We’ve talked about depression during menopause. It’s a common, joy-sapping beastie that rears its ugly head during this time of whacked-out hormones and middle-age adjustment.
After all, what with hot flashes, insomnia, loss of libido, mood swings, who wouldn’t feel depressed?
While we may not exactly sail through menopause, most of us make it through “the change” relatively unscathed. But for a few, the hormonal fluctuations that may precede menopause by a number of years is part of a larger picture—sort of a déjà vu experience that we ought to be aware of so as not to be blindsided by it.
Episodes of depression are common, and they are more common for women than for men. About 20 percent of women—one in five—will experience major depression at some point in life, and that’s twice the rate at which men become depressed, according to this report in “Dialogues in Clinical Neuroscience.”
Why this happens is unclear, but one obvious culprit is the normal hormonal fluctuations that occur at predictable points in a woman’s life: puberty, menstrual cycles, childbirth, and menopause. Some women appear to be more sensitive to these hormonal changes, and depression—sometimes crippling in its intensity—can result. These predictable points at which female hormones are on a roller coaster may be considered “windows of vulnerability.”
Perimenopause—the years immediately preceding active menopause—seems to be the point at which depressive episodes are more frequent. Even before a woman’s menstrual cycle is changing, her hormones may be dancing the rhumba. Perimenopause can last for five years, on average, and 95 percent of women enter it between the ages of 39 and 51.
“These periods are not only marked by extreme hormone variations but may also be accompanied by the occurrence of significant life stressors and changes in personal, family, and professional responsibilities,” writes researcher Claudio Soares in this report for Biomedcentral.com.
The thing to be aware of, however, is that the biggest predictor of perimenopausal or menopausal depression is a prior episode of depression. And the “reproductive life cycle event” most strongly correlated with perimenopausal depression is postpartum depression—the “baby blues.”
“We also found, however, a correlation between perimenopausal mood ratings and ratings at other reproductive cycle events, especially between perimenopausal depression and postpartum depression,” write the authors of this study published in the Journal of Clinical Psychiatry. “This suggests that there may be a subgroup of women who have a specific vulnerability to developing reproductive cycle event–related depression.”
Other well-regarded studies have confirmed these correlations.
What this means for you, as you head into your final and very challenging “reproductive life cycle event,” is that if you’ve experienced postpartum depression or hard-core premenstrual syndrome, you may be at higher risk for depression during perimenopause or menopause.
In fact, if you’ve had one prior incident of depression, your chances of having another are one in two (fifty percent). If you’ve had three previous depressive episodes, your likelihood of experiencing another is 95 percent, according to The Massachusetts Health Study cited in this report.
But that doesn't mean you're without resources: Forewarned, as they say is forearmed. In our next blog post, we'll talk about what you can do to increase awareness and keep yourself healthy—in body, heart, and mind.
Overall, estrogen is helpful to libido and sexual desire. Oral (systemic) estrogen can have the unintended effect of decreasing testosterone, which is linked to libido in women as well as men. The reason is complicated, but has to do with liver metabolism and a binding protein that reduces circulating testosterone.
The approach I take with patients is to use non-oral, transdermal (systemic) estrogen, which bypasses the liver and therefore doesn't affect testosterone levels. I've had patients who couldn't experience orgasm on oral estrogen but could with non-oral estrogen.
And for some women, I do consider adding testosterone. There isn't a product for women, so I use a very low level of male testosterone "off-label" and then monitor blood levels during use. Sometimes, as an alternative, Wellbutrin (buproprion), an anti-depressant, helps restore libido by affecting the neurotransmitter dopamine.
I'm afraid we women are complicated! There are, though, a number of options to experiment with until you've achieved the sex life that makes you happy.
What you describe is a natural result of the loss of natural estrogen through menopause. There are a number of localized estrogen options, including Estrace and Premarin creams, Vagifem tablets inserted in the vagina, and Estring, which is a ring also placed in the vagina.
The therapeutic dose of Estrace is 1 gram applied to the vagina and vulva two times a week; using less than that will be, as we doctors say, "subtherapeutic," which means it won't have sufficient effect! While the creams are effective when used as prescribed, many of my patients prefer and get more consistent doses from the ring or tablets.
You mention a family history of breast cancer. None of these options is "systemic," which means that they can be used by women with breast cancer risk factors--even by some breast cancer patients. There's a new option, too, that's non-estrogen: Osphena is an oral daily medication that showed "statistically significant improvement" in vaginal and vulvar pain.
It takes attention and consistency to regain comfort after being sexually inactive, but I'm sure you'll find it's worth the effort!
I suspect you've been reading the fine print on an advertisement or packaging for one of the estrogen products—for which I congratulate you! It's good to learn as much as you can about your treatment or options.
The mention of dementia is part of the "class labeling" required by the Food and Drug Administration since the Women's Health Initiative in 2002. Even some non-estrogen products in this class receive the same labeling.
In one WHI study, there was a slight increase in dementia for women who used hormone therapy, but it's important to remember that the women entering the study averaged 64 years of age. Additional studies have not replicated those results. It's also worth noting that post-menopausal women have a greater risk than men of developing Alzheimer disease; estrogen has a role in protecting the brain and its function.
For anyone considering hormone therapy, her age and the age at which she entered menopause are critical considerations for heart and brain health. And, as I've said before, every woman, in consultation with her knowledgeable menopause care provider, must weigh the benefits and the risks of hormone therapy for her specific quality of life.
Can’t remember the name of the new work colleague? Forgot the city your best friend lives in? Can’t recall the movie you saw last week?
Join the club.
A little-known fact about loss of estrogen is that it takes a bit of memory with it when it goes. That’s why memory decline is a common feature in post-menopausal women.
Insult to injury, if you ask me. Let’s face it, at this stage of the game, we can ill-afford to lose any bit of that precious function.
In a new study, however, Australian researchers have found that small daily doses of testosterone gel applied to the upper arm improved verbal memory in postmenopausal women.
Testosterone is an androgen—a male hormone—that governs all kinds of things in men, especially sex drive.
Women produce testosterone, too, in the ovaries and adrenal glands, but in miniscule amounts, and its function is not well understood. Testosterone levels drop quickly as women age until at age 40 a woman usually has about half the level of a 20 year old.
It affects libido and has been used successfully to treat low sexual drive in women, but its long-term effects—or even correct dosages—haven’t been rigorously studied.
Testosterone treatment for women hasn’t been approved in either the U.S. or Canada, so it has to be prescribed “off-label.” That means either the physician prescribes an FDA-approved male pharmaceutical product in very small doses (usually about one-tenth of dose recommended for men) or the hormone is compounded specially by a pharmacist.
In the Australian study, researchers found an intriguing link between verbal memory and testosterone in women. In the study, 92 post-menopausal women (between 55 and 65) were first given standard tests for cognitive function. Then they were randomly assigned to receive either a placebo or dosages of testosterone gel for 26 weeks.
At the end of the treatment period, the women receiving testosterone had higher levels of the hormone in their system, and they scored 1.6 times better in tests of verbal memory (recalling words from a list). Scores on other tests remained the same between the two groups.
While these results aren’t game-changers, they do represent one of those incremental steps that can lead to significant advances. “This is the first large, placebo-controlled study of the effects of testosterone on mental skills in postmenopausal women who are not on estrogen therapy," said Dr. Susan Davis, principal investigator in the study.
Since there is currently no treatment for memory loss, and since women suffer from dementia in greater numbers than men, this link between testosterone and memory could be an important finding.
Not to mention the potential side effect of improved libido.
Estring, a vaginal ring, is one method for delivering localized hormones—in this case estradiol. The ring itself includes silicone polymers, so I recommend to my patients that they use a water-based or hybrid lubricant. Among water-based lubricants, Yes and Aloe Cadabra are often ordered. Sliquid Organics Silk is popular among post-menopausal women; as a hybrid lubricant, it has the benefits of water-based but is more long lasting, like silicone-based.
Silicone-based lubricants aren't recommended for use with products made from
silicone—like the Estring and some vibrators or other sex toys—because the formula may cause disintegration of the surface.
A definition first: The endometrium is the mucous membrane that lines the uterus. For women who have had hysterectomies, the endometrium is not an issue in planning hormone therapy (HT).
For others, the endometrium is a "target tissue" (like many others) for estrogen and progesterone. During our reproductive years, those hormones signaled the lining of the uterus to thicken (proliferative endometrium influenced by estrogen) and then to shed (secretory endometrium influenced by progesterone), over and over in our menstrual cycle.
Endometrial cancer is a well-recognized consequence of "unopposed estrogen," a continual message to proliferate and thicken without the proper "opposing" influence of progesterone. Nearly all endometrial cancers will be "estrogen influenced."
When we plan HT for a woman in menopause with a uterus, we must balance estrogen and progesterone. (And, in fact, for a woman in reproductive years who doesn't ovulate, which typically triggers progesterone, we'll compensate with progesterone therapy.)
As with most cancers, there are factors we can't always explain. Obesity, however, is the most common risk factor; in fact, obese women are at higher risk than their friends on HT including both estrogen and progesterone. Fat (adipose) tissue produces estrone, an estrogen that is very weak but does influence the endometrium. Sometimes we biopsy obese women and find "precancer" of the endometrium; part of our treatment is progesterone in an effort to reduce their cancer risk.
Just one more reason, I'm afraid, to make healthy habits a priority—and to work with your health care provider for HT that takes your health history and priorities into account.
This is a common question; unfortunately, it’s complicated to answer. First let me say that while I know weight gain affects many women’s sense of being desirable, what I read and my own informal research suggests it’s rarely an issue for their partners (some of whom are, in fact, oblivious—in a good way—and just as attracted as ever).
There does seem to be a physiologic drive to deposit fat during the menopause transition. The theory is that fat produces estrogen (estrone—a relatively weak estrogen), so in the presence of impending organ failure (menopause) and loss of estrogen from the ovaries (estradiol-the major, more important estrogen) that will occur, the body does its defensive thing: It deposits fat, really efficiently and effectively.
Unfortunately, estrone doesn’t provide many favorable effects. The major location for depositing fat is the midsection. Women who have yo-yoed in weight over the years seem to struggle more; those fat cells seem to remember readily how to deposit fat. Even women who have no weight gain during this transition will have a waist circumference increase of up to two inches.
Minimizing the weight gain starts with maintaining a healthy weight over time; those who are most successful in this transition benefit from years of stability at a healthy body weight leading into those years.
Those menopause transition years will be an added challenge, so start to make small healthy changes early on. Women lose muscle mass quite readily at this time of life, so work to maintain or gain muscle with strength training activities.
It’s a fact of life that at this point, it takes more effort to get the same results, requires more dietary caution and exercise, and leaves little room for not paying attention. My motto: You’re now high maintenance; behave like it!
From what you describe, you've experienced the kind of atrophy that's very common in post-menopausal women. Without intervention, some estimate that women lose up to 80 percent of their genitals—which is surprising to many of us, just as puberty is sometimes surprising! It's good to act just as soon as you can, and then maintain the progress you've made.
From what you describe, I might recommend that you look at creams or tablets for localized hormones to start. The Estring is inserted for 90 days. Having any foreign body placed in fragile tissues causes irritation or ulcerations for some. But once you've achieved a healthy vagina, you could switch from other forms to the Estring, which certainly has a convenience advantage.
Adding estrogen for two to three months will tell you what other actions might be helpful. Along with the vaginal tissues becoming fragile and thin without estrogen, the vagina actually becomes shorter and more narrow. Dilators help to restore capacity, and they're easy to use.
Congratulations on deciding to reclaim intimacy with your husband! Best of luck, and we're here if you have questions along the way.
It’s no wonder we’re confused. First it’s good; then it’s bad. Now it’s up to you.
Hormone replacement therapy has had more media makeovers than Liz Taylor, and it continues to grab attention here and there.
The latest, and highly credible, statement on the issue is from an international roundtable of medical experts convened by the Society for Women’s Health Research (SWHR). The purpose of this gathering of experts, which represented various specialties, such as cardiovascular disease, osteoporosis, and cancer, was to take yet another objective and rigorous look at the evidence regarding hormone replacement therapy, and to make recommendations as to its use and safety. The results of this discussion just came out in the Journal of Women’s Health.
This roundtable is a good effort to shed some objective light on the risks and benefits of an issue that’s been hotly debated for over ten years now, ever since the Women’s Health Initiative (WHI) prematurely ended its groundbreaking study of women receiving hormone therapy in 2002 because of a high incidence of breast cancer and cardiovascular complications.
The problem, however, is that hormone therapy (HT) is still the only effective, FDA-approved treatment for menopausal symptoms, such as hot flashes and vaginal changes. Recently two non-hormonal drugs were just nixed by an FDA advisory panel because they were viewed as ineffective.
Ever since the WHI results were released, the pendulum has been swinging wildly with each new medical release or research report. And while this latest SWHR roundtable really moves the chess pieces very little, it does solidly reaffirm positions held by the North American Menopause Society.
(In fact, NAMS had released its latest position statement on hormone treatment barely a month earlier.)
What the roundtable did add, however, is something I strongly advocate: Give women solid information about their treatment options and let them make informed decisions about their own health.
Their findings include:
Here’s how the SWHR roundtable puts it: “It’s time to put HT back on the table so that women can discuss with their providers the option of symptom relief and possible long term health benefits.”
Amen to that.