Help For Perimenopausal Women
The new guidance gives women and their doctors a “gold standard” of care during menopause transition.
Perimenopausal Women and Depression
Pauline Maki has made her
career about women and mental health. As a professor of psychology,
psychiatry and OB-GYN at the University of Illinois—Chicago College of
Medicine, as well as the director of women’s mental health research and
associate director of the Center for Research on Women and Gender, she
knows what the research says about these issues. In fact, she has
conducted quite a bit of it herself, for which she received the 2018
Woman in Science Award, given by the American Medical Women's
Association.
But Maki also knows where the research gaps are, and about three years ago she found a big one that she decided to fill.
There
were, at that time, no comprehensive mental health guidelines for
practitioners to follow when caring for women in perimenopause, also
called menopause transition. The North American Menopause Society says
that this transition may last four to eight years, beginning long before
menopause, which is one year after the final menstrual period.
Until
recently, the biological processes behind perimenopause were not well
understood. “We tended to understudy and underdiagnose women” in
perimenopause, says Dr. Maureen Sayres Van Niel, a reproductive
psychiatrist in Cambridge, Massachusetts, and president of the American
Psychiatric Association Women's Caucus. “The different symptoms were
just considered an inconvenience to be endured with grace.” But in the
past few years, new research has looked into the various symptoms and
their treatments. “We now realize there are serious processes here that
need attention,” Van Niel says.
Maki
saw this new research as well, and she decided it was time to put it
all together. “There had never been any guidelines, so we created the
first ones on this topic,” she says.
Symptoms Overlap
In
2015, Maki served as president of the NAMS. As president, she got to
decide “what that year’s big project should be. I had this great
opportunity to leverage that position.” She chose perimenopause
guidelines. NAMS paired with the National Network of Depression Centers,
specifically the Women and Mood Disorders Task Force. “We thought it
would be a wonderful partnership to bring together these experts to do
these guidelines,” Maki says. First, the task force conducted a
systematic review of all the literature. “We wanted practitioners and
women to understand what we think the best approach is to this,” she
explains.
The
final guidelines, published this September in the journal Menopause and
the Journal of Women's Health, have been endorsed by the International
Menopause Society. Maki is the co-lead author, along with Susan
Kornstein, professor of psychiatry and obstetrics and gynecology at
Virginia Commonwealth University. The task force they co-chaired
reviewed the scientific literature on depressive disorders and symptoms
in perimenopausal women and focused on five areas: epidemiology,
clinical presentation, therapeutic effects of antidepressants, effects of hormone therapy and efficacy of other therapies such as psychotherapy, exercise and natural products.
One of the most important things they note is that symptoms of perimenopause and depression are often the same. Sleep disturbances,
for instance, can be exacerbated by hot flashes or night sweats; poor
sleep also can be a symptom of and can contribute to depression. Stress
is often heightened during this time of life, as women juggle parental
duties or sending kids off to college, work responsibilities and caring for aging parents,
which can add to symptoms of both perimenopause and depression. Loss of
appetite, mood swings, loss of interest in sex and problems with
concentration are other symptoms common to both. “So the question
becomes, how do you suss out the differences,” Van Niel says.
A Window of Vulnerability
The
guidelines suggest how to tell the difference between perimenopause and
depression. “The most important finding, the lowest hanging fruit, is
that perimenopause, like puberty and postpartum, is a window of
vulnerability,” Maki says. “Within that window, it is important to
distinguish between two types of mood disorders.” Providers need to be
most concerned about major depression,
which involves symptoms that affect function in a significantly
debilitating way, she says. “In addition, since every woman goes through
menopause if she lives long enough, it is important to talk about
symptoms that don’t meet the criterion for major depression but still
impact quality of life, well-being, work and interpersonal quality, what
we call elevated depressive symptoms.”
The
risk for elevated depressive symptoms applies to all women, regardless
of their own history of depression. “This is something all women need to
be aware of,” Maki says. However, major depression is largely confined
to women with a prior history, the data show. “This is important because
58 percent of women with a history of major depression will experience a
worsening of mood when transitioning to perimenopause,” she says.
The guidelines also state:
- Proven therapeutic options for depression (antidepressants, cognitive behavioral therapy and other psychotherapies) should remain as front-line antidepressive treatments for major depressive episodes during perimenopause.
- Clinicians should consider treating co-occurring sleep disturbance and night sweats as part of treatment for menopause-related depression.
- Estrogen therapy is ineffective as a treatment for depressive disorders in postmenopausal women.
- Hormonal contraceptives may improve depressive symptoms in women approaching menopause.
- Evidence is insufficient for the recommendation of botanical or alternative approaches for treating depression related to perimenopause.
The
recent suicide of the designer Kate Spade, at age 55, is one example of
the seriousness of mental health issues in midlife women, a group that
has shown a 45 percent increase in suicide rates over the past 15 years,
Maki says. Van Niel calls the new guidelines “very important. Some of
the things they found confirmed things we knew, and others gave us more
information. They elucidated risk factors, so we can ask about things
like significant stress and a history of depression. They will really
shed light on our practice. We finally have a gold standard for treating
women in menopause transition.”
David Levine, Contributor
David Levine has been covering mental and behavioral health for U.S. News since 2017. A former ... Read more
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