8-23-2006 — Women may find HRT to be helpful
By Patricia Kincare
Beth wondered what was wrong with her. All her life she’d been happy and content. She loved her husband, had enjoyed raising her kids who were now in college, and found her work and friendships interesting and fulfilling. But for the past six months she had been teary, didn’t want to see friends and had stopped pursuing her hobbies. Everyone was asking what was wrong, and she had no answers”¦
“Is it hot in here, or is it just me?” Julie was in the middle of presenting her ad agency’s proposal to a new client, when she felt it start. Heat, sweat running down her face, palpitations, anxiety, and even a slight shiver. Worst of all, she couldn’t remember the word she wanted to use to describe her client’s product.
About 1.3 million women enter menopause each year. The transition to menopause, known as “perimenopause,” usually begins in a woman’s 40s, and lasts four to eight years. Beyond menstrual changes, 45 percent to 85 percent of women experience “vasomotor symptoms.” These include night sweats and hot flashes, which can be accompanied by palpitations, a feeling of anxiety, and sometimes even by chills. There may be changes in sexual functioning, memory problems, significant insomnia and the risk for developing osteoporosis and cardiovascular disease also increases. Mood disturbances and surges in anxiety may occur, even in women with no history of difficulties.
We’ve come a long way in not pathologizing what is a normal transition for women. But what is the likelihood that a woman of “middle age” might develop depression?
A very interesting new study by Lee Cohen, MD, et al, has shed some light on this question. Researchers followed 460 “premenopausal” women ages 36 to 45, with no lifetime history of depression, for six years. They found that women entering “perimenopause” were twice as likely to develop significant depressive symptoms as those women who were strictly premenopausal. Perimenopausal women who reported hot flashes, had an even greater risk.
Another recent study by Ellen Freeman, PhD., et al, enrolled 231 premenopausal women between the ages of 35 and 47, with no history of depression, and followed them for eight years — interviewing them, drawing hormone levels, and assessing for the presence of depressive symptoms. They found that increased levels of two hormones, leutinizing hormone (LH) and follicular stimulating hormone (FSH) and increased variability in an individual woman’s LH, FSH and estradiol levels, were significantly linked to depressive symptoms. They reported that women were 2.5 times more likely to have depression diagnoses when they were perimenopausal, than when they were premenopausal.
Clearly, perimenopausal status and hormone variability seem to increase the risk for developing depression in some women. Are there other factors that might contribute as well? Absolutely.
Some people think that vasomotor symptoms lead to sleep disturbance, which in turn negatively affects mood. Estrogen may improve mood in two ways. First, it is a potent modulator in the brain. Second, as the discomfort of hot flashes and night sweats improves, sleep and mood often improve as well.
Of course large, prospective studies (HERS and WHI) have called into question the efficacy and safety of long-term use of hormone replacement therapy (HRT). However, short-term use has not been deemed unsafe, and individual women, in consultation with their physicians, still might find it a useful treatment. Interestingly, some of the newer antidepressants, used alone without any estrogen, have been successful in relieving hot flashes. Julie, in our example above, might find one of these strategies helpful. Women suffering from depression or anxiety along with hot flashes, might find an antidepressant helps across the board.
Other researchers remind us of the psychosocial factors influencing women at this time of their lives. Aging parents, children leaving home — or returning after college or a divorce “” may be stressful for women. Issues in the marital, or partner, relationship and how each individual woman feels about aging and moving beyond the reproductive years can be factors that contribute to changes in mood or anxiety as well.
So if you’re feeling like “it’s hot in here”, you may well be onto something. Most women move through this time with manageable amounts of discomfort. For these women, nurturing the important connections in their lives, and stepping up self-care routines can be very helpful. But don’t just “write-off” feeling depressed, because you’ve never felt depressed before. If, like Beth, you’re in the 15 to 18 percent of perimenopausal women who develop more disabling depression, know that help is available.
Patricia Kincare, M.D. is a Board Certified psychiatrist with Woodland Professional Associates of North Hampton, MAINE. She treats adults who have mood and anxiety disorders and has a special interest in women’s reproductive and childbearing issues.
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