Minding menopause: Psychotropics vs. estrogen? What you need to know now
Psychotropics have become a first-line therapy for hot flashes and depression in perimenopause. Will you be ready when Ob/Gyns call you for help?
Screening for estrogen decline. When you see a patient in your office, you can often determine whether her affective symptoms—irritability, mood swings, depressed mood, and forgetfulness—might be related to estrogen decline by asking two screening questions:
- Are you having any warm flushes or hot flashes?
- Do you have vaginal dryness?
Figure 2 Normal female reproductive cycle: The rhythm of the hypothalamic-pituitary-ovarian axis
LATE MENOPAUSE: ESTROGEN LOW, MOOD UP
During late menopause, approximately age 55 and older, women commonly complain of vaginal dryness, hot flashes, night sweats, sleep problems, and fatigue. Sexual interest may decrease, and a decline in sexual activity can become a problem for some couples. Asking “How is your sex life?” often will open a discussion of the couple’s sexual and emotional relationship.
Other physiologic changes caused by estrogen and androgen deficiency include thinning body hair—including pubic, auxiliary, and leg hair—decreased body odor, thinning skin, wrinkling skin, and decreasing bone density.
Table 4
Three phases of menopause: A 30-year process
| Early Ages 35 to 45 | Middle (perimenopause) Ages 46 to 55 | Late Ages 56 to 65+ |
|---|---|---|
| Physiologic changes | ||
| Ovary starts producing less inhibin 15 years before menses stop | Irregular menstrual cycles, with shorter cycles, skipping periods for 90% of women | Depletion of eggs and follicle |
| Decreased inhibin increases FSH and stimulates follicle to produce more estrogen | Some periods heavier, some lighter than usual | |
| Increased estrogen thickens endometrium and leads to heavier menstrual bleeding and increased risk of fibroids | ||
| Increased FSH produces more activin, which makes eggs develop faster and accelerates egg depletion | ||
| Lab values | ||
| Menses: Normal | Cycle shorter (24-26 days) | None for >12 months |
| FSH day 3: 10-25 mIU/mL | 20-30 mIU/mL | 50-90 mIU/mL |
| Estradiol day 3: 40-200 pg/mL | 40-200 pg/mL | 10-20 pg/mL |
| Inhibin B day 3: Varies | <45 pg/mL | 0 |
| Symptoms | ||
| Headaches, sleep disturbances, mood swings, urinary problems, sexual complaints | Warm flushes, hot flashes, night sweats in 82% of women (moderate to severe in 40%) | Vaginal dryness, hot flashes, night sweats, sleep problems, fatigue, sexual interest changes, thinning body hair (pubic, legs, axillary), decreased body odor, thinning skin, wrinkling skin, decreasing bone density, BUT mood starts to stabilize |
| FSH: follicle-stimulating hormone | ||
Urinary symptoms. Bladder problems and urinary symptoms are persistent symptoms of menopause for 75% of women. Although we psychiatrists don’t review the urinary system, it is important to remember that embarrassment because of urinary incontinence during sex may have a lot to do with a woman’s “loss of interest” in sexual intercourse.
Despite sometimes-difficult physiologic changes, the good news for many women is that mood symptoms start to stabilize after perimenopause (Table 4). Women whose moods are very responsive to hormonal fluctuations—such as those with severe premenstrual syndrome or premenstrual dysphoric disorder—sometimes get much better after menopause.
Related resources
- The Women’s Health Site. Duke Academic Program in Women’s Health. www.thewomenshealthsite.org
- Massachusetts General Hospital Center for Women’s Mental Health. www.womensmentalhealth.org
Drug brand names
- Citalopram • Celexa
- Fluoxetine • Prozac
- Gabapentin • Neurontin
- Paroxetine • Paxil
- Sildenafil • Viagra
- Venlafaxine • Effexor
Disclosure
Dr. Brizendine reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
