Is it Menopause or Depression? 2/15/2018

Is it Menopause or Depression?

Females in their 40s and 50s often present to their primary care providers with new-onset depressive symptoms. In developing a treatment plan, it is important to assess if the symptoms are part of menopause or perimenopause or if they represent a new-onset depressive disorder. A complicating factor is that menopause can independently increase the risk of a depressive episode even in a woman without a history of depression.

During the assessment, it is important to obtain a thorough menstrual history as well as ask if the patient is experiencing other physical symptoms of menopause. The menstrual history should include if her cycle is regular or irregular, the heaviness of the flow, and when she had her last menses. Perimenopause begins when the cycle begins to vary and ends 12 months after the last menses. If it is clinically unclear if a patient is in perimenopause, one can measure FSH and estrogen levels during the early follicular phase. During perimenopause, vasomotor symptoms (VMS) and mood lability may worsen. Vasomotor symptoms include hot flashes and night sweats. Other physical symptoms of menopause include: forgetfulness, insomnia, sexual changes (decreased desire, vaginal atrophy), vaginal dryness, joint pains, bladder discomfort, breast pain, and headaches.

Menopausal patients with vasomotor symptoms are more likely to have mood symptoms as well, which can include: irritability, insomnia, mood lability, and anxiety. Both the mood changes associated with menopause as well as the vasomotor symptoms are linked to dysregulation of monoaminergic neurotransmitter systems caused by fluctuating estrogen levels.

Treatment is based on where the patient is in the course of perimenopause/ menopause and on the severity of the mood symptoms. The other factor is the appropriateness of hormone replacement therapy (HRT). While there has been much controversy about HRT since the Women’s Health Initiative study in 2002 showed concerns about possible increased risk of breast cancer and limited cardiac protection of HRT, more recent evaluation of the study results has reduced many of these concerns. As a result estrogen is the only FDA approved treatment for VMS, and since mood symptoms of menopause are so intimately linked to VMS, theoretically estrogen would be a good treatment for depression linked to menopause as well.

If the patient is in perimenopause and HRT is an option, studies have shown that HRT can be helpful for both the mood symptoms of perimenopause as well as VMS, so it can be an appropriate treatment for women presenting with mild-moderate mood symptoms related to perimenopause. If HRT is not an option or if the mood symptoms are more severe, treatment with an antidepressant is an option. Studies have shown that the selective norepinephrine reuptake inhibitors (venlafaxine, duloxetine) are more helpful for VMS than the selective serotonin reuptake inhibitors (SSRIs), so if HRT is not an option, one might consider starting with an SNRI to treat both the mood symptoms as well as the VMS. If HRT is an option, one might consider a combination of HRT and an SSRI as an alternative

Posted in Depression, Menopause, older adults, Womens Health.