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Date: Tue, 28 Feb 95 14:27:46 CST
From: "Ted Weltzin,M.D." <tweltzin@facstaff.wisc.edu>
Subject: Estrogen in menopause
If the patient is not on estrogen replacement and has no risk factors such as breast or uterine cancer, consider this option. Although I have not found much information of this topic, some reports suggest that estrogen replacement may improve antidepressant response in menopausal women.
Date: Sat, 18 Nov 1995 16:31:05 -0500
From: mbiddel@interport.net (Miriam Biddelman)
Subject: Depressive symptoms in menopause
Since the baby boomers encompass about 40,000,000 females in the U.S., it is vitally important for psychiatrists to understand menopausal symptoms. The emotional components are often depression, with or without agitation, irritability, cognitive dysfunction, lowered libido, memory loss, and anxiety. Often the look and experience of the depression and anxiety are different than with males and non-menopausal females. The experiences I've described can't be shrugged off by talking about the travails of middle age. There are major hormonal changes and I believe changes in brain chemistry. I attended the North American Menopause Society meeting in September, there was a suggestion from an endocrinologist that estrogen replacement can potentiate the impact of an SSRI.
Date: Sun, 19 Nov 1995 21:28:55 -0500
From: mbiddel@interport.net (Miriam Biddelman)
Subject: Depressive symptoms in menopause
Menopausal symptoms can be seen as early as 35, and having regular periods does not rule out menopause. Classic symptoms which some have mentioned include memory loss, lowered libido, cognitve dysfunction, irritablity, and feeling like you don't want to be in your own skin.
I believe that any woman experiencing a cluster of these symptoms should not think she's crazy, but should get the proper medical attention. See a noted gynecologist (ask if they specialize in menopause; if they're strictly OB, don't go). Or see an endocrinologist who specializes in treating menopausal women.
There are different modes of treatment. There are varying points of view on hormone replacement. Each woman is different and should weigh her risks for osteoporosis, heart disease, breast cancer, etc., and follow the treatment plan that makes the most sense.
I chose to address my symptoms psychopharmacologically as much as I could. Through a low dose SSRI plus a low dose tricyclic and a benzodiazepine, my mood lifted and my anxiety left. Nonetheless, I was told that there was no way to treat the memory loss, the cognitive issues, and the low libido psychopharmacologically. I really did not want to take estrogen, but my endocrinologist felt that with low dose estrogen my memory would return and my confusion would clear up. With estrogen my memory came back miraculously and my cognitive difficulties vanished.
Women who are uncomfortable with drugs and hormone replacement can turn to Chinese herbs, acupuncture, ... "natural" hormones which the Women's International Pharmacy will mix, [and] products rich in estrogen, like soy products and tofu.
The best advice is to see a clinician who is hooked in to the latest information, [including] psychiatrists who know about menopause and the mind.
Date: Mon, 20 Nov 1995 19:52:29 -0800 (PST)
From: Peter Forster <forster@itsa.ucsf.EDU>
Subject: Estrogen in menopause
I want to second this message. I had a post menopausal woman I saw for two years who had severe depression and was only partially responsive, at best, to anything I threw her way. She also complained of memory problems. In desperation I added unopposed estrogen, and relatively rapidly this converted her to a good responder to venlafaxine (I suspect it might have worked with other partially effective medications that I had tried).
Date: 13 Oct 96 18:48:43 EDT
From: "Furey A. Lerro" <71544.3434@compuserve.com>
Subject: Estrogen in menopause
I've seen significant cognitive improvement in women who have begun hormone replacement therapy. Usually, I request that they speak with their gynecologist regarding its implementation. Jay Amsterdam of the University of Pennsylvania hosted a symposium on this topic within the past year and published a monograph of its highlights. You might want to contact him there about getting a copy of it.
Subject: Estrogen in menopause
Date: Tue, 3 Dec 96 16:40:59 -0500
From: "Samuel L. Kent" <samkent@eznet.net>
I see a great deal of exacerbation of previously stable depressive and anxiety disorder in women who are passing through the change of life. In one case a previously in-remission patient who'd had a hysterectomy had a very treatment-resistant relapse despite compliance when she was in her mid-40s. She happened to mention hot flashes and vaginal itching and dryness during one session, and I sent her for an FSH which was 57 (post-menopausal). Her internist and gynecologist agreed she should have estrogen replacement, and on oral estrogen, the previously effective antidepressant was again effective, plus the hypoestrogenic side effects remitted.
I have seen two patients who were partial responders and already on replacement for whom I did a follow up FSH (seldom done after prescribing the standard estrogen replacement unless classical perimenopausal symptoms persist). One had no vaginal dryness or hot flashes. The other noted, when asked, that for some time she'd been uncomfortable during intercourse and had to use a lubricant. Each had a high FSH and doubling their Premarin doses helped their depressive symptoms (in both cases with the knowledge and consent of their gynecologist).
I used FSH as a monitor of circulating estrogen activity with the thought that like TSH in hypothyroidism, the most sensitive measure of the end-organ's supply of the hormone is the feedback inhibited stimulating hormone.
From: MKomrad@aol.com
Date: Wed, 4 Dec 1996 01:27:25 -0500
Subject: Estrogen in menopause
There is literature on the value of estrogen replacement in enhancing antidepressant response in post-menopausal women.
Date: 11 Feb 97 00:24:42 EST
From: Leslie Gise <76106.413@CompuServe.COM>
Subject: Estrogen in menopause
We have had anecdotal reports and small case studies for a long time, but until we have proper clinical trials we will not know exactly how estrogen affects mood at menopause and how it best can be used. Basic science and clinical evidence to date suggest that it has properties in common with psychostimulants and improves mood, but it can also depress mood and the effect of progesterone is unclear. Since Alzheimer's is so devastating, trials of estrogen to improve cognition seem clinically warranted on an experimental basis.
Date: Fri, 25 Sep 98 06:37:11
From: Phyllis Edelheit, M.D. <edelheit@nassau.cv.net>
Subject: Estrogen in menopause
Testosterone and estradiol and estrone need to be measured -- too much is as difficult for a patient to tolerate as too little. In addition, estrogen, which is unopposed by testosterone, can make a person extremely irritable, obsessive, angry, depressed, and anxious -- Andrew Herzog has a paper:
Herzog, Andrew G. Perimenopausal depression: Possible role of anomalous brain substrates. Brain Dysfunction. 2 (3), May-Jun 1989, 146-154.
which may be helpful.
Date: Tue, 29 Dec 1998 01:54:59 -0500
From: Frank Feiner <nfrank@pol.net>
Subject: Estrogen in menopause
The effects of estrogen on mood have long been discussed in the literature. Whereas there were a few early studies noting no benefit of estrogen alone (6, 7), and one more recent study seemed to show a negative effect (5), and whereas there have been several calls (certainly appropriate) for "more complete investigation to settle the issue", I found via a PubMed search this evening that there is a plethora of studies which support the assertion that addition of estrogen perimenopausally, usually to a preexisting antidepressant, has a salutory effect on mood. Granted, most of these are not controlled studies and a good many are short anecdotal reports, although a few struck me as particularly robust (1, 2, 3, 4).
Date: Mon, 3 May 1999 14:49:10 -0400 (EDT)
From: Joelle Bunting <buntinjo@umdnj.edu>
Subject: Estrogen in menopause
I routinely have menopausal and post-menopausal women see a gynecologist for estrogen replacement therapy, especially when antidepressants are called for. In my experience, none of the antidepressants work as effectively as they will when the patient is on estrogen replacement therapy.
Date: Mon, 03 May 1999 21:18:15 -0400
From: herbert cohen <herbc@erols.com>
Subject: Depressive symptoms in menopause
Absolutely. As a matter of fact if the hormone replacement therapy is started before the SSRI,the latter may not be necessary. Estrogens were used for depression long before tricyclics.
From: deborahp@home.com (Deborah Pines, MD)
Date: Tue, 04 May 1999 07:14:34 -0400
Subject: Depressive symptoms in perimenopause
What about the perimenopausal patient who may be mid to late forties or early fifties and is still having menstrual cycles? In my experience, a good many gynecologists will tell such patients that if they are still having cycles, their estrogen levels are fine and don't have a role in any mood problem.I've dealt with gynecologists who still thought that hormone levels needed checking, with an eye to estrogen supplementation, if a patient wasn't responding well to antidepressants, even if the patient wasn't perimenopausal.--Tom Lewis, M.D.
From: "Swartz, Holly" <SwartzHA@MSX.UPMC.EDU>
Subject: Antidepressants in menopause
Date: Tue, 4 May 1999 10:10:18 -0400
Data from Thase and Frank and others suggest that individuals in a low estrogen state (e.g., men, post-menopausal women without hormone replacement therapy, and surgically-induced menopausal young women) respond less favorably to the SSRIs and more favorably to the tricyclics. By contrast, young (i.e., estrogenized) women do better on SSRIs. Mechanistically, you can postulate that estrogen potentiates the effects of central serotonin.
From: RICHMOND.JANET_S@BOSTON.VA.GOV
Subject: Depressive symptoms in perimenopause
Date: 4 May 1999 10:21 EDT
Several gynecologists in Boston have told me at different times, and for different patients, that as long as estrogen is still being produced by the ovaries, no replacement therapy is indicated. The explanation I have received is that the estrogen levels remain stable -- it's the FSH that rises in perimenopause and that rise pushes the ovaries to produce estrogen. That FSH surge is what causes the hot flashes (and I assume the other symptoms, such as mood lability), and there is no estrodiol depletion (as long as the FSH is working adequately) -- thus, no need, so I have been told, for estrogen replacement. (Therefore, psychotropics would be the gynecologists' choice of pharmacotherapy for perimenopausal mood lability, hyoscyamine and similar medications for hot flashes, etc.)
From: DLMCMA@aol.com
Date: Tue, 4 May 1999 12:24:38 EDT
Subject: Raloxifene in menopause
In a message dated 5/4/99 9:13:43 AM Eastern Daylight Time, sunrise@igc.org writes:
What is the recommendation in women for whom estrogen is medically contraindicated?I've used raloxifene (Evista) [a selective estrogen receptor modulator] for these women for replacement therapy in women with concurrent mood, chronic pain, and anxiety disorders, as well as several patients with bipolar disorder and depression (a contraindication is a history of phlebititis or DVT), and they've found it is helpful, particularly with cognitive dulling and memory. Since estrogen replacement therapy is considered to be beneficial to most if not all women and should be offered where there is no contraindication, it would be hoped that most postmenopausal women would have been offered and refused it in an informed manner before treatment for depression is on the table.
In my experience, many women with mood disorders do not do well on hormones (progestins, especially, both in oral contraceptives and in hormone replacement therapy) so for those with a uterus needing hormone replacement therapy, raloxifene is high on my list of treatments to offer, although a trial of estrogen/progestin is more first line. Many women do not like the bleeding that can occur in the first year of combined therapy and refuse. Raloxifene is a nice option, and seems to have the cognitive benefits of hormone replacement therapy (n = about 8).
Date: Tue, 04 May 1999 20:34:41 -1000
From: Leslie Gise <leslieg@maui.net>
Subject: Estrogen in menopause
If the depression is mild, especially if it does not meet DSM IV criteria, especially if vasomotor symptoms are prominent, and especially if she is going to take hormones anyway, a one month trial of estrogen is reasonable, but if she is not better in a month, she should consider treatment for depression with psychotherapy or antidepressant medication.
From: "Jim Pfrommer, M.D." <goodwrench@easy.com>
Subject: Progestins in menopause
Date: Sat, 12 Dec 1998 08:35:22 -0600
I've often found gynecologists give Provera and believe it's the same as progesterone, but only its actions on the uterus have probably ever been studied. I've seen so many anxiety and depression reactions from Provera that I've come to believe that it may work just like progesterone at the uterus, but also bind and block receptors at the central level. Most gynecologists are terribly reluctant to give unopposed estrogen, but a few weeks of a change in just this part of the current medication regimen could show just what contribution so-called progesterone replacement might be making to current complaints.
Date: Sat, 12 Dec 1998 06:56:27 -1000
From: Leslie Gise <leslieg@maui.net>
Subject: Progestins in menopause
Anecdotally, natural progesterone has fewer central side effects than medroxyprogesterone (Provera, a synthetic progestin).
Date: Sat, 12 Dec 1998 15:01:05 -0600
Subject: Hormones in menopause
From: linx13@juno.com (Linda Roos)
Natural progesterone (IMHO, preferable to Provera) is available and can be ordered from any compounding pharmacist as well as obtained from at least one commercial source. It is also possible to compound the estrogen with progesterone and testosterone into one capsule, cream or troche if desired. Estradiol is important for libido, while estrone has the best breast protective effects. If compunded you can put some of both in the preparation. John R. Lee has written What Your Doctor May Not Tell You About Menopause : The Breakthrough Book on Natural Progesterone, which might be of some interest. I take my headache patients off Provera and place them on natural progesterone with good results.
Date: Tue, 15 Dec 1998 01:30:34 -0500
From: "Phyllis B. Edelheit, MD" <edelheit@nassau.cv.net>
Subject: Hormones in menopause
Recently I gave a Grand Rounds on Neuroendocrine Aspects of Psychiatric Illness, and although I didn't touch on treatment, I went through the basic concepts of hormonal interactions.
Perhaps the best place to begin would be with the epileptogenic potential of estrogen as well as the anticonvulsant potential of progesterone. First of all, if you paint estrogen on a rat's brain, the rat will seize. There was a study of a group of epileptic woman given estrogen, and I don't remember the exact numbers, but it was something like 11/13 went on to seize, with one seizing for three days. Then, in Sweden, they gave progesterone to epileptic women and normalized their EEGs.
Andrew Herzog has demonstrated quite nicely the reciprocal relationship between seizure discharges and hormones. If you have right temporal lobe epilepsy (TLE), then you get hypogonadotropic hypogonadism; if you have left TLE, you get a polycystic ovarian syndrome (PCO) picture. The laterality and placement of temporal lobe seizure discharges alters the pulsatile secretion of GnRH and thereby plays a role in pituitary function. These hormones are active in the brain prenatally and have profound effects.
Estrogen is epileptogenic, and progesterone is a powerful anticonvulsant -- however, progesterone doesn't work without estrogen. So if estrogen goes too low -- or if the NMDA receptor isn't working well -- then progesterone won't be potentiated.
Antiepileptic drugs have various effects on hormones. Carbamazepine, phenytoin and phenobarbital are enzyme inducers. They help metabolize these hormones by inducing the enzymes. Valproate can act to increase estradiol levels.
If a person is being given estrogen, and their mood remains as unstable or becomes more unstable, you might begin to think seizure disorder -- some anticonvulsants will lower the estrogen level, others not. Before adding exogenous estrogens, I measure levels and then attempt to use a medication which will give me the desired hormonal as well as behavioral effects. You'd be surprised at how knowing what the drugs do hormonally, measuring a person's levels and attempting to normalize them can improve the patient's response.
Also, epilepsy (or whatever you want to call this subclinical picture; I like to call it cortical activation) can be comorbid with depression. For some people, you want to treat the epilepsy adequately, then treat the depression. And if you try to treat the depression first, you will fail. Dietrich Blummer writes on this quite nicely.
Unopposed estrogen can give you unresponsive obsessive-compulsive disorder, phobias, anger, hostility, hyper- or hypo-sexuality, mania, agitated depression, profound depression, and anxiety (for which benzodiazepines are a drop in the bucket; have you ever had a patient who can eat benzodiazepines like water and still be anxious?).
Herzog speaks of a very important concept -- that of the anomalous brain substrate. There are many people who tolerate the normal fluctuations of hormones without any problem, but for those with sensitive brains, those hormonal changes can have a profound effect on their mood. Even more complicated is the time surrounding menarche and menopause. Most adolescents will have their share of anovulatory cycles, and this could be devastating to the sensitive brain. The same thing is true as a woman becomes perimenopausal -- when she experiences some ovulatory and some anovulatory cycles.
As a case in point, I had a patient who had been experiencing anovulatory cycles (by measurement of day 22 luteal phase progesterone). She responded quite well to progesterone and then had a cycle of profound depression -- she probably ovulated, adding her progesterone to the exogenous progesterone, and, voila, too much. Herzog talks about a woman who cycles, 3 days on estrogen, 3 days off progestin, 3 days off all. That's what works for her -- she is off course on anything else -- she is unusual.
Hormones have three effects -- one is immediate, another is short term and one is over weeks to months and has to do with genomic transciption and translation.
From: deborahp@erols.com (Deborah Pines, MD)
Date: Mon, 14 Dec 1998 23:14:56 -0800
Subject: Hormones in menopause
Short term, I know no risks of unoppposed estrogen. Gynecologists are often unwilling to do it though. A month, or a few months, of unopposed estrogen can answer the question of whether or not progesterone is responsible for side effects or toxicity or symptoms.My understanding is that unopposed estrogen leads to profliferation of the uterine lining and exposes a woman to an increased risk of endometrial cancer. One shouldn't go three months -- according to my gynecologic resources -- without at least ten days of progesterone to bring on menses and shedding of the the build-up of endometrium.--Leslie Gise
This is also an excellent way to tease out whether the progesterone is causing the difficulty. With a ten day course every two months, one can really see the difference that the progesterone can make in terms of increased irritability, depression, etc.
Estrogen tends to improve mood. Progesterone seems to depress it.
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Dr. Bob is Robert Hsiung, MD,
dr-bob@uchicago.edu
URL: http://www.dr-bob.org/tips/split/Depressive-symptoms-in-men.html
Original tips copyright 1994-99 original authors.
Web page copyright 1995-99 Robert Hsiung.