Capítulo VI: Resultados de la investigación
6.1 Investigación etnográfica
Menopause is a normal life stage and tran-sition, which most women traverse, with little or no difficulty. Many welcome the cessation of menstruation and unwanted pregnancies, looking forward to new
opportunities with enthusiasm, described as postmenopausal zest. However, the notion that women become irritable and depressed at menopause, has long pre-vailed among clinicians and women.
Although population data shows that the menopausal years are not associated with an increase in depression for most women, there appears to be a small subset of women who are especially vulnerable to depression at this time of life. These are women with a history of depression, cur-rently experiencing severe psychosocial stress and fluctuating symptom severity, associated with shifts in gonadal hormone (Freeman et al, 2004).
The psychosocial context of middle-aged women’s lives greatly affects their adaptation to the biological changes of perimenopause. Most studies show that the psychosocial context of menopause may have a greater effect on symptoma-tology than any biological changes and caution against an overly reductionist hormonal approach to mood or cogni-tive symptoms.
Estrogen receptors are present in almost all tissues of the body and play an important role throughout the life span. Estrogen receptors are particular-ly plentiful in the brain, especialparticular-ly in the hypothalamus, medulla and limbic sys-tem. It is, accordingly, not surprising that sudden changes in estrogen levels, such as those at perimenopause, may affect mood, anxiety and cognition.
For several years there has been great interest in the use of estrogen to treat
ADVANCES IN WOMEN’S MENTAL HEALTH
perimenopausal depression, anxiety, and cognitive changes. Estrogen’s role in regulating neurotropic, neurotrans-mitter factors and neuropeptides may explain its impact on vasomotor, mood, and cognition symptoms in peri-menopausal women. Double-blind, placebo-controlled studies have shown significant antidepressant benefit with the use of transdermal estradiol in some perimenopausal women suffering from major depressive disorder, dysthymia, or minor depression (Schmidt et al, 2000; Soares et al, 2001). The antide-pressant benefit, after a 4-week washout period, despite the re-emergence of vasomotor symptoms suggests the exis-tence of an independent effect of estra-diol on vasomotor symptoms. Previous studies, using oral conjugated estrogen, showed negative therapeutic results, suggesting that the route of administra-tion may be important. Other studies have attempted to show the efficacy of estrogen as an adjunctive treatment in depressed perimenopausal or post-menopausal women on SSRIs. In gener-al, perimenopausal compared to post-menopausal women, appear to respond more favorably to estrogen. The con-comitant use of hormone therapy may maximize the benefits obtained with SSRIs in perimenopausal women. An antidepressant medication should be tried first in perimenopausal women who have major depressive disorder. In those women who remain unresponsive to antidepressant treatment, augmenta-tion with a small dose of estrogen at the lowest dose, for the shortest time possi-ble, is a reasonable option.
Other hormones have also been studied for their effects during perimenopause.
Progesterone appears to have a nega-tive effect on mood, mainly as a result of increased irritability and dysphoria.
Androgens, including testosterone and androstenedione, are produced in women by the adrenal glands and ovaries, and are reputed to have neuro-protective properties. Androstene-diones are currently under study for the treatment of mood and cognitive decline in perimenopausal women. The new selective estrogen receptor modu-lators (SERMs) are also being studied for their effects on mood and cognition but to date, have shown minimal effects.
For years, women and their health care providers were exhorted to use exoge-nous estrogen replacement therapy to treat a variety of menopausal mood and cognitive symptoms. Estrogens and progesterones were lauded for their protective effects on the cardiovascular system, bone density, general well-being, and the treatment of acute peri-menopausal symptoms, such as vasomo-tor flashes. The Women’s Health Initiative (WHI), a landmark primary prevention trial, randomly assigned over 6000 postmenopausal women aged 50 to 79 to receive estrogen plus proges-terone, or placebo. The primary out-come measure was coronary heart dis-ease, with invasive breast cancer as a primary adverse outcome. In May 2002, after a mean of 5.2 years of follow-up, the trial was stopped by the Data Safety Monitoring Board. The overall health deleterious effects, associated with
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bined estrogen and progesterone, exceeded the benefits. In general, there were more strokes, coronary heart dis-ease, invasive breast cancer and pul-monary emboli per 10 000 person years in the hormone group (The Writing Group for the WHI, 2002). In February 2004, the estrogen only arm of the WHI, was also stopped (Anderson et al, 2004).
Results of the WHI study also showed no beneficial effects on quality of life, including questions on general health, vitality, mental health, depressive symp-toms and sexual satisfaction at 3 years.
The Women’s Health Initiative Memory Study (WHIMS) was conducted on a subgroup of WHI women, 65 years or older, to assess the incidence of demen-tia or mild cognitive impairment in women treated with estrogen and prog-estins. Four years after randomization, there was increased risk for probable dementia, seen among women using estrogen plus progestins, as compared with placebo (Shumaker et al, 2004).
There was also no significant improve-ment in cognitive function among hor-mone users compared to placebo.
The results of the WHI surprised many physicians and their patients, leaving unanswered questions about the best management of various conditions, including depression, in midlife women.
In general, these studies on menopause, again, show the importance of random-ized controlled trials in evaluating treat-ment of women’s treat-mental health prob-lems. The genetic and environment stud-ies, are a welcome move away from uni-factorial explanations, towards studying the interactions of environmental and biological variables. The promise of new scientific methods including genetics, neuroimaging, hormones, psychology and social sciences continue to have a vital impact on our better understand-ing and treatment of mental disorders in women.
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Donna E. Stewart, Professor of Psychiatry, Lillian Love Chair in Women’s Health, Toronto General Hospital, 657 University Avenue M/L 2-004, ML-200-4, Toronto, Ontario, Canada M5G ZNZ
E-mail: [email protected]
Introduction
The discipline of old age psychiatry makes steady progress in advancing the understanding of and develops treat-ment for the elderly with treat-mental disor-ders.
A 2000 word summary can only high-light some areas, reflecting some domains of interest.
This report results from the contribu-tions from some members of the Section Executive Committee:
Dr Nori Graham (UK) Dr Nicoletta Tataru (Romania) Prof Cornelius Katona (UK)
Prof Edmond Chiu (Australia) (Chairman)