Depression, the perimenopause, and estrogen therapy

Estrogen deficiency affects synchronized neural connectivity in the olfactory bulb-nucleus accumbens circuit: A local field potential study in ovariectomized mouse model

Estrogen plays a crucial role in regulating various brain functions, including cognitive, emotional, and social behaviors. Menopausal women face a decline in estrogen levels, which has been linked to several physical and mental health issues. However, the impact of estrogen on the olfactory bulb-nucleus accumbens (OB-NAc) circuit, which is essential for regulating emotions and cognitive behaviors, remains poorly understood. To test the hypothesis that estrogen deficiency affects signal processing, we recorded local field potentials (LFPs) using intracranial electrodes implanted in four-week-old ovariectomized (OVX) mice during an open-field test (OFT). The results showed a decrease in locomotor activity and increase in anxiety-like behaviors in OVX mice. Furthermore, we found a decrease in high-gamma power in the OB. We analyzed coherence and inter-region phase-amplitude coupling (ir-PAC) to explore the connectivity between the OB and NAc. We observed a decrease in low-gamma and high-gamma coherence in OVX mice. Additionally, we found that the direction of connectivity from the NAc to the OB was disrupted in OVX mice. In summary, our study provides evidence that estrogen deficiency is linked to synchronized neural connectivity changes in the OB-NAc circuit. These findings have implications for our understanding of the roles played by the OB-NAc neural circuit and estrogen in the regulation of general exploratory behavior and anxiety-like behavior.

Estradiol effects on an emotional interference task in adolescents with current and remitted depression

Attentional biases to emotional stimuli are thought to reflect vulnerability for mood disorder onset and maintenance. This study examined the association between the endogenous sex hormone estradiol and emotional attentional biases in adolescent females with either current or remitted depression. Three groups of participants (mean age ± SD) completed the Emotional Interrupt Task: 1) 20 adolescent females (15.1 ± 1.83 years) currently diagnosed with Major Depressive Disorder (MDD), 2) 16 adolescent females (16.4 ± 1.31 years) who had experienced at least one episode of MDD in their lifetime but currently met criteria for MDD in remission, and 3) 30 adolescent female (15.4 ± 1.83 years) healthy controls. Attentional interference (AI) scores were calculated as differences in target response reaction time between trials with emotional facial expressions versus neutral facial expressions. Estradiol levels were assayed by Salimetrics LLC using saliva samples collected within 30 min of waking on assessment days. Robust multiple regression with product terms evaluated estradiol's main effect on AI scores, as well as hypothesized estradiol × diagnostic group interactions. Although neither mean estradiol levels nor mean AI scores in the current-MDD and remitted-MDD groups differed from controls, the relationship between estradiol and overall AI score differed between control adolescents and the remitted-MDD group. Specifically, the remitted-MDD adolescents performed worse (i.e., showed greater attentional interference) when they had higher estradiol; no significant relationship existed in the current-MDD group. Because this finding was driven by angry and not happy stimuli, it appears higher estradiol levels were associated with greater susceptibility to the attention-capturing effects of negatively-valenced emotional content in girls at risk for MDD from prior history.

Ameliorating Effect of the Edible Mushroom Hericium erinaceus on Depressive-Like Behavior in Ovariectomized Rats

Estrogen deficiency during menopause causes a variety of neurological symptoms, including depression. The edible Lion's Mane mushroom, Hericium erinaceus (Bull.: Fr.) Pers. (HE), is a medicinal mushroom that has the potential for a neuroprotective effect and ameliorating neurological diseases, such as depression, anxiety, and neurodegenerative diseases. HE contains phytoestrogens, including daidzein and genistein. However, the ameliorating effect of HE on menopausal symptoms is not well understood. Here we investigated the impact of methanol extract of the HE fruiting body on depressive-like behavior in postmenopausal model rats. The activation of estrogen receptor alpha (ERα) causes body weight loss and uterine weight gain. Body weight gain and uterine weight loss by estrogen deficiency in ovariectomized (OVX) rats were reversed with 17β-estradiol (E₂) but not with HE. Thus, the phytoestrogens in HE may hardly activate ERα. Estrogen receptor beta (ERβ) is expressed in the brain, and activation of ERβ ameliorates menopausal depressive symptoms. Notably, depressive-like behavior in OVX rats evaluated in forced swim test was reduced by administration of not only E₂ but also HE for 92 d. Long-term activation of ERα increases the risk of breast and uterine cancers. HE, therefore, may be effective in treating menopausal depression without the risk of carcinogenesis caused by ERα activation.

Estrogen administration attenuates post-stroke depression by enhancing CREB/BDNF/TrkB signaling in the rat hippocampus

A previous study demonstrated that 17β-estradiol (E2), which is an antidepressant, can ameliorate post-stroke depression (PSD); however, the underlying mechanisms governing this remain largely unknown. Therefore, the present study developed a PSD model in rats, which was induced by left middle cerebral artery occlusion followed by exposure to chronic mild stress for 2 weeks. The results revealed that the activity of the cAMP response element-binding protein (CREB), a cellular transcription factor, and the associated brain-derived neurotrophic factor (BDNF)/tyrosine kinase B (TrkB) signaling were all attenuated in the hippocampus in PSD rats. The depression-like behaviors were significantly improved after treatment with E2, along with increased CREB and the BDNF/TrkB signaling activity. These results provide novel insight into the molecular basis of PSD, and suggest the potential involvement of CREB/BDNF/TrkB signaling in E2-mediated improvement of PSD in rats.

Effects of Menopause in Women With Multiple Sclerosis: An Evidence-Based Review

Over two thirds of all individuals who develop multiple sclerosis (MS) will be women prior to the age of menopause. Further, an estimated 30% of the current MS population consists of peri- or postmenopausal women. The presence of MS does not appear to influence age of menopausal onset. In clinical practice, symptoms of MS and menopause can frequently overlap, including disturbances in cognition, mood, sleep, and bladder function, which can create challenges in ascertaining the likely cause of symptoms to be treated. A holistic and comprehensive approach to address these common physical and psychological changes is often suggested to patients during menopause. Although some studies have suggested that women with MS experience reduced relapse rates and increased disability progression post menopause, the data are not consistent enough for firm conclusions to be drawn. Mechanisms through which postmenopausal women with MS may experience disability progression include neuroinflammation and neurodegeneration from age-associated phenomena such as immunosenescence and inflammaging. Additional effects are likely to result from reduced levels of estrogen, which affects MS disease course. Following early retrospective studies of women with MS receiving steroid hormones, more recent interventional trials of exogenous hormone use, albeit as oral contraceptive, have provided some indications of potential benefit on MS outcomes. This review summarizes current research on the effects of menopause in women with MS, including the psychological impact and symptoms of menopause on disease worsening, and the treatment options. Finally, we highlight the need for more inclusion of MS patients from underrepresented racial and geographic groups in clinical trials, including among menopausal women.

Associations between estradiol and testosterone and depressive symptom scores of the Patient Health Questionnaire-9 in ovariectomized women: a population-based analysis of NHANES data

BACKGROUND

Women are well known to be susceptible to developing affective disorders, yet little attention has been given to effects of ovariectomy-reduced hormones and links with depression. This population-based cross-sectional study aimed to investigate possible associations between ovariectomy-reduced hormones and depression symptom scores of the Patient Health Questionnaire-9 (PHQ-9) in ovariectomized women.

METHODS

Data of PHQ-9 scores, demographics and comorbidities of ovariectomized women were extracted from the U.S. National Health and Nutrition Examination Survey (NHANES) database (2013-2016) and were analyzed retrospectively.

RESULTS

Among ovariectomized women in the NHANES database, serum estradiol levels were significantly positively associated with PHQ-9 scores (ß = 0.014, 95% CI: 0.001, 0.028, P = 0.040), whereas serum testosterone was negatively associated with PHQ-9 scores (ß = -0.033, 95% CI: - 0.048, - 0.018, P < 0.001) after adjusting for confounders. Further stratified analyses revealed that serum estradiol was positively associated with PHQ-9 only among women with history of estrogen use. Serum testosterone levels were negatively associated with PHQ-9 among women with or without prior estrogen use but this was only observed among women aged <  = 60 years (ß = - 0.057, - 0.076, - 0.038, P < 0.001).

CONCLUSIONS

Serum estradiol and testosterone are associated with PHQ-9 scores indicative for depression in ovariectomized women. The associations are modified by age and history of estrogen use. Future prospective studies are warranted to confirm these findings, carefully addressing possible confounding of age-related dementia.

N-3 Polyunsatured Fatty Acids in Menopausal Transition: A Systematic Review of Depressive and Cognitive Disorders with Accompanying Vasomotor Symptoms

Depression is one of the most important health problems worldwide. Women are 2.5 times more likely to experience major depression than men. Evidence suggests that some women might experience an increased risk for developing depression during “windows of vulnerability”, i.e., when exposed to intense hormone fluctuations, such as the menopause transition. Indeed, this period is associated with different symptoms, including vasomotor, depressive, and cognitive symptoms, which have all been shown to worsen as women approach menopause. Even though hormonal therapy represents the most effective treatment, side effects have been reported by several studies. Therefore, an increased number of women might prefer the use of alternative medicine for treating menopausal symptoms. N-3 long-chain polyunsaturated fatty acids (n-3 LCPUFAs) are included among these alternative treatments. We here provide a review of studies investigating the effects of n-3 LCPUFAs on hot flashes and depressive and cognitive disorders in menopausal women. The reported results are scattered and heterogeneous. In conclusion, a beneficial role of n-3 LCPUFAs in hot flashes, and depressive and cognitive symptoms related to menopausal transition is still far from conclusive.

Estrogen levels, emotion regulation, and emotional symptoms of women with premenstrual dysphoric disorder: The moderating effect of estrogen receptor 1α polymorphism

BACKGROUND

This study evaluated the association between estrogen levels, emotion regulation, depression, anxiety, and stress of women with premenstrual dysphoric disorder (PMDD). We also evaluated the moderating effect of estrogen receptor (ESR) α-Xbal polymorphism on the aforementioned association.

METHODS

A total of 100 women were diagnosed with PMDD based on psychiatric interviews and a prospective investigation of 3 menstrual cycles. A total of 96 normal individuals were recruited as controls. Their estrogen levels, depression, anxiety, stress, and ESR α-Xbal polymorphism in both premenstrual and follicular phases were assessed, and these data were included in the final analysis.

RESULTS

The PMDD group had high depression, anxiety, and stress and low emotional adjusting and tolerating in the premenstrual phase. Emotional adjustment was negatively associated with depression, anxiety and stress. No association was observed between PMDD and estrogen level. However, premenstrual estrogen level was negatively correlated with anxiety and stress in women with PMDD. The association was only significant in G carriers of ESR α-Xbal, as was the difference in premenstrual emotion regulation between the PMDD and control groups.

CONCLUSIONS

The results demonstrate the association between estrogen and anxiety in PMDD, supporting the claim that women with PMDD differ in their responses to normal estrogen levels. Furthermore, this association and dysfunctional emotional regulation in PMDD existed only among the G carriers of ESR α-Xbal polymorphism. Future studies should investigate the effect of estrogen on brain functions involving emotional regulation in women with PMDD, stratified by ESR α-Xbal polymorphism.

Study of Sex Differences in Duloxetine Efficacy for Depression in Transgenic Mouse Models

Clinical evidences show sex differences in risk of developing depressive disorders as well as effect of antidepressants in depression treatment. However, whether such a sex-dependent risk of depression and efficacy of antidepressants is dependent on endogenous estrogen level remain elusive. The aim of this study is to explore the molecular mechanisms of sex differences in antidepressant duloxetine. In the present study, we used genetic knockout or overexpression estrogen-synthesizing enzyme aromatase (Ar) gene as models for endogenous estrogen deficiency and elevation endogenous estrogen, respectively, to examine the anti-depressive efficacy of duloxetine in males and females by force swimming test (FST). We also measured the sex-specific effect of duloxetine on dopamine and serotonin (5-HT) metabolisms in frontal cortex and hippocampus (HPC). Elevation of brain endogenous estrogen in male and female mice showed a reduction of immobility time in FST compared to control mice. Estrogen deficiency in females showed poor response to duloxetine treatment compared to sex-matched wildtype (WT) or aromatase transgenic mice. In contrast, male mice with estrogen deficiency showed same anti-depressive response to duloxetine treatments as aromatase transgenic mice. Our data showed that the sex different effect of endogenous estrogen on duloxetine-induced anti-depressive behavioral change is associated with brain region-specific changes of dopamine (DA) and 5-HT system. Endogenous estrogen exerts antidepressant effects in both males and females. Lacking of endogenous estrogen reduced antidepressive effect of duloxetine in females only. The endogenous estrogen level alters 5-HT system in female mainly, while both DA and 5-HT metabolisms were regulated by endogenous estrogen levels after duloxetine administration.

Improvement of neurological disorders in postmenopausal model rats by administration of royal jelly

OBJECTIVE

Royal jelly (RJ) from honeybees (Apis mellifera) has estrogenic activity. Estrogen deficiency after menopause leads to a high risk of memory impairment and depression as well as metabolic syndrome and osteoporosis. We here investigated the effect of RJ on memory impairment and depression-like behaviors in ovariectomized (OVX) rats.

METHODS

OVX rats were administered with RJ for 82 days. Hippocampus-dependent spatial memory and depression-like behaviors were assessed by the Morris water maze test and the forced swimming test, respectively. The weights of body, brain and uterus and the contents of protein and myelin galactolipids including galactosylceramide and sulfatide were measured.

RESULTS

Memory impairment and depression-like behaviors in OVX rats were recovered to the levels of sham-operated rats by RJ administration. Increased body weight and decreased uterine weight in OVX rats were recovered to the levels of sham-operated rats by 17β-estradiol (E2) administration but not by RJ administration. In contrast, brain weight was slightly increased by RJ administration but not by E2 administration. The contents of protein and myelin galactolipids were higher in the brains of RJ-administered OVX rats than in the brains of E2-administered OVX rats.

CONCLUSION

The results suggest that RJ has a beneficial effect on neurological symptoms of a menopausal disorder.

Review: Puberty as a time of remodeling the adult response to ovarian hormones

During pubertal development, an animal's response to stress changes and sexual differentiation of the brain and behavior continue. We discovered that particular stressors, such as shipping from suppliers or an immune challenge with lipopolysaccharide, during the prolonged pubertal period of female mice result in long-term changes in behavioral responsiveness of the brain to estradiol assessed in adulthood. All behaviors influenced by estradiol and/or progesterone that we have studied are compromised by a stressor during pubertal development. Depending on the behavior, immune challenge or shipping from suppliers during pubertal development decreases, eliminates, or even reverses the effects of estradiol. Shipping during this period causes changes in the number of estrogen receptor-immunoreactive cells in key brain areas suggesting one cellular mechanism for this remodeling of the brain's response to hormones. We suggest that particular adverse experiences in girls may cause long-term alterations in the brain's response to estradiol and/or progesterone via activation of the immune system. This in turn could lead to an alteration in any aspect of mental health that is influenced by estradiol.

Strategies and methods to study female-specific cardiovascular health and disease: a guide for clinical scientists

BACKGROUND

In 2001, the Institute of Medicine's (IOM) report, "Exploring the Biological Contributions to Human Health: Does Sex Matter?" advocated for better understanding of the differences in human diseases between the sexes, with translation of these differences into clinical practice. Sex differences are well documented in the prevalence of cardiovascular (CV) risk factors, the clinical manifestation and incidence of cardiovascular disease (CVD), and the impact of risk factors on outcomes. There are also physiologic and psychosocial factors unique to women that may affect CVD risk, such as issues related to reproduction.

METHODS

The Society for Women's Health Research (SWHR) CV Network compiled an inventory of sex-specific strategies and methods for the study of women and CV health and disease across the lifespan. References for methods and strategy details are provided to gather and evaluate this information. Some items comprise robust measures; others are in development.

RESULTS

To address female-specific CV health and disease in population, physiology, and clinical trial research, data should be collected on reproductive history, psychosocial variables, and other factors that disproportionately affect CVD in women. Variables related to reproductive health include the following: age of menarche, menstrual cycle regularity, hormone levels, oral contraceptive use, pregnancy history/complications, polycystic ovary syndrome (PCOS) components, menopause age, and use and type of menopausal hormone therapy. Other factors that differentially affect women's CV risk include diabetes mellitus, autoimmune inflammatory disease, and autonomic vasomotor control. Sex differences in aging as well as psychosocial variables such as depression and stress should also be considered. Women are frequently not included/enrolled in mixed-sex CVD studies; when they are included, information on these variables is generally not collected. These omissions limit the ability to determine the role of sex-specific contributors to CV health and disease. Lack of sex-specific knowledge contributes to the CVD health disparities that women face.

CONCLUSIONS

The purpose of this review is to encourage investigators to consider ways to increase the usefulness of physiological and psychosocial data obtained from clinical populations, in an effort to improve the understanding of sex differences in clinical CVD research and health-care delivery for women and men.

17α-Estradiol: a candidate neuroserm and non-feminizing estrogen for postmenopausal neuronal complications

Extensive evidence suggests that decline in ovarian function with menopause is associated with neuronal dysfunction. Major cause of this is rise in oxidative stress and inflammatory cytokines because of estrogen deficiency. 17β-Estradiol (E2, hormone with potent antioxidant and anti-inflammatory activity) has profound protective actions on multiple organ systems, but feminizing side effects of β-estradiol limits its clinical efficacy. 17α-Estradiol (E2α), a non feminizing congener, gives a ray of hope to the scientific community as an alternative strategy to treat menopause associated neuronal pathologies. We assessed the protective actions of 17α-estradiol (5, 10μg/kg) against cognitive deficits, depression and motor coordination after 4weeks of ovariectomy in rats and compared its efficacy with E2 at same doses. After the behavioral assay animals were sacrificed and their brains were harvested for biochemical studies. Uterine weights were also assessed. E2 and E2α (5, 10μg/kg) were equally protective against attenuating cognitive deficits, depressive symptoms and motor incoordination in OVX rats. Both demonstrated significant antioxidant activity and E2, but not E2α, increased serum estradiol levels and proliferated uterine weights, markers of feminizing action. It can thus be concluded that E2α offers safe alternative to E2 in protecting against menopausal neuropathologies.

Cognition and mood in perimenopause: a systematic review and meta-analysis

OBJECTIVE

It is suggested that declines in estrogen around menopause are associated with declines in cognitive functioning as well as increased risk of depressive symptoms and depressive disorders. Existing studies of objective cognitive function and mood have differed in the criteria used to stage the menopausal transition and in the outcome measures used. The purpose of this review was to synthesize the existing studies of the relationship between menopausal stage and neuropsychological performance and depression.

DESIGN

A search of the literature of observational studies was performed using PubMed. Four cross-sectional studies on menopausal transition stage and cognitive function and four longitudinal studies on menopausal transition stage and risk of depression, as measured by symptom inventories and structured clinical interviews, were selected. For the cognitive outcomes, fixed effects models were used to estimate overall standardized effect sizes. For the depression outcomes, the results of group comparisons were summarized using the log odds ratio and its estimated standard error.

RESULTS

Postmenopausal women performed significantly worse than pre- and perimenopausal women on delayed verbal memory tasks, and significantly worse than perimenopausal women on phonemic verbal fluency tasks. Peri- and postmenopausal women were at significantly increased risk of depression, as measured by standard symptom inventories and structured clinical interviews, than premenopausal women.

CONCLUSIONS

The menopausal transition is a time of increased vulnerability to cognitive declines and increased risk of depressive symptoms and depressive disorders. However, these results cannot necessarily be generalized beyond the studies included in this review. This article is part of a Special Issue entitled 'Menopause'.

Among a sample of Iranian premenopausal and menopausal women differences in mood, sleep and health quality are small

BACKGROUND

Anecdotal evidence suggests that mood, sleep, and health quality change in women from premenopausal to menopausal period; however, data supporting these assumptions from non-Western countries are scarce. The aim of the present study was therefore to assess premenopausal and menopausal Iranian women with regard to mood, sleep, and general health.

METHODS

One hundred and twenty Iranian women took part in the study. Sixty were in a premenopausal state (mean age (M): = 46.9 years) and 60 in a menopausal state (M = 53.8 years). They completed a series of self-rating questionnaires related to sleep, mood, and health quality.

RESULTS

Compared to premenopausal women, menopausal women reported more difficulties such as falling asleep, and less general physical activities and vitality. No statistically significant differences were found for sleep quality, sleep schedules, difficulties in social life, general mood state, or general physical and mental health. Menopausal women reported to be more irritable, and to have more energy.

CONCLUSIONS

Data suggest that among a sample of Iranian premenopausal and menopausal women, differences in mood, sleep, and general health are small. Data, therefore, do not support "beliefs" and hearsay that mood, sleep, and general health do decrease from premenopausal to menopausal state.

Enduring influence of pubertal stressors on behavioral response to hormones in female mice

This article is part of a Special Issue "Puberty and Adolescence". The pubertal period is a time of change in an animal's response to stress, and it is a second period of sexual differentiation of the brain. Recently, it was discovered that particular stressors during the prolonged pubertal period of female mice result in enduring changes in behavioral responsiveness of the brain to estradiol and progesterone. Depending on the behavior, pubertal immune challenge or shipping from suppliers may decrease, eliminate, or even reverse the effects of estradiol. Pubertal immune challenge results in changes in the number of estrogen receptor-immunoreactive cells in key brain areas suggesting a cellular mechanism for this remodeling of the brain's response to hormones. A hypothesis is put forward that predicts that particular adverse experiences in girls may cause long-term alterations in the brain's response to estradiol and/or progesterone via activation of the immune system. This could lead to mood disorders or altered response to any behavior influenced by estradiol in humans.

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.

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.

Update on research and treatment of premenstrual dysphoric disorder

Many women in their reproductive years experience some mood, behavioral. or physical symptoms in the week prior to menses. Variability exists in the level of symptom burden in that some women experience mild symptoms, whereas a small minority experience severe and debilitating symptoms. For an estimated 5%-8% of premenopausal women, work or social functioning are affected by severe premenstrual syndrome. Many women in this group meet diagnostic criteria for premenstrual dysphoric disorder (PMDD). Among women who suffer from PMDD, mood and behavioral symptoms such as irritability, depressed mood, tension, and labile mood dominate. Somatic complaints, including breast tenderness and bloating, also can prove disruptive to women's overall functioning and quality of life. Recent evidence suggests that individual sensitivity to cyclical variations in levels of gonadal hormones may predispose certain women to experience these mood, behavioral, and somatic symptoms. Treatments include: antidepressants of the serotonin reuptake inhibitor class, taken intermittently or throughout the menstrual cycle; medications that suppress ovarian cyclicity; and newer oral contraceptives with novel progestins.

Predictors of first lifetime episodes of major depression in midlife women

BACKGROUND

Little is known about factors that predict first lifetime episodes of major depression in middle-aged women. It is not known whether health-related factors and life stress pose more or less of a risk to the onset of clinical depression than does the menopausal transition.

METHOD

The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) was used to assess diagnoses of lifetime, annual and current major depression in a community-based sample of premenopausal or early perimenopausal African American and White women. Menstrual cycle characteristics, psychosocial and health-related factors, and blood samples for assay of reproductive hormones were obtained annually. Two hundred and sixty-six women without a history of major depression at baseline constituted the cohort for the current analyses.

RESULTS

Over 7 years of follow-up, 42 (15.8%) women met criteria for a diagnosis of major depression. Frequent vasomotor symptoms (VMS; hot flashes and/or night sweats) (HR 2.14, p=0.03) were a significant predictor of major depression in univariate analyses. After simultaneous adjustment for multiple predictors in Cox proportional hazards analyses, frequent VMS were no longer significant; lifetime history of an anxiety disorder (HR 2.20, p=0.02) and role limitations due to physical health (HR 1.88, p=0.07) at baseline and a very stressful life event (HR 2.25, p=0.04) prior to depression onset predicted a first episode of major depression.

CONCLUSIONS

Both earlier (e.g. history of anxiety disorders) and more proximal factors (e.g. life stress) may be more important than VMS in contributing to a first episode of major depression during midlife.

Avaliação da sintomatologia depressiva de mulheres no climatério com a escala de rastreamento populacional para depressão CES-D

INTRODUÇÃO: O objetivo deste estudo foi avaliar a sintomatologia depressiva em mulheres climatéricas com a escala de depressão CES-D (Center for Epidemiological Studies Depression Scale), do National Institute of Mental Health (EUA). MÉTODO: Estudo transversal com 151 mulheres entre 40 e 65 anos de idade, usuárias de serviço de ginecologia geral em unidade de atenção básica à saúde no Rio de Janeiro. Aplicou-se a escala CES-D e um questionário estruturado para a obtenção de dados sociodemográficos, clínicos e ginecológicos. O nível de corte > 15 pontos na CES-D foi considerado como indicativo de quadro depressivo. RESULTADOS: A média de pontuação da amostra foi de 9,2 pontos (desvio padrão = 9,0). Os itens mais pontuados da escala foram relativos à insônia, tristeza e desânimo. Não houve associação significativa entre os escores e o período climatérico, características sociodemográficas, clínicas ou ginecológicas, exceto para as mulheres com presença de sintomas psíquicos, histórico depressivo pregresso e uso atual de antidepressivos (p = 0,000). Entre as 32 mulheres (21%) com pontuação > 15 na CES-D, 72% referiram episódio depressivo pregresso. Dentre as participantes sem histórico depressivo, as perimenopáusicas apresentaram escores > 15 com maior freqüência. CONCLUSÃO: Essa casuística, oriunda de serviço não-especializado em menopausa ou saúde mental, revelou baixas pontuações médias na escala de sintomas depressivos CES-D, e o item insônia foi o mais pontuado. O histórico de depressão foi fator de associação com a alta pontuação na escala, mas não a fase climatérica em que a mulher se encontrava. A maior freqüência de pontuação acima do nível de corte nas mulheres sem histórico depressivo pregresso que estavam na perimenopausa sugere a maior vulnerabilidade, nessa fase, a episódios depressivos novos.

Stress and glucocorticoid footprints in the brain-the path from depression to Alzheimer's disease

Increasingly, stress is recognized as a trigger of depressive episodes and recent evidence suggests a causal role of stress in the onset and progression of Alzheimer's disease (AD) pathology. Besides aging, sex is an important determinant of prevalence rates for both AD and mood disorders. In light of a recent meta-analysis indicating that depressed subjects have a higher likelihood of developing AD, a key message in this article will be that both depression and AD are stress-related disorders and may represent a continuum that should receive more attention in future neurobiological studies. Accordingly, this review considers some of the cellular mechanisms that may be involved in regulating this transition threshold. In addition, it highlights the importance of addressing the question of how aging and sex interplay with stress to influence mood and cognition, with a bias towards consideration of neuroplastic events in particular brain regions, as the basis of AD and depressive disorders.

Premenstrual syndrome

Most women of reproductive age have some physical discomfort or dysphoria in the weeks before menstruation. Symptoms are often mild, but can be severe enough to substantially affect daily activities. About 5-8% of women thus suffer from severe premenstrual syndrome (PMS); most of these women also meet criteria for premenstrual dysphoric disorder (PMDD). Mood and behavioural symptoms, including irritability, tension, depressed mood, tearfulness, and mood swings, are the most distressing, but somatic complaints, such as breast tenderness and bloating, can also be problematic. We outline theories for the underlying causes of severe PMS, and describe two main methods of treating it: one targeting the hypothalamus-pituitary-ovary axis, and the other targeting brain serotonergic synapses. Fluctuations in gonadal hormone levels trigger the symptoms, and thus interventions that abolish ovarian cyclicity, including long-acting analogues of gonadotropin-releasing hormone (GnRH) or oestradiol (administered as patches or implants), effectively reduce the symptoms, as can some oral contraceptives. The effectiveness of serotonin reuptake inhibitors, taken throughout the cycle or during luteal phases only, is also well established.

Women's perception of sexuality around the menopause: Outcomes of a European telephone survey

OBJECTIVE

Women's attitudes and experience towards sexuality around the menopause were investigated in Europe by a telephone survey. In addition, it was qualified to what extent reduced sex drive and vaginal dryness affect personal life, taking into account cultural differences.

STUDY DESIGN

A survey on 1,805 post-menopausal women (age range: 50-60 years), experiencing at least one menopausal symptom (hot flushes or sleeplessness) or not menstruating for at least 1 year, was conducted in six European countries (United Kingdom, France, Germany, Italy, The Netherlands, Switzerland) by computer-assisted telephone interviewing. A structured interview analysed menopausal profile, sexuality-related menopausal symptoms, mental well-being and attitudes towards sexuality.

RESULTS

Apart from hot flushes or sleeplessness, women particularly experienced sexual symptoms, such as reduced sexual desire and vaginal pain/dryness during the menopausal transition: one third (34%) of the women mentioned experiencing a reduced sex drive whereas one half (53%) of the women noticed that they became less interested in sex in spite of the majority of the sample reporting finding it important to maintain an active sex life (71%). Sex is experienced as an important part of the relationship with a partner, especially for Italian and Swiss women and ageing seems to play a critical role in sexual functioning, particularly for Italian and Dutch women. A general positive attitude toward sex was supported by the evidence that almost half of the study sample reported having sexual contact at least four times a month. Mental and sexual well-being interfered with self-worth and enjoyment of life, as did vaginal discomfort.

CONCLUSIONS

These data suggest that European middle-aged women experience the menopause as a process that brings about mood and sexual changes able to impair their personal life. However, cultural values and health beliefs influence perception of sexuality at the time of the menopause and will also influence the need for treatment.

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.

Hormone therapy, dilemmas, medical decisions

The decision for women to go on hormone therapy (HT) remains controversial. An historical oscillation of beliefs exists related in part to expectations of the medicinal value of HT over longer-term use beyond the initial peri-menonpausal period. Studies thought to resolve issues surrounding the efficacy of HT were perhaps overstated as confusion still permeates the decision making with regard to HT. Overzealous advertising and exaggerated understanding of the results (negative or positive) undermine patient and physician decision making. There remains no magic bullet with regard to HT. What remains is still the possibility of HT longer-term efficacy on diverse end organ systems with pockets of clinical and scientific ambiguity while working to engender reasonable expectations.

Botanical and dietary supplements for mood and anxiety in menopausal women

OBJECTIVE

This paper reviews the commonly used botanicals for treatment of mood and anxiety disorders in perimenopausal and postmenopausal women and presents information on their safety and efficacy.

DESIGN

The MEDLINE and EMBASE databases were searched for clinical trials related to the use of botanicals for depression, anxiety, and mood disturbances. Papers were excluded if they were in a language other than English, did not include midlife women as study participants, or did not report on changes in mood, depression, or anxiety.

RESULTS

Five of seven trials of St. John's wort for mild to moderate depression showed a significant improvement. The one randomized, controlled trial of ginseng in postmenopausal women reported improvements in mood and anxiety. All three randomized, controlled trials of ginkgo found no effect on depression. In four of eight controlled trials, kava significantly reduced anxiety. Black cohosh significantly reduced depression and anxiety in all studies reviewed.

CONCLUSIONS

St. John's wort and black cohosh appear to be the most useful in alleviating mood and anxiety changes during menopause. Ginseng may be effective, but more research needs to be done. Kava holds promise for decreasing anxiety in peri- and postmenopausal women; however, women should be careful in the amount and duration of use. Finally, ginkgo and valerian do not appear to be useful in reducing depression or anxiety in this population.

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.

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.

Sex steroid hormone gene polymorphisms and depressive symptoms in women at midlife

Single nucleotide polymorphism (SNP) genotype frequencies were examined to determine whether variation in 6 estrogen-related genes was associated with differences in self-reported depressive symptoms in women. In this substudy of the Study of Women's Health Across the Nation (SWAN), DNA from a multiracial/multiethnic sample of 1,538 African American, Caucasian, Chinese, and Japanese women aged 42 to 52 years participating in SWAN was genotyped. Depressive symptoms were measured with the Center for Epidemiologic Studies-Depression (CES-D) scale. After excluding data from women taking antidepressants (n=103), statistical models were fit using multivariate logistic regression to predict the association of estrogen-related polymorphisms with the dichotomized CES-D score. Among Caucasian women, those with the CYP1A1 rs2606345 CC and AC genotypes had approximately 2-fold greater odds of having depressive symptoms than did those with the AA genotype (95% confidence intervals [CIs], 1.33 to 4.66 and 1.25 to 3.14, respectively). African American women with the CC genotype of the same SNP had 10-fold greater odds of having more depressive symptoms than did women with the AA genotype (95% CI, 1.20 to 86.20). In Japanese women, the odds of depressive symptoms were nearly 5-fold higher among those with CYP 19 rs936306 TT genotype (95% CI, 1.10 to 22.17) than in women with the CC genotype and 9.6-fold higher (95% CI, 2.01 to 45.81) than in women with the CT genotype. The odds of depressive symptoms among Chinese women with the 17HSD rs615942 TT genotype were nearly 11-fold higher than in those with the GT genotype (95% CI, 1.94 to 60.84) and >7-fold higher than in those with the GG genotype (95% CI, 1.13 to 51.82). These data provide evidence that selected genes involved in estrogen synthesis and metabolism increase the odds of more depressive symptoms in women who are premenopausal or perimenopausal.