In the Dealing with Depression workshop we talk about gender differences for depression, noting that women have a higher incidence of depression than men. While some of this difference may be explained by the way we screen for and diagnose depression, there are also likely to be biological differences.
Depression associated with hormonal changes is commonly seen in women – premenstrual dysphoric disorder, postnatal depression, and perimenopausal mood changes are issues regularly dealt with in a general practice setting.
The menopause can be a unique and challenging time for women, and they will often present to a GP with symptoms of menstrual irregularity and hot flushes. Enquiring about psychological changes is important as women may not have made the link between mood changes and ovarian insufficiency.
How is depression different at the Menopause?
Mood changes may not present in a typical way. Perimenopausal depression can be relatively sudden in onset, moderately severe, and be associated with suicidality. It typically presents with symptoms of irritability, hostility, agitation and anxiety. Importantly mood changes can predate physical changes of menopause by up to 5 years.
Australian Prescriber as an excellent podcast on this topic – click here and scroll down to episode 39 to listen.
But why do women experience psychological changes with menopause?
Over 74% of postmenopausal Australian women younger than 55 years experience VMS and 28% of women aged 40 to 65 describe their VMS as ‘moderately to severely bothersome.’4 Furthermore, VMS persisted in over 42% of women aged 60 to 65 years.
Depression may be directly linked to the impact of low oestrogen levels on the brain as we know the oestradiol is neuroprotective. Sleep disturbance is commonly associated with menopause and may contribute. Poor psychological adjustment to this life transition may also play a part.
How does this affect treatment?
While Menopausal hormone therapy (MHT) – when did they stop calling it HRT; is indicated for the management of vasomotor symptoms, in women who don’t wish to take MHT, or it is contraindicated, other therapy options include selective serotonin reuptake inhibitors (e.g. paroxetine, escitalopram) and selective noradrenaline reuptake inhibitors (e.g. venlafaxine and desvenlafaxine), clonidine and gabapentin. Treatment options for menopause are well outlined in the Revised Global Consensus Statement on Menopausal Hormone Therapy published on line in 2016.
Treatment of depression may require combination therapy with hormones and antidepressants. Lifestyle changes are important for general and psychological health, and women are often receptive to healthy lifestyle messages at this time. Psychological interventions may also be indicated.
There is a plethora of information available on menopause so it is important to refer patients to credible sources.
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