Mood and Menopause: Mental Health

Mood and Menopause

Objectives

• A key objective is understanding the development and risk factors associated with perimenopausal mood symptoms.
• Assessing perimenopausal mood symptoms to establish treatment approaches based on symptom presentation and goals is another objective.
• Recognizing the roles of both non-pharmacologic and pharmacologic treatments is also an objective.
• Applying a holistic approach to promote healthy aging is another aim.

Perimenopause and Mental Health

• Experiencing depressive symptoms is 2-4 times more frequent than average.
• Depressive symptoms during Perimenopause are reported as more severe on average.
• New Onset Depression and Anxiety risks are increased.
• Regarding depressive symptoms, the Personality and Total Health (PATH) Longitudinal Study reported a Relative Risk (RR) of 1.35 (1.08-1.68).
• Anxiety symptoms had a Relative Risk (RR) of 1.22 (1.02-1.46).
• PTSD symptom severity appears to worsen.
• Depression correlates with greater estrogen, FSH, and LH variability, not absolute levels.

Depression Risk Factors

• Prior depression incidence increases lifetime and new-onset depression in perimenopause.
• Childhood adversity increases new-onset depression in perimenopause.
• Premenstrual Syndrome (PMS) is a risk factor for depression.
• A history of postpartum depression also increases the risk.
• A longer menopausal transition is associated with a higher risk of depressive symptoms.
• Lack of social support, poor educational attainment, and financial difficulties are risk factors.
• Health conditions like smoking, elevated BMI, sleep disturbances, vasomotor symptoms (VMS), and chronic pain are associated with an increased risk.

Additional Mood-Related Symptoms in Perimenopause

• Insomnia is another mood-related symptom.
• Fatigue is a common symptom during perimenopause.
• Irritability and Impaired concentration are symptoms reported.
• Memory and Attention Difficulties can occur during this time.
• A feeling of disconnect, can occur during perimenopause.

Insomnia and Perimenopause

• Among nonpregnant women aged 40–59, the percentage who slept less than 7 hours on average in a 24-hour period was measured by menopausal status.
• Only 35.1% total slept 7 hours on average.
• 32.5% who were premenopausal slept 7 hours on average.
• 56% who were perimenopausal slept 7 hours on average.
• 40.5% who were postmenopausal slept 7 hours on average.

Contributors to Insomnia at Perimenopause

• Vasomotor Symptoms (VMS), sleep disturbance is a contributor.
• mood symptoms such as Depression and anxiety exacerbate insomnia.
• Pain is a possible contributor to insommia
• If the individual is Being Sendentar, that can lead to insomnia.
• Medications are a potential factor.
• Experiencing Nocturia can affect the ability to sleep.
• Partner issues may disrupt the ability to sleep and can lead to insomnia.

When to Consider a Sleep Medicine Referral

• Consider a seep medicine referral if you experience these sleep symptoms, loud snoring.
• Excessive daytime drowsiness are symptoms of insomnia you can consult a doctor for.
• Memory problems or mild cognitive impairment are symptoms of insomnia you can consult a doctor for.
• Depression and Headaches are symptoms of insomnia you can consult a doctor for.
• Diabetes and High Blood Pressure are symptoms of insomnia you can consult a doctor for.

Other Potential Influences on Mental Health

• Physical activity is a lifestyle factor that can influence mental health.
• Social Support networks contribute significantly to mental well-being.
• Major stressors and social role transitions during midlife impact mental health.
• Personal and cultural perspectives influence the mental well-being of older people.
• Chronic pain, medical issue may affect mental health.

Evaluating Mood Symptoms in Menopause & Risk Factors

• Mood symptoms to ask about: Depressed mood and Excessive worry.
• Menopause symptoms to ask about: Vasomotor symptoms and sleep disturbance, Decreased sexual desire, and vaginal dryness/atrophy
• Risk factors to ask about: Past psychiatric history and Current social support

Treatment Approach

• Treatment approach is to focus on predominant symptom – whether it is mood, VMS, or both.
• Discuss non-pharmacologic option is important in treatment.
• The patient must consider other health conditions, potential risks/benefits from MHT
• Consider potential medication side effects
• treatment can be determined by considering one medication at a time. To adjust or add on.
• Shared decision making.

Non-Pharmacologic Options

• Non-pharmacologic options for depression or anxiety are typically recommended for patients experiencing symptoms that are considered less severe.
• A more healthy lifestyle is diet and exercise is one non-pharmacologic option for patients with depression or anxiety.
• Cognitive behavior therapy (CBT) including mindful exercise and meditation are non-pharmacologic options.
• Yoga can also be a non-pharmacologic treatment option.

Estradiol and Mood

• Estradiol is effective when prescribed (over placebo) to women experiencing major depressive disorder (MDD).
• Estradiol can be used as monotherapy provided the patient is taking a progestin because they have a uterus or as an augmenting antidepressant.
• It can take 4 – 6 weeks to reach a benefit.
• Estradiol is not FDA-approved for such conditions.
• Important questions when prescribing estradiol include the Optimal dose and delivery systems, and the length of use.

Treatment for More Severe Mood Symptoms

• Healthy lifestyle changes and professional management of the mood disorder are typically recommended.
• if the patient chooses, Use of agents that activate serotonin system is an option for patients with severe mood symptoms.
• In selecting the appropriate agent, consider what may have worked for the patient in the past.

Psychotropics

• Selective serotonin reuptake inhibitors (SSRIs) include

  • Paroxetine salt 7.5 mg: Single dose is effective, no titration needed.
  • Paroxetine 10-25 mg/d: Start with 10 mg/d.
  • Citalopram 10-20 mg/d: Start with 10 mg/d.
  • Escitalopram 10-20 mg/d: Start with 10 mg/d.

• Serotonin-norepinephrine reuptake inhibitors (SNRIs) include:

  • Desvenlafaxine 100-150 mg/d: Start with 25-50 mg/d and titrate up.
  • Venlafaxine 37.5-150 mg/d: Start with 37.5 mg/d.

• Gabapentinoids

  • Prescribed for sleep and anxiety if side effects limit other options.
  • Gabapentin 900-2,400 mg/d: Start with 100-300 mg at night and add 300 mg or separate it into a morning dose of 300 mg.

Perimenopausal with VMS Affecting Sleep and QoL

• For patients without prior diagnosis who will/can take MHT, its a gold standard for symptom relief.
• For those who can't/wont take MHT, Gabapentin is a solution.
• For those who can't/wont take MHT, Low dose SSRI/SNRI is a solution.
• For patients without prior diagnosis who are not interested in meds, use Alternative tx (CBT-I, yoga exercise).
• For concurrent mood disorder treatment, use SSRI/SNRI.

Insomnia Interventions in Women with VMS

• Most effective intervention in CBT for Insomnia (CBT-I).
• Also effective:
  • Exercise
  • Yoga
  • Antidepressants
• Estrogen not FDA-approved for insomnia; may improve subjective sleep quality but not sleep parameters on polysomnography.

Beyond Symptoms to Health Maintenance

• Midlife depression means there is a higher decline in health and functioning later in life.
• Perimenopause is a pivotal time for health promotion and disease prevention.
• Tips To BOOST Your Health as You Age by making living adjustments to help you stay around longer and better.
  • Get moving by gardening, biking, or walking.
  • Choose Healthy Food rich in nutrients
  • Manage Stress by using yoga or keep a journal
  • Lean something new, take a class or join a club
  • Connect with friends and family.
  • Visit the Doctor Regularly.