Understanding Perimenopause (PART 2)

This is the conclusion of an article on Perimenopause, a condition where women have reached the end of their childbearing years, but before the actual menopause period starts. We regret the absence of this article that was promised to our readers on January 28.

The Hormonal Connection

The links between hormonal fluctuations and physical symptoms during perimenopause are becoming clearer. Take hot flashes, for example. “The temperature-regulating centre in the hypothalamus [of the brain] appears to be influenced by oestrogen and progesterone,” Dr Soares explains. Researchers speculate that during perimenopause the fluctuations of these hormones can cause the hypothalamus to regulate body heat less efficiently, he says.

Dr Soares reminds us that fluctuations in reproductive hormones are associated with depression at other points in the reproductive cycle. For instance, women may experience depressed or irritable mood in the premenstrual part of their cycle – which, depending on severity may be called either premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). In addition, some new mothers develop symptoms of depression in the days, weeks or months following the birth of their baby (the postpartum period).

Antidepressant medication and psychotherapy continue to be the treatments of choice for depression occurring during the perimenopausal period. But recent studies show that oestrogen-replacement therapy can reduce symptoms of mild-to-moderate depression in some perimenopausal women. Furthermore, in one of the first double-blind, placebo-controlled studies on perimenopause and depression, Dr Soares and a team of researchers discovered that hormone-replacement therapy could reduce symptoms of major depression in perimenopausal women.

The study, published in June 2001 in the Archives Of General Psychiatry, tested the effectiveness of estradiol (the most potent form of naturally occurring oestrogen) in easing major depression in perimenopausal women. Fifty women aged 40 to 55 were studied. All had irregular menstrual cycles. They used blood tests that measured levels of some key hormones to determine that the women in the study were in the perimenopausal phase. Standardised tests were used to determine the degree of depressive symptoms and 26 of the women were diagnosed with major depression.

The women were divided randomly into two groups. One group received therapeutic doses of estradiol through a skin patch. The others received a placebo patch that contained no medication. The women wore the patches for 12 weeks.

The study found that 17 of the women (68 per cent) who received estradiol had a significant reduction in symptoms of depression. Of the women getting a placebo, only five women (20 per cent) had a similar decrease in depression.

Dr Soares, who works in the Prenatal And Reproductive Psychiatry Clinical Research Programme at Massachusetts General Hospital, says the fact that the oestrogen effect seen in his study suggests the strong influence of hormonal changes in the development of these symptoms. This important biological cause thus must take its place among other presumed causes of symptoms of depression, such as sadness over aging, the loss of certain physical capacities, or the departure of children from home.

“You may have some very well-adjusted women who are working and sexually happy with their partners and suddenly they get depressed as they approach menopause, ” says Dr Soares. “The reason may be related to their hormonal changes … rather [than] to stressful life events.”

Could it be that women who took estradiol patches were less depressed simply because they stopped having hot flashes and other uncomfortable physical symptoms? Probably not, Dr Soares says.

“When we stopped using estrogen after 12 weeks of treatment and saw them [the women in the study] after four weeks off of oestrogen, most of them were suffering from a relapse of physical symptoms but were feeling well emotionally,” he says. “There was no significant relapse of depression.” Dr Soares says this suggests that the anti-depressive effects of oestrogen continue for a significant period of time after it is stopped.

These findings are encouraging, though Dr Soares acknowledges that a larger study must be carried out in this area. He suggests that doctors consider estrogen for the treatment of depressive symptoms in some perimenopausal women, especially those who also are experiencing physical symptoms, such as hot flashes, or have a high risk to develop osteoporosis.

Oestrogen Not For Every Woman

But Dr Soares warns that while oestrogen may offer some women a two-for-one benefit – reducing physical and emotional symptoms – it’s not the treatment of choice for every perimenopausal woman suffering from depression. Estrogen-replacement therapy comes with drawbacks, such as increased risk of breast and uterine cancer. Women who are severely depressed, should seek comprehensive psychiatric treatment, including an evaluation for traditional antidepressant therapy, Dr Soares says.

Each woman must carefully weigh the benefits and risks of oestrogen-replacement therapy for the depression that occurs during perimenopause. Many women will want to consider consulting their primary-care physician, their gynaecologist and a psychiatrist to help them make the best decision. Such factors as the specific symptoms, the medical and psychiatric history, and the family’s medical history are very important, he says.