Hot & Bothered

by Women's Brain Health Initiative:At midlife – roughly mid-forties to mid- sixties – many women juggle responsibilities at work (during the peak years of their careers) and at home (sometimes caring for both children and aging parents). At the same time, women in this cohort experience physical and emotional changes associated with aging and menopause. It can be a particularly stressful time for women – full of significant life changes, mood swings, and, in some cases, depression.With all that women face during this phase in their lives, it is not surprising that research has shown that perimenopause is a time of increased vulnerability for depressive symptoms and clinical depression (formally called major depressive disorder).Menopause is usually diagnosed after the fact, once a woman has not had a menstrual period or any spotting for 12 months consecutively.Perimenopause, also referred to as the menopause transition, is commonly defined as the period of time starting when the first changes related to approaching menopause begin, and ending one year after the final menstrual period. Changes in the menstrual cycle can commence four to eight years before menopause, but the average length of perimenopause is four years.While both peri- and postmenopausal women have a considerably increased risk of worsening depressive symptoms compared to premenopausal women, depression risk appears to be higher during perimenopause than after menopause.In fact, depression risk begins very early in the menopausal transition, during “early perimenopause” when the menstrual cycles first begin to change in regularity.The risk for clinical depression is highest for middle-aged women who have previously experienced major depression. One study conducted by Dr. Joyce Bromberger and colleagues, published in Psychological Medicine in 2015, examined data of approximately 443 women, aged 42-52, enrolled in the Study of Women’s Health Across the Nation (SWAN) in Pittsburgh. Among women who had never experienced depression before, the risk of developing new onset major depression during the study’s 13-year span was 28% (slightly higher than the risk during premenopause). For women who had experienced depression in the past, the risk of experiencing an episode of major depression during the study period was 59%.Why are Perimenopausal Women More Vulnerable to Depression?One factor that has been studied for its effect on women’s depression throughout the life cycle is hormones. Estradiol, in particular, has received much attention from researchers because it is the predominant estrogen present during a woman’s reproductive years. Among other things, estradiol affects levels of serotonin, a brain chemical that is involved in depression.It was first suspected that low levels of estradiol might be the reason for increased risk of depression. However, estradiol does not just gradually taper off as a woman transitions to menopause. Rather, levels of estradiol fluctuate widely during the transition period, and it is now believed that these dramatic fluctuations are what influences mood disruption.While all women experience fluctuations of estradiol during the menopause transition, only some experience depression. Despite the fact that hormone fluctuations are universal, the duration of exposure to estradiol throughout one’s adult years varies substantially among women. Dr. Wendy Marsh and colleagues conducted a study examining patterns of estrogen exposure during the reproductive years and the risk of depression during the menopausal transition and early postmenopausal years.They discovered that being exposed to estradiol for a longer period of time from the start of menstruation until the onset of menopause was significantly associated with a reduced risk of depression during the transition to menopause and for up to ten years postmenopause.Women who experienced earlier menopause or who had fewer menstrual cycles in their lives (and therefore had less estrogen exposure) were at higher risk for depression. Another interesting finding from this study was that longer duration of birth control use was associated with a decreased risk of depression, but the number of pregnancies or incidence of breastfeeding was not. These findings were published in Menopause in July 2017.Changes in another hormone, progesterone, during perimenopause may also play an important role in depression. Allopregnanolone, a by-product of progesterone, is an important regulator of stress responsivity in women. Changes in this system may predispose women to depression. These findings were described in a research paper by Dr. Jennifer Gordon and colleagues, published in January 2015 in The American Journal of Psychiatry.It appears that hormones play a significant role in a woman’s vulnerability to depression during midlife. Other factors can certainly be involved, too. It is possible that hormones are interacting with a woman’s biological vulnerability and life stress to affect her individual susceptibility to depression. There is still a lot to be learned about midlife depression in women, but enough is known at this point for women and health care providers to take proactive steps to identify and treat midlife depression.Taking Action on Perimenopausal Depression: New guidelines for health professionalsIn September 2018, the North American Menopause Society (NAMS) and the Women and Mood Disorders Task Force of the National Network of Depression Centers (NNDC) released guidelines to help health professionals better understand and address perimenopausal depression. These guidelines, the first of their kind, were developed by an 11-member expert panel that conducted a systematic review of the literature on depressive disorders and symptoms in perimenopausal and postmenopausal women.The guidelines – published in both Menopause and Journal of Women’s Health in September 2018 – summarize the latest information about depression during perimenopause and provide a comprehensive list of recommendations for the evaluation and treatment of depression during the menopause transition.Highlights from the article by Dr. Pauline Maki and colleagues entitled “Guidelines for the Evaluation and Treatment of Perimenopausal Depression: Summary and Recommendations” include the following:SymptomsWomen with depression during midlife experience the classic symptoms of depression (e.g., feeling constant and persistent sadness, feeling worthless, and loss of interest in favourite activities), often along with menopause-specific symptoms (e.g., hot flashes, night sweats, sleep, and sexual disturbances, and changes in cognitive function) and psychosocial challenges (e.g., stress). Some of the common menopause-specific symptoms complicate or overlap with the classic depression symptoms.Diagnosis“To determine whether a perimenopausal woman should be diagnosed and treated for major depression, a health provider should complete a comprehensive evaluation that considers: menopausal stage, co-occurring and overlapping menopause and psychiatric symptoms, and psychosocial risk factors,” said Dr. Maki, a Professor of Psychiatry and Psychology at the University of Illinois at Chicago. “Although menopause-specific assessment tools do not yet exist, health professionals can use existing tools to help disentangle symptoms and distinguish diagnoses.”Treatment“We recommend that the same drugs and psychotherapies used to treat depression in the general population should be used to treat major depressive episodes experienced during perimenopause,” noted Dr. Maki. “Treatment for hot flashes and night sweats could also be helpful, especially if they are affecting sleep.”There is some evidence that estrogen therapy can help with depression in perimenopausal women, but it appears to be ineffective for helping depressed postmenopausal women. The expert team also reviewed the research evidence on alternative therapies. “If someone is experiencing depressive symptoms that don’t reach the threshold for clinical depression, things like mindfulness-based stress reduction, yoga, and a good diet might help,” continued Dr. Maki. “But for cases of clinical depression, we concluded that there is insufficient evidence at this time to recommend any herbal or complementary approaches, the one exception being exercise, which has been shown in research to help.” Common Symptoms of PerimenopauseAlthough most women go through the transition into menopause without experiencing a major depressive episode, it is important that those who do experience depression receive the help that they need.Sometimes a person feels sad or down for a brief period of time. This experience is completely normal and would be referred to as a depressive symptom (which likely does not require treatment), rather than clinical depression (which does require treatment). You might be suffering from clinical depression – and should consult with your doctor – if you experience any of the following symptoms for the majority of the day, almost every day, for at least two weeks consecutively:

• Feelings of sadness or irritation;
• Loss of interest in favourite activities;
• Feelings of worthlessness;
• Thoughts of death or suicide;
• Difficulty concentrating or making decisions;
• Fatigue or lack of energy;
• Sleeping too much or too little; and
• Weight gain or loss.

“We hope that these clinical guidelines will raise awareness about the link between the menopausal transition and mood,” said Dr. Maki. “Our goals are to help more women recognize symptoms and seek medical advice as needed, and also help health professionals know how to identify depression in perimenopausal women and how best to help women who experience mood issues at this time in their lives.” The guidelines are being promoted to doctors around the world, through media exposure after the launch and ongoing presentations by Dr. Maki.Source: MIND OVER MATTER V8