Evidence-Based Reviews

Psychiatric considerations in menopause

Current Psychiatry. 2018 October;17(10):11-16,53

References

1. Bromberger JT, Kravitz HM. Mood and menopause: findings from the study of women’s health across the nation (SWAN) over 10 years. Obstet Gynecol Clin North Am. 2011;38(3):609-625.
2. Almeida OP, Marsh K, Flicker L, et al. Depressive symptoms in midlife: the role of reproductive stage. Menopause. 2016;23(6):669-765.
3. Sajatovic M, Friedman SH, Schuermeyer IN, et al. Menopause knowledge and subjective experience among peri- and postmenopausal women with bipolar disorder, schizophrenia and major depression. J Nerv Ment Dis. 2006;194(3):173-178.
4. Ayers BN, Forshaw MJ, Hunter MS. The menopause. The Psychologist. 2011;24:348-353.
5. Bromberger JT, Kravitz HM, Chang YF, et al. Major depression during and after the menopausal transition: Study of Women’s Health Across the Nation (SWAN). Psychol Med. 2011;41(9):1879-1888.
6. Cohen LS, Soares CN, Vitonis AF, et al. Risk for new onset of depression during the menopausal transition: the Harvard study of moods and cycles. Arch Gen Psychiatry. 2006;63(4):385-390.
7. Freeman EW, Sammel MD, Lin H, et al. Associations of hormones and menopausal status with depressed mood in women with no history of depression. Arch Gen Psychiatry. 2006;63(4):375-382.
8. Georgakis MK, Thomopoulos TP, Diamantaras AA, et al. Association of age at menopause and duration of reproductive period with depression after menopause: a systematic review and meta-analysis. JAMA Psychiatry 2016;73(2):139-149.
9. DiBonaventura MC, Wagner JS, Alvir J, et al. Depression, quality of life, work productivity, resource use, and costs among women experiencing menopause and hot flashes: a cross-sectional study [published online November 1, 2012]. Prim Care Companion CNS Disord. 2012;14(6): pii: PCC.12m01410. doi: 10.4088/PCC.12m01410.
10. Llaneza P, Garcia-Portilla MP, Llaneza-Suárez D, et al. Depressive disorders and the menopause transition. Maturitas. 2012;71(2):120-130.
11. Vivian-Taylor J, Hickey M. Menopause and depression: is there a link? Maturitas. 2014;79(2):142-146.
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13. Friedman SH, Stankowski JE, Sajatovic M. Bipolar disorder in women. The Female Patient. 2007;32:15-24.
14. Soares C, Cohen L. The perimenopause, depressive disorders, and hormonal variability. Sao Paulo Med J. 2001;119(2):78-83.
15. Friedman SH, Sajatovic M, Schuermeyer IN, et al. Menopause-related quality of life in chronically mentally ill women. Int J Psychiatry Med. 2005;35(3):259-271.
16. Schmidt PJ, Ben Dor R, Martinez PE, et al. Effects of estradiol withdrawal on mood in women with past perimenopausal depression: a randomized clinical trial. JAMA Psychiatry. 2015;72(7):714-726.
17. Carretti N, Florio P, Bertolin A et al. Serum fluctuations of total and free tryptophan levels during the menstrual cycle are related to gonadotrophins and reflect brain serotonin utilization. Hum Reprod. 2005;20(6):1548-1553.
18. Borrow AP, Cameron NM. Estrogenic mediation of serotonergic and neurotrophic systems: implications for female mood disorders. Prog Neuropsychopharmacol Biol Psychiatry. 2014;54:13-25.
19. Hu LY, Shen CC, Hung JH et al. Risk of psychiatric disorders following symptomatic menopausal transition: a nationwide population-based retrospective cohort study. Medicine (Baltimore). 2016;95(6):e2800. doi: 10.1097/MD.0000000000002800.
20. Riecher-Rossler AW. Estrogens and schizophrenia. In: Bergemann N, Riecher-Rossler A, eds. Estrogen effects in psychiatric disorders. Wien, Austria: Springer-Verlag Wien; 2005:31-52.
21. Pope CJ, Oinonen K, Mazmanian D, et al. The hormonal sensitivity hypothesis: a review and new findings. Med Hypotheses. 2017;102:69-77.
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23. Caan B, LaCroix AZ, Joffe H, et al. Effects of estrogen and venlafaxine on menopause-related quality of life in healthy postmenopausal women with hot flashes: a placebo-controlled randomized trial. Menopause. 2015;22(6):607-615.
24. Seeman MV. Psychosis in women: Consider midlife medical and psychological triggers. Current Psychiatry. 2010;9(2):64-68,75-76.
25. Sajatovic M, Friedman SH, Sabharwal J, et al. Clinical characteristics and length of hospital stay among older adults with bipolar disorder, schizophrenia or schizoaffective disorder, depression, and dementia. J Geriatr Psychiatry Neurol. 2004;17(1):3-8.
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28. Kulkarni J, Gavrilidis E, Gwini SM, et al. Effect of adjunctive raloxifene therapy on severity of refractory schizophrenia in women: a randomized clinical trial. JAMA Psychiatry. 2016;73(9):947-954.
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31. Ballard KD, Kuh DJ, Wadsworth MEJ. The role of the menopause in women’s experiences of the ‘change of life.’ Sociology of Health & Illness. 2001;23(4):397-424.
32. Clayton AH, Ninan PT. Depression or menopause? Presentation and management of major depressive disorder in perimenopausal and postmenopausal women. Prim Care Companion J Clin Psychiatry. 2010;12(1):PCC.08r00747. doi: 10.4088/PCC.08r00747blu.

The biopsychosocial approach to treatment is particularly important in menopause.¹¹ Common transitions in midlife include changes in relationships, employment, and financial status, and illness or death of family and friends.³¹ Therapy may focus on accepting a role transition and coping with loss of fertility. Cognitive-behavioral therapy may be helpful for menopausal symptoms, including hot flashes,⁴ as well as depressive symptoms.¹¹

Although there are overlapping symptoms with both MDD and the perimenopause, these are typically restricted to impaired energy, sleep, and concentration, or changes in libido and weight.³² Therefore, it is vital to obtain a clear history and explore these symptoms in greater depth, as well as collect further information related to additional criteria such as appetite, agitation, feelings of worthlessness or guilt, and suicidal ideation.

Starting an antidepressant

On evaluation, Mrs. J discloses that she had experienced thoughts of wanting to end her life by overdose, although she had not acted on these thoughts. She appears subdued with poor eye contact, latency of response, and a slowed thought process. Mrs. J has blood tests to rule out thyroid abnormality or anemia. FSH and LH levels also are measured; these could provide a useful reference for later.

After a discussion with Mrs. J, she agrees to start an antidepressant. She also plans to speak to her gynecologist about the possibility of hormone replacement therapy. She is referred for psychotherapy to help support her with current life stressors. Mrs. J is started on escitalopram, 10 mg/d, and, after a month, she notices some improvement in her mood, psychomotor symptoms, sleep, and energy levels.

Bottom Line

Menopause is an important transition in our patients’ lives—both biologically and psychosocially. Women’s symptom patterns and medication needs may change during menopause.

Related Resource

The North American Menopause Society. Depression & menopause. https://www.menopause.org/for-women/menopauseflashes/mental-health-at-menopause/depressionmenopause.

Drug Brand Names
Citalopram • Celexa
Duloxetine • Cymbalta
Escitalopram • Lexapro
Raloxifene • Evista
Venlafaxine • Effexor

Psychiatric considerations in menopause

References

Starting an antidepressant

Bottom Line

Related Resource

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