Perimenopausal Depression: Covering Mood and Vasomotor Symptoms; Hormones, Antidepressants, or Psychotherapy-What Would You Recommend?

Article excerpt

Symptoms of perimenopausal depression are not inherently different from those of depression diagnosed at any other time in life, but they present in a unique context:

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* Hormonal fluctations may persist for a long duration.

* Women experiencing hormonal fluctations may be vulnerable to mood problems.

* Psychosocial/psychodynamic stressors often complicate this life transition.

Managing perimenopausal depression has become more complicated since the Women's Health Initiative (WHI) studies found fewer benefits and greater risks with hormone replacement therapy (HRT) than had been perceived. This article discusses the clinical presentation of perimenopausal depression, its risk factors, and treatment options in post-WHI psychiatric practice.

Who is at risk?

Perimenopausal depression is diagnosed when onset of major depressive disorder (MDD) is associated with menstrual cycle irregularity and/or somatic symptoms of the menopausal transition. (1) Diagnosis is based on the overall clinical picture, and treatment requires a thoughtful exploration of the complex relationship between hormonal function and mood regulation.

Presentation. For many women, perimenopause is characterized by mild to severe vasomotor, cognitive, and mood symptoms (Table 1, page 40). Thus, in your workup of depression in midlife women, document somatic symptoms--such as hot flushes, vaginal dryness, and incontinence--and affective/behavioral symptoms such as mood and sleep disturbances.

Table 1
Vasomotor, cognitive, and mood symptoms of perimenopause

Vasomotor                       Cognitive, and mood

Hot flushes                     Decreased concentration
Sweating                        Anxiety
Heart palpitations              Irritability
Painful intercourse             Mood lability
Vaginal dryness and discomfort  Memory difficulty
Sleep disruption
Headache

Explore psychiatric and medical histories of your patient and her close relatives. Ask about depression, dysthymia, hypomania, or mood fluctations around hormonal events such as menses, pregnancy, postpartum, or starting/stopping oral contraceptives. In the differential diagnosis, consider:

* Is low mood temporally connected with hot flushes and disturbed sleep?

* Is low mood secondary to stressful life events?

* Does the patient have another medical illness (such as thyroid disorder) with symptoms similar to depression?

* Is low mood secondary to anxiety or another psychiatric disorder?

Screening. Menopause is considered to have been reached after 12 months of amenorrhea not due to another cause. Median ages for this transition in the United States are 47.5 for perimenopause and 51 for menopause, with an average of 8 years between regular cycles and amenorrhea. (2) Therefore, begin talking with women about perimenopausal symptoms when they turn 40.

Evidence supports screening perimenopausal women for depressive symptoms even when their primary complaints are vasomotor. The Greene Climacteric Scale (3) is convenient for quantifying and monitoring perimenopausal symptoms. It includes depressive symptoms plus physical and cognitive markers. The Quick Inventory of Depressive Symptomatology--Self Report (QIDS-SR) (4) questionnaire:

* takes minutes to complete

* is easy to score

* quantitates the number and severity of depressive symptoms (see Related Resources, page 50).

Table 2

Risk factors for depression in women

Predictive over lifetime              High risk during menopausal
                                              transition

History of depression                 History of PMS, perinatal
                                      depression, mood symptoms
                                      associated with contraceptives

Family history of affectiv disorders  Premature or surgical menopause

Insomnia                              Lengthy menopausal transition
                                      ([greater than or equal to] 27
                                      months)

Redued physical activities            Lengthy menopausal transition
                                      ([greater than or equal to]27
                                      months)

Weighy gain                           Persistent and/or severe
                                      vasomotor symptoms

Less education                        Negative attitudes toward
                                      menopause and aging

Perceived lower economic status

Perceived lower social support

Perceived lower health status

Smoking

Stressful life events

History of trauma

Marital dissatisfaction

PMS: Premenstrual syndrome

Figure

Biopsychosocial milieu of depression during perimenopause

          Depression

Social         Structural family changes; social support; losses in
               peers and extended family

Psychological  Personality characteristics; perceptions of menopause
               and aging

Biological     Hormonal fluctation; hot flushes and night sweats;
               disrupted sleep; painful intercourse

Psychosocial factors can predict depression at any time in life, but some are specific to the menopausal transition (Table 2). …