Minding menopause: Psychotropics vs. estrogen? What you need to know now

The FDA is considering other testosterone preparations—including a testosterone patch for women and a gel in female-sized doses.

Using the Sexual Energy Scale. To monitor for a therapeutic response, ask the patient to use the Sexual Energy Scale (Figure 1).^29,30 Instruct her to define her “10” as the time in life when she had the most fulfilling sexual life, was the most easily aroused, had the most sexual pleasure, and the best orgasms. Her “1” would be when she felt the worst sexually and had the least desire.

Giving supplemental estrogen. If you prescribe estrogen plus testosterone (Estratest), start with Estratest HS, which contains 0.625 mg esterified estrogens and 1.25 mg of methyl testosterone. Add a progestin if the patient is postmenopausal and has not had a hysterectomy, to protect the uterus from endometrial hyperplasia.

Women with vaginal dryness also need supplemental estrogen, which can be applied vaginally (such as Premarin cream or Estrace cream). A vaginal lubricant is not sufficient to avoid age-related vaginal atrophy, which may make intercourse difficult or impossible.

Figure 1 How to use the Sexual Energy Scale to monitor response to therapy

Libido improves modestly

Ann returns in 4 weeks with gradually improving sex drive (Sexual Energy Score is now 5). She had sexual intercourse twice in the past month and didn’t “dread” it, but also did not enjoy it or reach orgasm. You have told her that venlafaxine may slow or prevent orgasm, but she wants to keep taking it. She reports that her marital relationship is improving.

You order repeat testosterone and SHBG blood levels and find her free androgen index has improved to 1.10, which is still low. You increase the Androgel dosage to 1/5th of a 2.5 mg packet (0.5 mg/day) and continue to monitor Anne’s Sexual Energy Scale ratings at monthly follow-up visits. She has set a Sexual Energy Scale rating of 7 to 8 as her target. Anne says she appreciates your help with—as she puts it—“this embarrassing problem.”

Medicine’s understanding of menopause’s physiologic and psychological consequences is changing, just as the “baby-boom” generation is navigating this passage called the change of life. Many midlife women are unaware that the menopause transition does not begin around age 50 but spans 30 years—from ages 35 to 65. Natural menopause begins 15 years before and ends 15 years after menstruation ceases—as the brain and tissues adjust to first fluctuating then decreased estrogen levels. It occurs in three phases—early menopause, perimenopause, and late menopause—that reflect a progression of hormone changes.

EARLY MENOPAUSE: OVULATION ACCELERATES

At approximately age 35, the ovaries start producing lower levels of inhibin—a glycoprotein that inhibits pituitary production of follicle-stimulating hormone (FSH) (Figure 2). Less inhibin means less negative feedback to the pituitary and an increase in pituitary FSH production. More FSH means more activin—an ovarian glycoprotein that stimulates ripening of eggs—and so ovulation begins to accelerate at approximately age 36. Activin stimulates more and more eggs in the ovary to develop faster and faster.

By age 37, the ovarian egg reserve starts to decline, and—because FSH has increased—the follicle is driven to produce greater amounts of estrogen. Estrogen serum levels in fertile women average 100 pg/mL. During perimenopause, estrogen levels sometimes soar to 300, 400, or even 500 pg/mL, then may crash down to 50 to 80 pg/mL. These wild fluctuations are thought to trigger headaches, sleep disturbance, mood swings, and sexual complaints in some women.

Hysterectomy and mood symptoms. Women in their early 40s are exposed to high levels of estrogen in some menstrual cycles and low levels in others. Excess estrogen thickens the endometrium—causing heavier bleeding—and stimulates fibroid growth, which is the leading reason for hysterectomies.

One in four American women undergoes surgical menopause. The average age of the 700,000 U.S. women who undergo hysterectomy each year is 40 to 44. Women who have had a hysterectomy and have mood symptoms and sexual adjustment problems are likely to see psychiatrists earlier than women who undergo a more gradual natural menopause.

PERIMENOPAUSE: HOT FLASHES, DRY VAGINA

At ages 45 to 55, most women (90%) who have not had a hysterectomy start to cycle irregularly, tending at first toward shorter cycles and then skipping periods. Some periods are heavier and some lighter than usual. The remaining 10% of women continue to cycle regularly until their menstrual periods stop abruptly.

Many women notice temperature dysregulation during perimenopause. When they exercise, their cool-down times may double. Menopausal symptoms such as hot flashes occur when estrogen levels drop below the point that some researchers call a woman’s “estrogen set point.”