By Consultant Psychiatrist Dr.V.Mangala
Depression is one of the common psychological problems in women. The menstrual cycle has often been closely associated with depression and anxiety in women. This article describes the association between depression and menopause.
Menopause:
Menopause refers to stopping of menstrual cycles and usually occurs between ages 44 and 55 years. Perimenopause is the period before menopause when ovarian function begins to decline. This causes hormonal changes, which causes the physical symptoms that several women experience. The level of the hormone oestrogen estradiol becomes very less following menopause.
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These low level of oestrogen cause the various symptoms of perimenopause, like hot flushes and cold sweats. These can persist for several years after the last period.
Hot flushes are associated with perspiration, breathlessness, dizziness and tachycardia. These can be confused with panic attacks as they can happen all of a sudden and are associated with anxiety. Night sweats cause sleep disturbances causing decreased concentration, fatigue and irritability subsequently.
Epidemiological studies have shown that women are not at any greater risk for depression during menopause when compared with other times of their lives.
However, some subgroups of women are at increased risk for perimenopausal depression. They are:
- Those with past history of the premenstrual depressive disorder.
- History of OC pill related mood changes.
- History of postpartum depression (Depression following delivery)
- Presence of chronic physical illness
- Remaining widowed separated or divorced.
- Having significant caregiving responsibilities( looking after sick relative at home)
Symptoms of Depression:
The most important thing of all is the alteration in mood, a feeling of sadness, despair, and despondency.
- Sadness, anxiety, or “empty” feelings
- Decreased energy, fatigue, being “slowed down”
- Loss of interest or pleasure in activities that were once enjoyed,
- including sex
- Insomnia, oversleeping or waking much earlier than usual
- Loss of weight or appetite, or overeating and weight gain
- Feelings of hopelessness and pessimism
- Feelings of helplessness, guilt, and worthlessness
- Thoughts of death or suicide, or suicide attempts
- Difficulty concentrating, making decisions, or remembering
- Restlessness, irritability, or excessive crying
- Chronic aches and pains or physical problems that do not respond to treatment
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The vegetative symptoms commonly accompany depressive symptoms but can also be the primary presenting complaints. The clinical presentation of depression across all cultures is multiple vague somatic symptoms of chronic duration with no underlying physical problem diagnosed on examination or investigations.
Among women especially in India vaginal discharge, headache and low backache have been the most common physical complaints. Vaginal discharge with no evidence of any urogenital infection has been frequently seen as a presenting complaint in women with depression in our country.
The psychological symptoms are essential to establish a diagnosis which is quite easily elicited in most of the patients. Anxiety is usually present along with depression in many of them. It is not absolutely essential to differentiate the two, when coexistent, as treatment is similar.
Evaluation and Management
Evaluation should involve documentation of menstrual cycle patterns, sexual function and vasomotor symptoms. Lab investigations need to be done to rule out to estimate thyroid levels and FSH levels. Physical exam and investigations to rule out other medical illnesses that can cause depression like cancers, autoimmune disorders, heart disease etc.
Subclinical or mild depression usually responds well with harmone replacement therapy alone as reduction of physical symptoms, especially vasomotor, decreases depressive symptoms. If depressive symptoms continue to persist after relief from vasomotor symptoms, standard psychiatric treatment needs to be initiated.
Management:
Treatment consists of a combination of pharmacotherapy and psychotherapy. Mild to moderate depression can be treated with psychotherapy alone.Cognitive behavioural therapy and social skills group may be of use as a preventive strategy. Antidepressants with drugs to reduce anxiety will help.