are particularly high during this phase. Perimenopausal depression is characterized by affective symptoms as well as menopause-specific somatic complaints. Currently, a variety of questionnaires are used to assess mood during the perimenopause. The aim of this review is to determine the instruments employed to assess perimenopausal depression.

METHODS

We searched the databases PubMed, Cochrane Library and PsycINFO for human studies investigating perimenopausal depression, and subsequently screened for the assessment instruments used to measure mood and menopause. A total of 37 articles were included.

RESULTS

Altogether, 14 different instruments were applied to assess mood during menopause. The CES-D was by far the most frequently used depression scale, appearing in 16 out of the 37 studies. The methods used to identify perimenopausal status and symptoms were inconsistent.

LIMITATIONS

Due to lacking information about data and methodology, a selection bias is conceivable. Additionally, a publication bias is possible. Finally, there is inevitable subjectivity in the screening process of a systematic search.

CONCLUSIONS

The assessment of depression in the menopausal transition is highly heterogeneous, reducing the overall comparability of study results. Furthermore, menopausal complaints are not sufficiently taken into account. Accordingly, the use of a menopause-specific depression scale is highly recommended in order to account for physical and mood-related symptoms in the menopausal transition.

The bidirectional relationship between vasomotor symptoms and depression across the menopausal transition: a systematic review of longitudinal studies

OBJECTIVE

To explore the nature of the bidirectional relationship between vasomotor symptoms (VMS) and depression, and to determine whether hot flashes and night sweats differentially affect the association between VMS and depression through their effect on sleep disruption.

METHODS

Multiple databases were searched from 1961 until July 31, 2016, and a manual search of reference lists of identified articles was conducted. Sixteen articles that involved 10,008 participants were identified and analyzed.

RESULTS

The methods of analyses and measurement of VMS and depression varied across the studies. Two studies explored the bidirectional association, but only one was significant in both directions (odds ratio [OR] depression to VMS 3.06, 95% confidence interval [CI] 1.43-6.58; OR VMS to depression 8.88, 95% CI 2.57-30.68). In both cases, the association between VMS leading to depressive symptoms was stronger than the opposite. Eleven studies examined VMS leading to depression, but only five showed a significant effect (OR 1.57-1.81, P ≤ 0.02). Treating VMS and depressive symptoms as continuous variables (n = 3) diminished the relationship. Three studies showed a significant association of depression leading to VMS (OR 1.62-1.94, P ≤ 0.01). We found little evidence for a specific effect of night sweats on the association between VMS and depressive symptoms. The effect might not be related to sleep disruption.

CONCLUSIONS

There is a bidirectional association between VMS and depressive symptoms. The menopausal transition appears to increase the risk of recurrent episodes of depression that might not be explained only by VMS. Further investigation is needed to explain the differential effect of night sweats and hot flashes on depression.

Effect of previous diagnoses of depression, menopause status, vasomotor symptoms, and neuroticism on depressive symptoms among climacteric women: A 30-month follow-up

OBJECTIVES

The research was designed to examine the impact of the previous diagnoses of depression, menopause status, vasomotor symptoms, and neuroticism on depressive symptoms among menopausal women in Taiwan over a 30-month follow-up.

MATERIALS AND METHODS

A community-based sample of 190 middle-aged women was enrolled. The Menopausal Symptoms Scale, Neuroticism Extraversion Openness Five Factor Inventory-Chinese version, and Ko's Depression Inventory were applied, and results were assessed. In addition, each woman underwent a semistructured diagnostic interview with the Chinese version of the Modified Schedule of Affective Disorders and Schizophrenia-Lifetime to obtain her lifetime psychiatric history. After 30 months, 111 participants completed follow-up questionnaires.

RESULTS

Results of the hierarchical multiple regression analyses showed that depressive symptoms during the menopause transition predicted depressive symptoms over 30 months. After controlling for depressive symptoms during the menopause transition, the previous diagnoses of depression, menopause status, and vasomotor symptoms could not predict depressive symptoms over 30 months, whereas neuroticism still predicted depressive symptoms over 30 months.

CONCLUSION

The research suggested that neuroticism plays an important role in the persistence of depression among climacteric women after 30 months.

Hypothalamic orexin's role in exacerbated cutaneous vasodilation responses to an anxiogenic stimulus in a surgical menopause model

Distressing symptoms such as hot flashes and sleep disturbances affect over 70% of women approaching menopause for an average of 4-7 years, and recent large cohort studies have shown that anxiety and stress are strongly associated with more severe and persistent hot flashes and can induce hot flashes. Although high estrogen doses alleviate symptoms, extended use increases health risks, and current non-hormonal therapies are marginally better than placebo. The lack of effective non-hormonal treatments is largely due to the limited understanding of the mechanisms that underlie menopausal symptoms. One mechanistic pathway that has not been explored is the wake-promoting orexin neuropeptide system. Orexin is exclusively synthesized in the estrogen receptor rich perifornical hypothalamic region, and has an emerging role in anxiety and thermoregulation. In female rodents, estrogens tonically inhibit expression of orexin, and estrogen replacement normalizes severely elevated central orexin levels in postmenopausal women. Using an ovariectomy menopause model, we demonstrated that an anxiogenic compound elicited exacerbated hot flash-associated increases in tail skin temperature (TST, that is blocked with estrogen), and cellular responses in orexin neurons and efferent targets. Furthermore, systemic administration of centrally active, selective orexin 1 or 2 and dual receptor antagonists attenuated or blocked TST responses, respectively. This included the reformulated Suvorexant, which was recently FDA-approved for treating insomnia. Collectively, our data support the hypothesis that dramatic loss of estrogen tone during menopausal states leads to a hyperactive orexin system that contributes to symptoms such as anxiety, insomnia, and more severe hot flashes. Additionally, orexin receptor antagonists may represent a novel non-hormonal therapy for treating menopausal symptoms, with minimal side effects.

A lack of consistent evidence for cortisol dysregulation in premenstrual syndrome/premenstrual dysphoric disorder

Although decades of research has examined the association between cortisol regulation and premenstrual syndrome/premenstrual dysphoric disorder (PMS/PMDD), no review exists to provide a general set of conclusions from the extant research. In the present review we summarize and interpret research that has tested for associations between PMS/PMDD and cortisol levels and reactivity (n=38 original research articles). Three types of studies are examined: correlational studies, environmental-challenge studies, and pharmacological-challenge studies. Overall, there was very little evidence that women with and without PMS/PMDD demonstrate systematic and predictable mean-level differences in cortisol, or differences in cortisol response/reactivity to challenges. Methodological differences in sample size, the types of symptoms used for diagnosis (physical and psychological vs. only affective), or the type of cortisol measure used (serum vs. salivary), did not account for differences between studies that did and did not find significant effects. Caution is recommended before accepting the conclusion of null effects, and recommendations are made that more rigorous research be conducted, considering symptom-specificity, within-person analyses, and multiple parameters of cortisol regulation, before final conclusions are drawn.

Perimenopause and Menopause Are Associated With High Frequency Headache in Women With Migraine: Results of the American Migraine Prevalence and Prevention Study

OBJECTIVES

To examine the relationship of headache frequency to the stages of the menopausal transition in mid-life women with migraine.

BACKGROUND

Past studies suggest that the perimenopause is associated with an increased prevalence of migraine, particularly in those with a history of premenstrual syndrome. The effect of the menopausal transition on the frequency of headache attacks in women with migraine has not been explored.

METHODS

This was a cross-sectional observational study. Using data from the 2006 American Migraine, Prevalence and Prevention study survey, women meeting modified ICHD-3 beta criteria for migraine between the ages of 35-65 years were included in analyses. Women who had never menstruated or were pregnant, breastfeeding, or using exogenous sex hormones were excluded. The 2006 survey was selected because it included detailed questions on the menstrual cycle. The stages of the menopausal transition were defined based upon the self-reported cycle length and/or duration of amenorrhea. The primary outcome, high vs low headache frequency, was defined using a cut score of ≥10 headache days per month. Binary logistic regression models were used to assess the influence of menopausal stage on headache frequency category using premenopause as the reference group. Adjustments for stage of menopausal transition and sociodemographics (eg, age and income) were included in the first model, while the second model included sociodemographics, depression, body mass index, preventative medications, and medication overuse.

RESULTS

The study sample included 3664 women at a mean age of 46 years. Among women who were premenopausal, 8.0% (99/1242) were in the high frequency headache group in comparison with 12.2% (154/1266) of perimenopausal and 12.0% (131/1095) of postmenopausal women. Compared with premenopausal women, the adjusted odds of being in the high frequency headache group was 1.62 (95% CI = 1.23, 2.12) for perimenopausal and 1.76 (95% CI = 1.23, 2.52) for postmenopausal women (Model 1). In model 2, high frequency headache was only increased in perimenopausal women with an OR of 1.42 (95% CI = 1.03, 1.94).

CONCLUSIONS

The risk of high frequency headache is increased in women during the perimenopause compared to premenopause in the fully adjusted model. The fact that the increased risk of high frequency headache was not statistically significant for menopause in the fully adjusted models suggests that different mechanisms might account for the increased risk for this stage of the menopausal transition. Recognition of the increased risk of high frequency headache during the menopausal transition suggests a need for optimized preventive treatment of migraine during this time of women's life.

Symptom severity of bipolar disorder during the menopausal transition

Background

Little is known about the mood symptom experience of women with bipolar disorder during the menopausal transition (MT). Yet times of rapid hormonal decline, such as the postpartum, are associated with increased risk of severe mood episodes in bipolar disorder, and the MT is a time of increased risk for unipolar depression in women with or without a history of depression.

Methods

Enrollment included 56 women 40–60 years old diagnosed in the bipolar spectrum who were experiencing menopausal symptoms or were up to 5 years since their final menstrual period. Menopausal stages included early menopause, late menopause, or early postmenopause based on standardized criteria. Observational, prospective standardized mood symptom and reproductive hormone assessments were completed periodically. Concurrent menopausal symptoms as well as history of mood exacerbation during past reproductive events were assessed.

Results

Forty-four women were included in the main analysis. The average Montgomery-Asberg Depression Rating Scale (MADRS) score was 4.43 points higher in the late transition/early postmenopausal stage women (n = 29) compared to the early menopausal stage women (n = 15) (±SE 2.14; p = 0.039), corresponding to a roughly 10 % higher score (range 0–40) in the late/post stage across all study visits. Results were similar for the Young Mania Rating Scale (YMRS), where the average score was 2.54 points higher in the late/early postmenopausal stage women compared to the early menopausal stage women (±SE 1.15; p = 0.027), also roughly 10 % higher (range 0–26). Estradiol and follicle-stimulating hormone (FSH) absolute levels as well as between-visit change in levels were not notably associated with YMRS or MADRS during study observation. Total Greene Climacteric Symptom (menopausal symptom) score was significantly associated with MADRS but not YMRS. History of mood exacerbation premenstrually and/or postpartum was not significantly associated with YMRS or MADRS severity during the MT.

Conclusions

These results support the theory that times of increased reproductive hormonal changes, such as the late MT and early postmenopause, here compared to early MT, are associated with greater mood symptom severity in bipolar spectrum women. Nonetheless, absolute or change in FSH and estradiol levels were not significantly associated with depression or mood elevation severity.

Association between personality traits and DSM-IV diagnosis of insomnia in peri- and postmenopausal women

OBJECTIVE

The aim of this study was to determine the role of personality factors in the development of DSM-IV insomnia coincident with perimenopause.

METHODS

Perimenopausal women (35 women with DSM-IV insomnia and 28 women with self-reported normal sleep) underwent clinical assessments and completed menopause-related questionnaires, the NEO Five Factor Inventory and the Structured Interview for DSM-IV Personality. Logistic regressions determined whether personality factors and hot flash-related interference were associated with an insomnia diagnosis concurrent with the menopausal transition.

RESULTS

Women with insomnia reported higher neuroticism, lower agreeableness, and lower conscientiousness than controls on the NEO Five Factor Inventory. Moreover, women with insomnia were more likely to meet DSM-IV criteria for cluster C personality disorders, particularly obsessive-compulsive personality disorder, on the Structured Interview for DSM-IV Personality. Women with insomnia were more likely to have had a past depressive episode and a history of severe premenstrual symptoms. Findings from regressions revealed that higher neuroticism and greater interference from hot flashes were associated with insomnia classification even after controlling for history of depression, suggesting that sensitivity to hot flashes and a greater degree of neuroticism are independent contributors toward establishing which women are most likely to have sleep problems during perimenopause.

CONCLUSIONS

Findings show the relevance of personality factors, particularly neuroticism and obsessive-compulsive personality, to a woman's experience of insomnia as she goes through the menopausal transition.

Effects of sex and gender on adaptation to space: behavioral health

This article is part of a larger body of work entitled, "The Impact of Sex and Gender on Adaptation to Space." It was developed in response to a recommendation from the 2011 National Academy of Sciences Decadal Survey, "Recapturing a Future for Space Exploration: Life and Physical Sciences for a New Era," which emphasized the need to fully understand sex and gender differences. In this article, our workgroup-consisting of expert scientists and clinicians from academia and the private sector-investigated and summarized the current body of published and unpublished human research performed to date related to sex- and gender-based differences in behavioral adaptations to human spaceflight. This review identifies sex-related differences in: (1) sleep, circadian rhythms, and neurobehavioral measures; (2) personality, group interactions, and work performance and satisfaction; and (3) stress and clinical disorders. Differences in these areas substantially impact the risks and optimal medical care required by space-faring women. To ensure the health and safety of male and female astronauts during long-duration space missions, it is imperative to understand the influences that sex and gender have on behavioral health changes occurring during spaceflight.

Asptects of mental health care in the gynecological setting

Psychological disorders are commonly associated with gynecological conditions, but are frequently undetected and untreated, and may influence the presentation and treatment outcomes of the physical condition. A literature search was conducted in order to provide a narrative review of psychological aspects of menopause, premenstrual syndrome, premenstrual dysphoric disorder, chronic pelvic pain, incontinence and polycystic ovarian syndrome. All the conditions that have been addressed in this review can be associated with an increased risk of psychological symptoms and disorders. Anxiety and depression are common and are associated with significant morbidity. Gynecological conditions, by their nature, are likely to be accompanied by impairments in social, occupational and personal functioning. Greater emphasis should be placed on the mental health aspects of gynecological conditions.

Risk factors for night sweats and hot flushes in midlife: results from a prospective cohort study

OBJECTIVE

This study aims to identify social, lifestyle, and reproductive history risk factors for night sweats (NS) only, hot flushes (HF) only, and both NS and HF.

METHODS

Risk factors and symptoms among 10,454 participants of the Australian Longitudinal Study on Women's Health who were aged 45 to 50 years in 1996 were measured at baseline and 3-year intervals (surveys 2-6) for 15 years. Multinomial logistic regression analyses were performed.

RESULTS

Compared with neither symptom, both symptoms together were reported less often by highly educated women (odds ratio, 0.61; 99.9% CI, 0.50-0.74), but more often by women who were heavier (odds ratio, 1.23; 99.9% CI, 1.08-1.40), were current smokers (odds ratio, 1.31; 99.9% CI, 1.09-1.56), were high-risk drinkers (odds ratio, 1.44; 99.9% CI, 1.10-1.89), were perimenopausal (odds ratio, 6.57; 99.9% CI, 5.52-7.82) or postmenopausal (odds ratio, 4.74; 99.9% CI, 4.00-5.63), had gained weight (odds ratio, 1.15; 99.9% CI, 1.01-1.31), or had premenstrual tension (odds ratio, 1.86; 99.9% CI, 1.48-2.34), than by women without these characteristics. HF only was reported less often by highly educated women (odds ratio, 0.73; 99.9% CI, 0.59-0.90), but more often by perimenopausal (odds ratio, 3.58; 99.9% CI, 2.95-4.35) or postmenopausal (odds ratio, 2.97; 99.9% CI, 2.47-3.57) women and by those with premenstrual tension (odds ratio, 1.60; 99.9% CI, 1.25-2.04). Finally, NS only was reported more often among current smokers (odds ratio, 1.55; 99.9% CI, 1.11-2.19), high-risk drinkers (odds ratio, 1.76; 99.9% CI, 1.04-2.97), perimenopausal women (odds ratio, 1.53; 99.9% CI, 1.14-2.06), those with diabetes (odds ratio, 1.91; 99.9% CI, 1.08-3.35), those with premenstrual tension (odds ratio, 1.67; 99.9% CI, 1.09-2.56), or those of early age at first pregnancy (odds ratio, 1.45; 99.9% CI, 1.05-1.99).

CONCLUSIONS

The presence of both symptoms is associated with social, behavioral, and menstrual factors. Some differences in risk factors among women who report only one symptom or both symptoms are observed, suggesting a slightly different etiology for each.

Ethnic differences in the clusters of menopausal symptoms

Our purpose for this study was to identify clusters of midlife women by menopausal symptoms in a multiethnic sample, and to determine ethnic differences in the clusters. This was a secondary analysis of data from 501 women in a larger Internet study on menopausal symptom experiences. The data were analyzed using factor analysis, hierarchical cluster analysis, and multinominal logistic analysis. A three cluster solution was adopted (F = 575.71, p <.01). The clusters differed significantly in the country of birth and ethnicity (p <.05). Only in the low symptomatic cluster were there significant ethnic differences in menopausal symptoms.

Missing and Possible Link between Neuroendocrine Factors, Neuropsychiatric Disorders, and Microglia

Endocrine systems have long been suggested to be one of the important factors in neuropsychiatric disorders, while the underlying mechanisms have not been well understood. Traditionally, neuropsychiatric disorders have been mainly considered the consequence of abnormal conditions in neural circuitry. Beyond the neuronal doctrine, microglia, one of the glial cells with inflammatory/immunological functions in the central nervous system (CNS), have recently been suggested to play important roles in neuropsychiatric disorders. However, the crosstalk between neuroendocrine factors, neuropsychiatric disorders, and microglia has been unsolved. Therefore, we herein introduce and discuss a missing and possible link between these three factors; especially highlighting the following hormones; (1) Hypothalamic-Pituitary-Adrenal (HPA) axis-related hormones such as corticotropin-releasing hormone (CRH) and glucocorticoids, (2) sex-related hormones such as estrogen and progesterone, and (3) oxytocin. A growing body of evidence has suggested that these hormones have a direct effect on microglia. We hypothesize that hormone-induced microglial activation and the following microglia-derived mediators may lead to maladaptive neuronal networks including synaptic dysfunctions, causing neuropsychiatric disorders. Future investigations to clarify the correlation between neuroendocrine factors and microglia may contribute to a novel understanding of the pathophysiology of neuropsychiatric disorders.

Premenstrual symptoms are associated with psychological and physical symptoms in early pregnancy

The reproductive life of women is characterised by a number of distinct reproductive events and phases (e.g. premenstrual phase, peripartum, perimenopause). The hormonal transitions during these phases are often associated with both psychological and physical symptoms. Associations between these reproductive phases have been shown by numerous studies. However, the relationship between symptoms during the premenstrual phase and during early pregnancy has received little attention thus far, although early pregnancy is a time of dramatic hormonal as well as physical adaptation. Findings are based on a prospective longitudinal study with N = 306 pregnant women (MARI study). Three hundred five women that had menstrual bleeding in the year before pregnancy rated the severity of psychological and physical symptoms during premenstrual phases in the year preceding pregnancy. Besides this, they rated the severity of the same symptoms during early pregnancy (weeks 10 to 12 of gestation). The overall severity of premenstrual symptoms was significantly associated with the overall severity of early pregnancy symptoms (b = 0.4, 95% CI = 0.3-0.5; p < 0.001). The overall severity of early pregnancy symptoms was best predicted by the severity of premenstrual irritability. The best predictor for a particular symptom in early pregnancy mostly was the corresponding premenstrual symptom. The associations between premenstrual and early pregnancy symptoms support the reproductive hormone sensitivity hypothesis that some women are prone to repeatedly experience specific psychological and physical symptoms during different reproductive phases. The findings further imply that the nature of symptoms might be rather consistent between different reproductive phases.

What factors determine whether a woman becomes depressed during the perimenopause?

Perimenopause has long been associated with psychological distress, both anecdotally and clinically. Research has identified this time as a period of increased risk for both first-episode depression and for depression reoccurrence. However, we know that the majority of women do not experience these difficulties during perimenopause. This review examines the current research literature looking at the factors associated with depression during perimenopause, with a view to identifying those factors which are protective and those factors which predict increased risk. From the literature, it is evident that some women have a hormonal vulnerability to mood disorders. However, this does not account for the phenomenon of perimenopausal depression in and of itself. Rather, there appears to be a complex interplay between hormonal vulnerability, the psychosocial resources one has (coping skills and social support), their overall well-being (exercise and other lifestyle factors) and the demands on their coping resources (stressful life events). The complexity of the relationship between perimenopause and depression means that there is a need to look beyond either as a sole explanation of mood during midlife. Education is required for both general practitioners and for women regarding the individual risks of psychological distress during perimenopause, as well as the knowledge of the life factors which we know to be protective.

Association of past and recent major depression and menstrual characteristics in midlife: Study of Women's Health Across the Nation

OBJECTIVE

The aim of this study was to examine the association of a history of major depression (MD) with menstrual problems in a multiethnic sample of midlife women.

METHODS

Participants were 934 women enrolled in the Study of Women's Health Across the Nation, a multisite study of menopause and aging. The outcomes were menstrual bleeding problems and premenstrual symptoms in the year before study entry. The Structured Clinical Interview for the Diagnosis of DSM-IV Axis I Disorders was conducted to determine recent and past psychiatric diagnoses. Covariates included sociodemographic, behavioral, and gynecologic factors.

RESULTS

One third of the participants reported heavy bleeding, 20% reported other abnormal bleeding, and 18% reported premenstrual symptoms. One third had past and 11% had recent MD. Past MD was associated with an increased likelihood of heavy bleeding (odds ratio, 1.89; 95% CI, 1.25-2.85), adjusting for recent MD, menopause status, and other covariates. Past MD was not associated with other abnormal bleeding or premenstrual symptoms in the final analysis that adjusted for recent MD.

CONCLUSIONS

Midlife women with a history of MD are more likely to report heavy bleeding.

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.

Effects and Mechanisms of 3α,5α,-THP on Emotion, Motivation, and Reward Functions Involving Pregnane Xenobiotic Receptor

Progestogens [progesterone (P(4)) and its products] play fundamental roles in the development and/or function of the central nervous system during pregnancy. We, and others, have investigated the role of pregnane neurosteroids for a plethora of functional effects beyond their pro-gestational processes. Emerging findings regarding the effects, mechanisms, and sources of neurosteroids have challenged traditional dogma about steroid action. How the P(4) metabolite and neurosteroid, 3α-hydroxy-5α-pregnan-20-one (3α,5α-THP), influences cellular functions and behavioral processes involved in emotion/affect, motivation, and reward, is the focus of the present review. To further understand these processes, we have utilized an animal model assessing the effects, mechanisms, and sources of 3α,5α-THP. In the ventral tegmental area (VTA), 3α,5α-THP has actions to facilitate affective, and motivated, social behaviors through non-traditional targets, such as GABA, glutamate, and dopamine receptors. 3α,5α-THP levels in the midbrain VTA both facilitate, and/or are enhanced by, affective and social behavior. The pregnane xenobiotic receptor (PXR) mediates the production of, and/or metabolism to, various neurobiological factors. PXR is localized to the midbrain VTA of rats. The role of PXR to influence 3α,5α-THP production from central biosynthesis, and/or metabolism of peripheral P(4), in the VTA, as well as its role to facilitate, or be increased by, affective/social behaviors is under investigation. Investigating novel behavioral functions of 3α,5α-THP extends our knowledge of the neurobiology of progestogens, relevant for affective/social behaviors, and their connections to systems that regulate affect and motivated processes, such as those important for stress regulation and neuropsychiatric disorders (anxiety, depression, schizophrenia, drug dependence). Thus, further understanding of 3α,5α-THP's role and mechanisms to enhance affective and motivated processes is essential.

Evaluation and management of depressive and anxiety symptoms in midlife

OBJECTIVES

Evaluation and management of anxiety and depression during the menopausal transition are complicated by the overlap between some symptoms of affective disorder with those of menopausal symptoms, and also by inconsistencies in the literature regarding the relationship between the menopausal transition and affective disorders.

METHODS

We have reviewed key studies over the past three decades addressing depression and anxiety during the menopause transition, in order to present a practical, clinical approach to the evaluation and management of anxiety and depressive symptoms at midlife.

RESULTS

Symptoms of anxiety and depression are common at midlife and may coincide with menopausal symptoms. Some menopausal symptoms are also symptoms of anxiety and/or depression. Management should include treatment of troublesome menopausal symptoms, providing strategies to deal with psychosocial stressors, and exclusion of clinically significant anxiety and depressive disorders. Interventions such as exercise and cognitive behavior therapy may improve mood and general health at menopause, and a multifocal approach is recommended. Depression of greater than moderate severity requires treatment with an antidepressant. Some selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors may also improve vasomotor symptoms and these should be considered in women with both affective disorder and vasomotor symptoms.

CONCLUSIONS

There is no clear evidence that the menopause transition alone increases the risk of clinically significant affective disorders, except in women with risk factors such as psychosocial stressors, severe and prolonged vasomotor symptoms and a previous history of affective disorders. Nevertheless, anxiety and depression are common in women and clinicians should be alert to the symptoms of these conditions at all encounters.

Developmental associations between adolescent change in depressive symptoms and menstrual-cycle-phase-specific negative affect during early adulthood

The causal factors associated with increases in depressive symptoms among adolescent girls remain an area of theoretical debate, and the limited research considering a hormonal influence has provided mixed results. The goal of the present study was to test a set of longitudinal associations, that, if found, would provide support for a hormonal contribution to these changes. Specifically, this study tested the hypotheses that changes in depressive symptoms among adolescent girls would be associated with phase-specific symptoms of the menstrual cycle during early adulthood; that these associations would differ across three phases of the menstrual cycle; and that the pattern of associations would differ for changes in depressive symptoms during early- and late-adolescence. The sample consisted of 47 women with longitudinal data from 12 to 21 years old (approximately 91% European Canadian, 4% Middle Eastern Canadian, 2% Haitian Canadian, and 2% Asian Canadian). Consistent with expectations, results showed that early-adolescent increases in depressive symptoms were negatively associated with menstrual-phase negative affect, and positively associated with mid-cycle negative affect, but not associated with premenstrual negative affect; whereas late-adolescent change in depressive symptoms was only associated with depressive symptoms at 20-21 years. Thus, early-adolescent changes in depressive symptoms are longitudinally associated with later mood change across the menstrual cycle, suggesting a common underlying cause, which is hypothesized to be hormonal. Moreover, results suggest that, with respect to variables that are involved in affective development, important differences exist between early- and late-adolescence. The discussion considers menstrual-cycle-related symptoms (e.g., dysmenorrhea) during adolescence, and the need to study their effects on development. It is suggested that focused intervention and prevention efforts may be indicated to interrupt negative developmental outcomes.

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.

Negative attitudes and affect do not predict elective hysterectomy: a prospective analysis from the Study of Women's Health Across the Nation

OBJECTIVE

Cross-sectional studies suggest an association between hysterectomy and negative affect. Using prospective data, we examined the associations of negative affect, attitudes toward aging and menopause, premenstrual symptoms, and vasomotor symptoms with elective hysterectomy in midlife.

METHODS

Data were from the Study of Women's Health Across the Nation, a multisite, community-based prospective cohort study of the menopausal transition (n = 2,818). Annually reported hysterectomy at visits 2 to 9 was verified with medical records when available (71%). Anxiety, perceived stress, depressive symptoms, attitudes toward aging and menopause, vasomotor symptoms, and premenstrual symptoms were assessed at baseline using standardized questions. Cox proportional hazards models were used to relate these variables to subsequent elective hysterectomy. Covariates included demographic variables, menstrual bleeding problems, body mass index, hormone levels, and self-rated health, also assessed at baseline.

RESULTS

Elective hysterectomy was reported by 6% (n = 168) of participants over an 8-year period. Women with hysterectomy were not higher in negative affect or negative attitudes toward aging and menopause compared with women without hysterectomy. Vasomotor symptoms (hazard ratio [HR], 1.44; 95% CI, 1.03-2.01; P = 0.03) and positive attitudes toward aging and menopause (HR, 1.74; 95% CI, 1.04-2.93) at baseline predicted hysterectomy over the 8-year period, controlling for menstrual bleeding problems, site, race/ethnicity, follicle-stimulating hormone, age, education, body mass index, and self-rated health. Menstrual bleeding problems at baseline were the strongest predictor of hysterectomy (HR, 4.30; 95% CI, 2.05-9.05).

CONCLUSIONS

In this prospective examination, negative affect and attitudes were not associated with subsequent hysterectomy. Menstrual bleeding problems were the major determinant of elective hysterectomy.

One woman's low is another woman's high: Paradoxical effects of the menstrual cycle

Although past research on affective changes associated with the menstrual cycle has focussed on a specific pattern commonly referred to as Premenstrual Syndrome, there are compelling reasons to hypothesize that an opposite pattern, with a mid-cycle increase and a premenstrual low in symptoms, may also exist. Focusing on depression and anxiety, the present study tested whether this mid-cycle pattern of symptoms could be identified, using a sample of 213 female university students, who completed daily questionnaires for two menstrual cycles. Results confirmed the existence of a group of women who demonstrate the mid-cycle pattern of symptom changes (13%), in addition to the classic PMS pattern (61%), and individuals demonstrating no cyclical pattern of symptoms (26%). Moreover, women with a strong PMS pattern showed lower average levels of depression/anxiety than women with no cyclical changes. These findings require that current conceptions of menstrual-cycle related psychological changes be redefined to include the mid-cycle pattern, and suggest that women with strong PMS symptoms may actually benefit from a mid-cycle sense of wellness.