Estradiol variability, stressful life events, and the emergence of depressive symptomatology during the menopausal transition

Relationships Between Vasomotor Symptoms and Mood in Midlife Urban Chinese Women: Observations in a Prospective Study

CONTEXT

During the menopausal transition, there is a greater likelihood of the prevalence of various bothersome symptoms, including vasomotor symptoms (VMS) and mood symptoms.

OBJECTIVE

To investigate the association among bothersome VMS and symptoms of anxiety and depression in Chinese women during perimenopause and early in menopause.

DESIGN, PATIENTS, SETTING, AND INTERVENTIONS

This study included 430 midlife Chinese women who had experienced natural menopause and were followed up for 10 years. A structured questionnaire was provided annually, comprising the VMS Bother Score (range 1-8) from the Menopause-Specific Quality of Life questionnaire, the Hospital Anxiety and Depression Scale, and other physical and behavioral factors.

RESULTS

Among the 430 women evaluated, 78.8% had experienced VMS during long-term follow-up. The overall level of VMS bother score was relatively low (1.92 ± 1.32). Both anxiety and depressive symptoms were significantly associated with VMS bother. After adjusting for potential covariates, the association between anxiety or depression symptoms and VMS bother remained highly significant. Menopausal stage, body mass index, general health, follicle-stimulating hormone, and estradiol were independent contributors to VMS. In time-lagged (1-year) models, VMS bother scores significantly predicted the risk of symptoms of both anxiety and depression the following year. In contrast, anxiety symptoms, rather than depressive symptoms, could predict VMS bother the following year.

CONCLUSION

The prevalence of VMS in our cohort was higher than has been previously reported; however, the overall level of bother was relatively low. This study demonstrated a strong relationship between VMS bother and mood symptoms in Chinese women progressing from perimenopause through natural menopause.

EEG Revealed That Fragrances Positively Affect Menopausal Symptoms in Mid-life Women

During mid-life, women experienced not only physical but also neurological transition. Because of this, many women suffer from physiological and/or psychological menopausal symptoms. Although hormone therapy (HT) was broadly used to alleviate menopausal symptoms, HT showed inconsistent effects in case of psychological symptoms. Moreover, mid-life women’s brains have distinct characteristics than in other periods of life, it is needed to study psychological symptoms in shifted brain network of mid-life women. As an alternative, inhalation of fragrances may alleviate psychological menopausal symptoms. To characterize the alleviation mechanism by fragrances, we tested the effect of fragrances on menopausal symptoms using electroencephalographic (EEG) methods. We hypothesized that fragrance could restore mid-life women’s brain response to stressful situations. We tested six fragrance conditions, including no-odor condition (solvent only) in twenty-eight mid-life women (49.75 years±3.49). Our results showed that fragrances increased alpha power and decreased β/α ratio depending on the severity of menopausal symptoms in a stressful situation. Our study would be helpful in psychological menopausal symptom alleviation as well as fragrance screening for well-being in mid-life.

The effects of physical activity and sedentary behavior in the associations between cardiovascular diseases and depression: A four-way decomposition

BACKGROUND

Negative effects of cardiovascular diseases (CVDs) on depression have been reported, but the relative contribution of physical activity (PA) and sedentary behavior (SB) to such effects remains unclear. Our objective was to precisely quantify the effects modified or mediated by PA and SB using the recently developed four-way effect decomposition.

METHODS

Our analysis included 22,117 adults (aged≥20 years) participating in the 2007-2016 National Health and Nutrition Examination Survey (NHANES). Depression was assessed by the Patient Health Questionnaire-9. Moderate recreational activity (MRA), moderate work activity (MWA), and walk or bicycle for transportation, were measured by the Global Physical Activity Questionnaire (GPAQ). A four-way decomposition was applied with PA and SB as mediator to decompose the total effects of CVDs on depression into four components: controlled direct effect (CDE), pure indirect effect (PIE), reference interaction (INT_ref), and mediated interaction effect (INT_med).

RESULTS

There were statistically significant associations between CVDs, MRA, and depression, with the adjusted odds ratios (95% confidence intervals) of being 1.73 (1.42~2.30), 1.81 (1.42~2.30), respectively. With MRA as a mediator, there were interaction and mediation effects in the associations between CVDs and depression, and the proportions attributable of INT_ref, INT_med, and PIE were 94.08% (P<0.001), 3.92% (P = 0.007), and 1.68% (P = 0.006), respectively. Furthermore, the mediation effect was statistically significant in females rather than males.

CONCLUSIONS

MRA strongly modified and mediated the effects of CVDs on depression, especially in females. Our results suggested that sufficient MRA (at least 150 min per week) was considered as requirement for preventing depression in CVDs patients in females.

Estradiol and Women's Health: Considering the Role of Estradiol as a Marker in Behavioral Medicine

The sex hormone estradiol, as measured through saliva, represents a non-invasive and cost-effective approach to understanding the influence of hormonal factors on physical and psychological well-being among women. Estradiol levels dramatically change at hormonal transitions, such as puberty, menopause, and postpartum. It is at these transitions where women are at increased risk for psychological and somatic distress. Salivary estradiol also has implications for decision-making and has been broadly associated with engagement in health-compromising behaviors which can influence women's ability to cope with and manage chronic health conditions. This review summarizes the evidence for salivary estradiol as a marker of physical and psychological health, and discusses practical information regarding saliva collection and assay. The overall intent is to expand and clarify knowledge of the relation between changes in salivary estradiol and women's health as well as to provide a means of integrating salivary estradiol into future behavioral medicine research.

Progesterone modulates theta oscillations in the frontal-parietal network

The neuroactive metabolites of the steroid hormones progesterone (P4) and testosterone (T) are GABAergic modulators that influence cognition, yet, the specific effect of P4 and T on brain network activity remains poorly understood. Here, we investigated if a fundamental oscillatory network activity pattern, often related to cognitive control, frontal midline theta (FMT) oscillations, are modulated by steroids hormones, P4 and T. We measured the concentration of P4 and T using salivary enzyme immunoassay and FMT oscillations using high-density electroencephalography (EEG) during eyes-open resting-state in 55 healthy women and men. Electrical brain activity was analyzed using Fourier analysis, aperiodic signal fitting, and beamformer source localization. Steroid hormone concentrations and biological sex were used as predictors for scalp and source-estimated amplitude of theta oscillations. Elevated concentrations of P4 predicted increased amplitude of FMT oscillations across both sexes, and no relationship was found with T. The positive correlation with P4 was specific to the frontal midline electrodes and survived correction for the background aperiodic signal of the brain. Using source localization, FMT oscillations were localized to the frontal-parietal network (FPN). Additionally, theta amplitude within the FPN, but not the default mode network, positively correlated with P4 concentration. Our results suggest that P4 concentration modulates brain activity via upregulation of theta oscillations in the FPN.

Progesterone, reproduction, and psychiatric illness

Mood and anxiety disorders are vastly overrepresented in women, and one important contributor to these differences is the fluctuation in sex steroids in women during the reproductive years. Considerable evidence supports a role for abnormal sensitivity to these hormonal fluctuations for some women, who develop mood symptoms associated with reproductive transitions. This chapter presents evidence of the role of endogenous progesterone and its metabolites in such mood symptoms, and then goes on to cover the evidence concerning exogenous progesterone's effects on mood. Overall, the literature does not support an association between exogenous progesterone and negative mood in the general population, but does indicate that subset of women may be vulnerable to such effects. Research is lacking on women with psychiatric illness.

Transdermal estradiol for postpartum depression: results from a pilot randomized, double-blind, placebo-controlled study

Postpartum depression (PPD) is a common complication following delivery, though evidence-based treatment options are limited. This study explores the feasibility and efficacy of outpatient PPD treatment with transdermal estradiol (TE). In a pilot, double-blind, placebo-controlled trial, women with PPD were randomized to receive transdermal 17β-estradiol (100 mcg/day) or placebo patch. Over 6 weeks, women completed weekly ratings on the Beck Depression Inventory (BDI), Edinburgh Postnatal Depression Scale (EPDS), and Hamilton Depression Scale (HAM-D). Primary outcome measures were treatment response (> 50% decrease from baseline BDI) and remission (BDI < 10) at 6 weeks, and secondary outcome measures included severity on all scales at weeks 3 and 6. Of 12 recruited women, 6 received TE and 6 received placebo. By week 6, 5 women receiving TE responded to treatment and 4 showed symptom remission, compared to 2 responders and 1 remitter in the placebo group. This difference was not significant (p = 0.24). In a mixed-model of BDI ratings, TE was associated with a 9.2 point decrease at 3 weeks (95%CI - 19.5 to + 1.0, p = 0.074) and a 10.5 point decrease at 6 weeks (95%CI - 21.0-0.0, p = 0.049) compared to placebo, though these differences did not survive multiple comparisons correction. Analogous effects were found for HAM-D but not EPDS scores. Interestingly, no significant difference in plasma estradiol levels existed between groups. We were unable to demonstrate a significant therapeutic benefit of TE compared with placebo in PPD. Although limited by under-recruitment and loss to follow-up, our results suggest TE is a feasible option for outpatient PPD management, with preliminary evidence (based on secondary outcomes) for efficacy. Therapeutic effects may be seen as early as 3 weeks and may not directly depend on peripheral measures of estradiol.

Depression during perimenopause: the role of the obstetrician-gynecologist

Depression in women is more common during perimenopause (the transition to menopause) than at other times in the life cycle. Symptoms of depression may be different in perimenopausal women compared to younger or older women, and are often dismissed as part of normal menopause. This is an expert narrative review. There are several evidence-based screening modalities which can be integrated into routine women's health visits, and can facilitate distinguishing between depression and normal perimenopausal symptoms. There is emerging evidence regarding the effect of hormonal changes on the development of perimenopausal depression and its optimal treatment, though critical research gaps remain. Obstetrician-gynecologists and other primary care providers play a vital role in the detection and management of depression in women. Providers caring for women during perimenopause have a unique opportunity to diagnose depression in their patients and identify appropriate treatment options.

Oral contraceptive use in adolescence predicts lasting vulnerability to depression in adulthood

BACKGROUND

Previous evidence suggests that use of oral contraceptives (OCs), especially during adolescence, may increase women's vulnerability to depression in the short term. Here, we investigate whether women who had first used OC in adolescence show an increased prevalence of depression in the long term.

METHODS

We examined 1,236 women in the United States National Health and Nutrition Examination Survey for whom information on depression and age at first OC use was publicly available. We compared women who reported first use of OCs in adolescence to women who had never used OCs and women who had first used OCs in adulthood on 1-year prevalence of major depressive disorder (MDD) assessed by trained interviewers.

RESULTS

Compared with women who had used OCs during adolescence, women who had never used OCs were less likely to meet the criteria for MDD within the past year in adulthood [odds ratio (OR) = 0.31, 95% CI = 0.16-0.60], and so were women who only started using OCs in adulthood (OR = 0.54, 95% CI = 0.30-0.95). Third factors that have previously been proposed to explain the relationship between OC use and depression risk such as age at sexual debut, and, importantly, current OC use, did not account for the results in propensity score analyses.

CONCLUSIONS

We show a long-term association between adolescent OC use and depression risk in adulthood regardless of current OC use. Our findings suggest that adolescence may be a sensitive period during which OC use could increase women's risk for depression, years after first exposure.

Psychobiological indicators of the subjectively experienced health status - findings from the Women 40+ Healthy Aging Study

BACKGROUND

Healthy aging is particularly important in women, as their life-span is generally longer than men's, leaving women at higher risk for age-related diseases. Understanding determinants of women's healthy aging is therefore a major public health interest. Clinical utility of previous research is limited, through its focus on either single psychosocial or biological predictors. The present study investigated psychobiological predictors of women's healthy aging, for the first time including positive psychological traits and biomarkers of healthy aging.

METHODS

Totally, 121 generally healthy women aged 40 to 75 were investigated cross-sectionally. Healthy aging was operationalized via self-rated health (SRH). To gain a nuanced view of the particularities at the upper end of the illness-wellness continuum, women with excellent SRH and those with good SRH were analyzed as distinct groups. Socioeconomic and sociodemographic variables, health behavior, resilience, optimism, and self-worth as well as menopausal symptoms, and levels of steroid hormones and gonadotropins were considered as predictors of SRH. Binary logistic regression analyses using the forward conditional method were performed with the two health status groups as dependent variable.

RESULTS

Women with a lower body mass index (BMI; OR = .59, 95% CI = .33-1.03), higher intensive physical activity (OR = 2.27, 95% CI = 1.06-4.86), and higher resilience (OR = 2.37, 95% CI = 1.34-4.18) were more likely to rate their health as excellent compared to good. No clinically significant differences could be found regarding endocrine levels.

CONCLUSION

Psychobiological indicators (lower BMI, intensive physical activity, higher resilience) discriminated SRH at the top level of the health spectrum. In healthy women, the predictive value of endocrine markers seems to be secondary. Interventions targeting these indicators could promote women's healthy aging.

Estradiol administration differentially affects the response to experimental psychosocial stress in post-menopausal women with or without a history of major depression

BACKGROUND:

The effects of estradiol on the brain regions involved in the response to stress and emotional processes may be particularly important in women who have alterations in these systems that make them vulnerable to Major Depressive Disorder (MDD). This study examined whether the effect of estradiol administration on the subjective distress and mood response to a laboratory-based psychosocial stress task differs in women with and without a history of MDD.

METHODS:

Participants were 65 euthymic postmenopausal women, with and without a history of MDD. They received either 3 months of open-label oral estradiol or did not receive estradiol. After 3 months, participants completed the Montreal Stress Imaging Task (MIST) and subjective distress and mood ratings.

RESULTS:

The effect of estradiol on subjective distress following the MIST differed based on MDD history. In women without a history of MDD, estradiol administration was associated with greater subjective distress than no estradiol. However, in women with a history of MDD, estradiol administration was associated with less subjective distress compared to no estradiol.

LIMITATIONS:

This study included open-label administration of estradiol and participants were not blinded to administration. Interpretation of result should include consideration of the relatively small group sizes and that results may not generalize to currently depressed individuals.

CONCLUSIONS:

In euthymic women with a history of MDD, estradiol may benefit the affective response to psychosocial stress while having comparatively little benefit in women with no MDD history. Further work should explore whether estradiol administration reduces the risk of depression recurrence in post-menopausal women with past MDD.

Effects of perimenopausal transdermal estradiol on self-reported sleep, independent of its effect on vasomotor symptom bother and depressive symptoms

OBJECTIVE

The aim of this study was to determine the efficacy of transdermal estradiol (E2) plus intermittent progesterone (EPT) for improving self-reported sleep in perimenopausal women, after controlling for vasomotor symptoms (VMS) bother and depressive symptoms.

METHODS

Using a double-blind, placebo-controlled design, 172 healthy women meeting STRAW+10 criteria for being in the menopausal transition or early postmenopause were randomized to 12 months of transdermal E2 (0.1 mg/d) + 200 mg progesterone (12 d every 3 mo) or placebo. Using standard questionnaires, self-reported sleep, depression, and VMS bother were obtained at baseline and bimonthly postrandomization.

RESULTS

Controlling for baseline levels, EPT (vs placebo) led to reductions in minutes to fall asleep (estimate = -0.12, P = 0.002) and number of awakenings (estimate = -0.24, P = 0.04) over the 12 months. Controlling for changes in VMS bother and depressive symptoms, EPT still predicted reductions in minutes to fall asleep (estimate = -0.28, P = 0.02) and number of awakenings (estimate = -0.11, P = 0.02) over the 12 months.

CONCLUSIONS

We extend existing research by demonstrating that hormone therapy (HT) in subjective sleep cannot be fully explained by improvements in VMS bother or depressive symptoms. Research to examine the mechanism (s) underlying HT's effects on sleep would have public health significance for perimenopausal women and also advance our general understanding of the pathophysiology of impaired sleep.

Ovarian Hormones as a Source of Fluctuating Biological Vulnerability in Borderline Personality Disorder

PURPOSE OF REVIEW

To examine the potential role of ovarian hormones in biological vulnerability to borderline personality disorder (BPD). The review focuses primarily on research examining the menstrual cycle as a source of short-term lability of BPD symptom expression, while discussing the currently understudied possibility of ovarian hormone influence in the developmental course of BPD.

FINDINGS

Several patterns of menstrual cycle effects on BPD symptoms and relevant features in non-clinical samples have been observed in empirical studies. Most symptoms demonstrated patterns consistent with perimenstrual exacerbation; however, timing varied between high and low arousal symptoms, potentially reflecting differing mechanisms. Symptoms are typically lowest around ovulation, with an exception for proactive aggression and some forms of impulsive behaviors. Preliminary evidence suggests ovarian hormones may exert strong effects on BPD symptom expression, and further research is warranted examining mechanisms and developing interventions. Recommendations for researchers and clinicians working with BPD are provided.

Stress, sex hormones, inflammation, and major depressive disorder: Extending Social Signal Transduction Theory of Depression to account for sex differences in mood disorders

Social Signal Transduction Theory of Depression is a biologically plausible, multi-level theory that describes neural, physiologic, molecular, and genomic mechanisms that link experiences of social-environmental adversity with internal biological processes that drive depression pathogenesis, maintenance, and recurrence. Central to this theory is the hypothesis that interpersonal stressors involving social threat (e.g., social conflict, evaluation, rejection, isolation, and exclusion) upregulate inflammatory processes that can induce several depressive symptoms, including sad mood, anhedonia, fatigue, psychomotor retardation, and social-behavioral withdrawal. The original article describing this formulation (Psychol Bull 140:774-815, 2014) addressed critical questions involving depression onset and recurrence, as well as why depression is strongly predicted by early life stress and comorbid with anxiety disorders and certain physical disease conditions, such as asthma, rheumatoid arthritis, chronic pain, and cardiovascular disease. Here, we extend the theory to help explain sex differences in depression prevalence, which is a defining feature of this disorder. Central to this extension is research demonstrating that ovarian hormone fluctuations modulate women's susceptibility to stress, brain structure and function, and inflammatory activity and reactivity. These effects are evident at multiple levels and are highly context-dependent, varying as a function of several factors including sex, age, reproductive state, endogenous versus exogenous hormones, and hormone administration mode and dose. Together, these effects help explain why women are at greater risk for developing inflammation-related depressed mood and other neuropsychiatric, neurodevelopmental, and neurodegenerative disorders during the reproductive years, especially for those already at heightened risk for depression or in the midst of a hormonal transition period.

Cognition, Mood and Sleep in Menopausal Transition: The Role of Menopause Hormone Therapy

During the menopausal transition, which begins four to six years before cessation of menses, middle-aged women experience a progressive change in ovarian activity and a physiologic deterioration of hypothalamic-pituitary-ovarian axis function associated with fluctuating hormone levels. During this transition, women can suffer symptoms related to menopause (such as hot flushes, sleep disturbance, mood changes, memory complaints and vaginal dryness). Neurological symptoms such as sleep disturbance, "brain fog" and mood changes are a major complaint of women transitioning menopause, with a significant impact on their quality of life, productivity and physical health. In this paper, we consider the associations between menopausal stage and/or hormone levels and sleep problems, mood and reduced cognitive performance. The role of estrogen and menopause hormone therapy (MHT) in cognitive function, sleep and mood are also discussed.

Psychoneuroendocrinology and Clinical Psychology

Hormones impact on cognition, emotions, and behaviour. Given that mental disorders are defined by abnormalities in these very same domains, clinical psychologists may benefit from learning more about alterations in endocrine systems, how they can contribute to symptoms commonly experienced by patients, and how such knowledge may be put to use in clinical practice.

The aim of the present scientific update was to provide a brief overview of endocrine research relevant to the aetiology, diagnostics, and treatment of mental disorders, including some of the latest studies in this area.

Hormones appear to be intrinsic to the development and maintenance of mental disorders. Oxytocin is involved in social cognition and behaviour and as such may be relevant to mental disorders characterised by social deficits (e.g., autism spectrum disorder and schizophrenia). Stress and sex steroids exert demonstrable effects on mood and cognition. In patients with depression and anxiety disorders, initial attempts to lower/enhance such hormones have thus been undertaken within conventional therapies in order to improve outcomes. Finally, hunger and satiety hormones may be involved in the vicious circle of dysfunctional eating behaviours and weight loss/gain in anorexia or bulimia nervosa.

Three conclusions can be drawn from this review: First, endocrine research should be considered when patients and clinicians are developing multidimensional illness models together. Second, endocrine markers can complement conventional assessments to provide a more comprehensive account of a patient’s current state. Third, endocrine testing may guide treatment choices and inform the development of novel treatments.

Hormones are intrinsic to the development and maintenance of mental disorders

Endocrine research should be incorporated into multidimensional illness models

Endocrine markers can complement conventional diagnostic assessments

Endocrine testing may guide treatment choices and inform the development of new treatments

Estradiol Fluctuation, Sensitivity to Stress, and Depressive Symptoms in the Menopause Transition: A Pilot Study

The menopause transition is associated with an increased risk of depressed mood. Preliminary evidence suggests that increased sensitivity to psychosocial stress, triggered by exaggerated perimenopausal estradiol fluctuation, may play a role. However, accurately quantifying estradiol fluctuation while minimizing participant burden has posed a methodological challenge in the field. The current pilot project aimed to test the feasibility of capturing perimenopausal estradiol fluctuation via 12 weekly measurements of estrone-3-glucuronide (E1G), a urinary metabolite of estradiol, using participant-collected urine samples in 15 euthymic perimenopausal women ages 45-55 years. Furthermore, it aimed to correlate E1G fluctuation (standard deviation across the 12 E1G measurements) with weekly mood and cardiovascular, salivary cortisol, and subjective emotional responses to the Trier Social Stress Test (TSST) at weeks 4, 8, and 12. Protocol acceptability and adherence was high; furthermore, E1G fluctuation was positively associated with anhedonic depressive symptoms and weekly negative affect. E1G fluctuation was also associated with increased heart rate throughout the TSST as well as higher levels of rejection, anger, and sadness. E1G fluctuation was not significantly associated with TSST blood pressure or cortisol levels. This study suggests a feasible method of assessing estradiol fluctuation in the menopause transition and provides support for the hypothesis that perimenopausal estradiol fluctuation increases sensitivity to psychosocial stress and vulnerability to depressed mood.

Low estradiol levels escalate menopausal symptoms leading to mild cognitive impairment in postmenopausal women

BACKGROUND Women in menopause experience dramatic alterations in gonadal hormone concentrations, including diminished estradiol levels. It has been hypothesized that these hormonal changes may be responsible for the occurrences of menopausal symptoms, such as hot flushes, sleep disruption, night sweats, and irritability, as well as mild cognitive impairment (MCI) in postmenopausal women. Therefore, this study was aimed to determine if there is any association between hormonal changes and menopausal symptoms, including MCI in postmenopausal women.METHODS A total of 245 postmenopausal women were recruited for this cross-sectional study and classified into 2 groups; MCI and non-MCI groups. Diagnosis of MCI was made using the modified Petersen criteria. Variables such as subjects’ age, duration of menopause, menopausal symptoms, anthropometric status, hormone levels, and cognitive status were assessed and statistically analyzed.RESULTS Of the 245 subjects enrolled in this study, 53.9% had MCI. Multivariate analysis found that sleep disruption and estradiol levels were independent risk factors of MCI in postmenopausal women. No significant correlation was found between menopausal symptoms and estradiol concentration.CONCLUSIONS Low estradiol levels were associated with higher risks of experiencing menopausal symptoms and MCI. Sleep disruption and estradiol levels were the most influential factors in the development of MCI in postmenopausal women.

Assessment of perimenopausal depression: A review

BACKGROUND

Within the female life cycle, the perimenopause is considered as a critical period for the development of depression. Prevalence rates are particularly high during this phase. Perimenopausal depression is characterized by affective symptoms as well as menopause-specific somatic complaints. Currently, a variety of questionnaires are used to assess mood during the perimenopause. The aim of this review is to determine the instruments employed to assess perimenopausal depression.

METHODS

We searched the databases PubMed, Cochrane Library and PsycINFO for human studies investigating perimenopausal depression, and subsequently screened for the assessment instruments used to measure mood and menopause. A total of 37 articles were included.

RESULTS

Altogether, 14 different instruments were applied to assess mood during menopause. The CES-D was by far the most frequently used depression scale, appearing in 16 out of the 37 studies. The methods used to identify perimenopausal status and symptoms were inconsistent.

LIMITATIONS

Due to lacking information about data and methodology, a selection bias is conceivable. Additionally, a publication bias is possible. Finally, there is inevitable subjectivity in the screening process of a systematic search.

CONCLUSIONS

The assessment of depression in the menopausal transition is highly heterogeneous, reducing the overall comparability of study results. Furthermore, menopausal complaints are not sufficiently taken into account. Accordingly, the use of a menopause-specific depression scale is highly recommended in order to account for physical and mood-related symptoms in the menopausal transition.

Testosterone is related to GABA+ levels in the posterior-cingulate in unmedicated depressed women during reproductive life

BACKGROUND

The role of testosterone (T) in the pathophysiology of affective disorders and anxiety is broadly supported. Evidence suggests that T has anxiolytic and antidepressant properties. One proposed route for the central effects of T is its interaction with the gamma-aminobutyric acid (GABA) system. We explored the relationship between T levels and GABA+ levels in anterior-cingulate (ACC) and the posterior-cingulate (PCC) regions in depressed women, using magnetic resonance spectroscopy (1H-MRS).

METHODS

Twenty-one depressed patients with regularly cycling who were not taking hormonal or psychotropic drugs were recruited. We assessed severity of depression using the Hamilton Depression Rating Scale (HDRS). Blood samples were taken for quantification of free (FT) and total testosterone (TT) on the day of the magnetic resonance (MR) scan. We evaluated GABA+ levels in the PCC and ACC, using the Hadamard Encoding and Reconstruction of MEGA-Edited Spectroscopy (HERMES) sequence. Pearson correlations were used to evaluate the association between FT, TT, GABA+ concentrations, and HDRS scores.

RESULTS

TT and FT levels were positively correlated with GABA+ levels in the PCC. No correlation was observed between T levels and GABA+ levels in the ACC. The HDRS total scores correlated negatively with FT levels.

LIMITATIONS

Limitations include the cross-sectional evaluation and the lack of a comparative healthy group.

CONCLUSIONS

Our findings suggest that the potential anxiolytic and antidepressant properties of T are related to increased GABA+ levels in the PCC. This observation may contribute to increased understanding of the role of T in depressive and anxiety symptoms in women.

Hormone variability and hot flash experience: Results from the midlife women's health study

OBJECTIVE

Hot flashes are believed to be related to hormonal changes. However, the relationship between hormonal fluctuations and hot flashes has not been studied. The objective of this study is to determine hormone measurement summaries that best explain the incidence of hot flashes in midlife women.

STUDY DESIGN

In a cohort study of 798 midlife women over 1-7 years, women provided 4 weekly blood samples annually and completed a survey detailing life history, ongoing behaviors, and menopausal symptoms. Estradiol, progesterone, and testosterone were measured in all serum samples. Annual summary variables of each hormone were median, mean, maximum, minimum, variance, and range. The association of these values with hot flashes was assessed using multivariable logistic regression and Bayesian network analysis, controlling for smoking history and menopausal status.

MAIN OUTCOME MEASURES

Hot flash incidence, severity, and frequency.

RESULTS

For most outcomes, the best-fit model included progesterone variability; increased progesterone variance or range was correlated with decreased hot flash frequency (OR = 0.82, 95% CI = 0.74-0.91) and severity (OR = 0.82, 95% CI = 0.77-0.88). In the Bayesian network model, the maximum estradiol value was negatively correlated with many outcomes (OR for hot flashes = 0.68). Relationships between progesterone variability, maximum estradiol level, maximum progesterone level, and hot flashes indicate that the effects of progesterone variance on hot flash outcomes are likely mediated through progesterone's relationship with maximum estradiol level.

CONCLUSIONS

Variability of progesterone, as opposed to mean values, should be used as an indicator of risk of hot flashes in midlife women.

Depression During and After the Perimenopause: Impact of Hormones, Genetics, and Environmental Determinants of Disease

Vulnerability to depression is increased across the menopause transition and in the early years after the final menstrual period. Clinicians should systematically screen women in this age group; if depressive symptoms or disorder are present, treatment of depression should be initiated. Potential treatments include antidepressants for moderate to severe symptoms, psychotherapy to target psychological and interpersonal factors, and hormone therapy for women with first-onset major depressive disorder or elevated depressive symptoms and at low risk for adverse effects. Behavioral interventions can improve physical activity and sleep patterns.

Perimenstrual exacerbation of symptoms in borderline personality disorder: evidence from multilevel models and the Carolina Premenstrual Assessment Scoring System

BACKGROUND

Individuals with a borderline personality disorder (BPD) suffer from a constellation of rapidly shifting emotional, interpersonal, and behavioral symptoms. The menstrual cycle may contribute to symptom instability among females with this disorder.

METHODS

Fifteen healthy, unmedicated females with BPD and without dysmenorrhea reported daily symptoms across 35 days. Urine luteinizing hormone and salivary progesterone (P4) were used to confirm ovulation and cycle phase. Cyclical worsening of symptoms was evaluated using (1) phase contrasts in multilevel models and (2) the Carolina Premenstrual Assessment Scoring System (C-PASS), a protocol for evaluating clinically significant cycle effects on symptoms.

RESULTS

Most symptoms demonstrated midluteal worsening, a perimenstrual peak, and resolution of symptoms in the follicular or ovulatory phase. Post-hoc correlations with person-centered progesterone revealed negative correlations with most symptoms. Depressive symptoms showed an unexpected delayed pattern in which baseline levels of symptoms were observed in the ovulatory and midluteal phases, and exacerbations were observed during both the perimenstrual and follicular phases. The majority of participants met C-PASS criteria for clinically significant (⩾30%) symptom exacerbation. All participants met the emotional instability criterion of BPD, and no participant met DSM-5 criteria for premenstrual dysphoric disorder (PMDD).

CONCLUSIONS

Females with BPD may be at elevated risk for perimenstrual worsening of emotional symptoms. Longitudinal studies with fine-grained hormonal measurement as well as hormonal experiments are needed to determine the pathophysiology of perimenstrual exacerbation in BPD.

Tibolone improves depression in women through the menopause transition: A double-blind randomized controlled trial of adjunctive tibolone

BACKGROUND

Many women with no past psychiatric history experience severe mood symptoms for the first time in their life during the menopausal transition, with debilitating long-term consequences. Women with a history of depression can experience a relapse or worsening of symptoms during the menopause transition. Traditional antidepressants, SSRIs or SNRIs, are commonly prescribed as the first line response. However, such treatment has shown only small improvements with side effects. Hormone therapies directly targeting the perimenopausal fluctuations in reproductive hormonal systems such as tibolone, have significant potential to treat perimenopausal depression. Our study investigated the use of adjunctive tibolone, selective tissue estrogenic activity regulator, to treat de-novo or relapsing depression occurring during the menopause transition period.

METHODS

Women who were going through the menopause transition with depressive symptoms were invited to participate in a double-blind, 12 week randomized control trial with two arms: tibolone (2.5 mg oral/day) or oral placebo (NCT01470092). Forty-four women met inclusion/exclusion criteria; 22 were randomized to tibolone and 22 were randomized to oral placebo. Symptoms were measured with the 'Montgomery- Asberg depression rating scale' (MADRS) as the primary outcome measure. Latent growth curve analysis was used to assess the MADRS scores change over time.

RESULTS

Participants in the tibolone group demonstrated a significant improvement in depression scores, as compared to the placebo group, without any significant side effects.

LIMITATIONS

This trial only monitored tibolone's effects over 12 weeks. Future research should be conducted over an extended timeframe and explore whether the benefits of tibolone extend to other symptoms of perimenopausal depression.

CONCLUSIONS

The use of hormone therapies such as tibolone provide exciting innovations for the treatment of depression during the menopause transition.

Development and validation of a new rating scale for perimenopausal depression-the Meno-D

The menopause transition is a time when women experience an increased risk for new onset depression, as well as relapse of depression. While there are overlapping symptoms between major depression and depression during menopause, differences suggest 'perimenopausal depression' may be a unique subtype of depression associated with characteristic symptoms. There is currently no validated scale designed to measure perimenopausal depression. The aim of the current study was to develop and validate the 'Meno-D', a self-reporting or clinician rated questionnaire, designed to rate the severity of symptoms of perimenopausal depression. The development phase of the Meno-D involved literature review, clinical observation, and focus groups. A 12-item questionnaire was developed and clinically reviewed for face validity for content. The Meno-D was administered to women experiencing symptoms of perimenopausal depression as part of a larger baseline assessment battery. Validation involved confirmatory factor analysis (CFA). The development of the Meno-D resulted in 12 items. A total of 93 participants with perimenopausal depression were involved in the baseline assessments, 82 completed the Meno-D. Factor analysis identified five sub-scales of the Meno-D "somatic; cognitive; self; sleep; sexual" with high-internal consistency; discriminant validity and a good construct and convergent validity. The Meno-D provides a unique tool for clinicians and researchers to measure the presence of perimenopausal depression.

Symptoms of menopause - global prevalence, physiology and implications

The symptoms of menopause can be distressing, particularly as they occur at a time when women have important roles in society, within the family and at the workplace. Hormonal changes that begin during the menopausal transition affect many biological systems. Accordingly, the signs and symptoms of menopause include central nervous system-related disorders; metabolic, weight, cardiovascular and musculoskeletal changes; urogenital and skin atrophy; and sexual dysfunction. The physiological basis of these manifestations is emerging as complex and related, but not limited to, oestrogen deprivation. Findings generated mainly from longitudinal population studies have shown that ethnic, geographical and individual factors affect symptom prevalence and severity. Moreover, and of great importance to clinical practice, the latest research has highlighted how certain menopausal symptoms can be associated with the onset of other disorders and might therefore serve as predictors of future health risks in postmenopausal women. The goal of this Review is to describe in a timely manner new research findings on the global prevalence and physiology of menopausal symptoms and their impact on future health.

Efficacy of Transdermal Estradiol and Micronized Progesterone in the Prevention of Depressive Symptoms in the Menopause Transition: A Randomized Clinical Trial

IMPORTANCE

The menopause transition and early postmenopausal period are associated with a 2- to 4-fold increased risk for clinically significant depressive symptoms. Although a few studies suggest that hormone therapy can effectively manage existing depression during this time, to our knowledge, there have been no studies testing whether hormone therapy can prevent the onset of perimenopausal and early postmenopausal depressive symptoms.

OBJECTIVE

To examine the efficacy of transdermal estradiol plus intermittent micronized progesterone (TE+IMP) in preventing depressive symptom onset among initially euthymic perimenopausal and early postmenopausal women. A secondary aim was to identify baseline characteristics predicting TE+IMP's beneficial mood effects.

DESIGN, SETTING, AND PARTICIPANTS

Double-blind, placebo-controlled randomized trial at the University of North Carolina at Chapel Hill from October 2010 to February 2016. Participants included euthymic perimenopausal and early postmenopausal women from the community, aged 45 to 60 years.

INTERVENTIONS

Transdermal estradiol (0.1 mg/d) or transdermal placebo for 12 months. Oral micronized progesterone (200 mg/d for 12 days) was also given every 3 months to women receiving active TE, and identical placebo pills were given to women receiving placebo.

MAIN OUTCOME MEASURES

Scores on the Center for Epidemiological Studies-Depression Scale (CES-D), assessed at baseline and months 1, 2, 4, 6, 8, 10, and 12 after randomization, and the incidence of clinically significant depressive symptoms, defined as a CES-D score of at least 16.

RESULTS

Of 172 participants, 130 were white (76%), and 70 were African American (19%), with a mean household income of $50 000 to $79 999. The mean age was 51 years, and 43 developed clinically significant depressive symptoms. Women assigned to placebo were more likely than those assigned to TE+IMP to score at least 16 on the CES-D at least once during the intervention phase (32.3% vs 17.3%; odds ratio [OR], 2.5; 95% CI, 1.1-5.7; P = .03) and had a higher mean CES-D score across the intervention period (P = .03). Baseline reproductive stage moderated the effect of treatment (β, -1.97; SEM, 0.80; P for the interaction = .03) such that mood benefits of TE+IMP vs placebo were evident among women in the early menopause transition (β, -4.2; SEM, 1.2; P < .001) but not the late menopause transition (β, -0.9; SEM, 0.3; P = .23) or among postmenopausal women (β, -0.3; SEM, 1.1; P = .92). Stressful life events in the 6 months preceding enrollment also moderated the effect of treatment on mean CES-D score such that the mood benefits of TE+IMP increased with a greater number of events (β, 1.22; SEM, 0.40; P = .003). Baseline estradiol levels, baseline vasomotor symptoms, history of depression, and history of abuse did not moderate treatment effects.

CONCLUSIONS

Twelve months of TE+IMP were more effective than placebo in preventing the development of clinically significant depressive symptoms among initially euthymic perimenopausal and early postmenopausal women.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01308814.

Depressed mood during the menopausal transition: is it reproductive aging or is it life?

BACKGROUND

Although there has been noteworthy attention to both depressed mood symptoms and majordepressive disorder during the menopausal transition (MT), recently investigators have questioned whether there is an over-pathologizing of the MT by emphasizing hormonal effects on depression and deflecting attention from the everyday conditions of women's lives as they relate to depressed mood. In addition, fluctuation of mood over short periods of time may not be captured by measures of depressed mood symptoms such as the CESD, especially when administered using a reference period such as a week or more. The purpose of this study was to examine the association of menopausal transition factors, health-related factors, stress factors, social factors and symptoms with repeated measures of depressed mood reported for a 24 h period.

METHODS

Seattle Midlife Women's Health Study participants (n = 291, 6977 observations) provided data from 1990 to 2013 including annual questionnaires, symptom diaries and urine specimens assayed for hormones several times per year. Multilevel modeling was used to test bivariate and multivariable models accounting for depressed mood severity.

RESULTS

In individual models with age as the measure of time, being in early postmenopause, exercising more, and being partnered were associated with less severe depressed mood; greater perceived stress, having a history of sexual abuse, difficulty getting to sleep, early awakening, and awakening at night were each associated with higher depressed mood severity. In a multivariable model (n = 234, 6766 observations), being older, being in the early postmenopause, exercising more, being partnered, were associated with less severe depressed mood; reporting greater perceived stress, history of sexual abuse, difficulty getting to sleep and early awakening were associated with more severe depressed mood.

CONCLUSIONS

Clinicians need to consider the context in which midlife women experience the menopausal transition and mood symptoms as well as hormonal transitions during this part of the lifespan.

Trajectories of mood and stress and relationships with protective factors during the transition to menopause: results using latent class growth modeling in a Canadian cohort

The menopause transition is characterized by significant hormonal changes that may predispose women to psychosocial maladjustment. Prospective studies to date have focused primarily on negative mood states and show equivocal findings. The primary goal of this study was to identify patterns of change with respect to positive and negative mood states (vigor, depression, tension, and stress) over a 5-year period in a cohort of women undergoing the transition to menopause. A secondary aim was to determine whether the identified trajectories were associated with menopause status as well as baseline health-related and psychological characteristics. This longitudinal study observed 102 healthy Canadian women who were premenopausal at baseline (age 47-55 years). Analyses consisted of latent class growth modeling. Mood states were predominantly normal and stable, raising doubts regarding the notion that psychosocial distress is a common and natural occurrence during the transition to menopause. Neither time spent in perimenopause nor BMI had a significant influence on levels of mood indicators. However, higher scores on body image, self-esteem, and general health perceptions were predictive of more positive psychological outcomes over the 5-year period. Targeting improvements in self-perceptions may promote a healthier psychological adjustment during this natural transitional period in a women's lifespan.

"Is it menopause or bipolar?": a qualitative study of the experience of menopause for women with bipolar disorder

Background

Menopause can be a time of change for women and may be marked by disturbances in mood. For women living with a mental illness, such as bipolar disorder, little is known about how they experience mood changes during menopause. This study aimed to explore how women with bipolar disorder constructed mood changes during menopause and how this impacted on treatment decisions.

Methods

Semi-structured interviews were undertaken with fifteen women who reported they had been diagnosed with bipolar disorder. Data was analysed using thematic analysis guided by a social constructionist framework.

Results

Themes identified included ‘Constructions of mood change: menopause or bipolar disorder?’,‘ Life events, bipolar disorder and menopause coming together’; ‘Treatment choices for mood change during menopause’.

Conclusions

The accounts suggested that women related to the experience of mood changes during menopause through the lens of their existing framework of bipolar disorder, with implications for understanding of self and treatment choices.

Electronic supplementary material

The online version of this article (10.1186/s12905-017-0467-y) contains supplementary material, which is available to authorized users.

Metabolic and hormone influences on emotion processing during menopause

Disturbances of emotion regulation and depressive symptoms are common during the menopause transition. Reproductive hormone levels are not directly correlated with depressive symptoms, and other factors may influence mood symptoms during menopause. In this study, we sought to determine the role of metabolic function in mood symptoms during menopause, hypothesizing an association with menopause status and long-term glucose load. We studied 54 women across three menopause transition stages (15 premenopause, 11 perimenopause, and 28 postmenopause), examining effects of age, hormones, and metabolism on mood and neural activation during emotional discrimination. We assessed participants using behavioral and functional MRI measures of negative emotion and emotion discrimination, and glycated hemoglobin A1c, to assess long-term glucose load. We found that emotionally unpleasant images activated emotion regulation (amygdala) and cognitive association brain regions (prefrontal cortex, posterior cingulate, temporal-parietal-occipital (TPO) junction, hippocampus). Cognitive association region activity increased with menopause stage. Perimenopausal women had left TPO junction activation, and postmenopausal women had prefrontal cortex, posterior cingulate, and TPO junction activation. Negative affect was associated with decreased amygdala activation, while depression symptoms and negative mood were associated with increased TPO junction activation. Hemoglobin A1c was associated with negative interpretation bias of neutral images and cognitive region recruitment during emotion discrimination. FSH levels, indicating menopause stage, were associated with negative mood. Age was not associated with any behavioral measures or activation patterns during the emotion task. Our results suggest that an interaction between metabolic and hormonal factors may influence emotion regulation, leading to increased risk for depression during menopause.

Naturally Occurring Changes in Estradiol Concentrations in the Menopause Transition Predict Morning Cortisol and Negative Mood in Perimenopausal Depression

Risk of depression increases considerably during the menopause transition (or perimenopause) - the 5-6 years surrounding the last menstrual period. While the mechanisms underlying this increased risk are unknown, we have hypothesized that excessive estradiol (E2) fluctuation, which accompanies the perimenopause, may be implicated. We have furthermore proposed that dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis may underlie E2 fluctuation's effect on mood. This study examined the relationship between weekly changes in salivary E2, salivary cortisol levels and weekly mood in 30 perimenopausal women recruited to achieve equal numbers of women with current depression, past depression, and no history of depression. Greater weekly increases in E2 were associated with increased cortisol among past and currently depressed women; greater E2 increases were also associated with negative mood among currently depressed women. These findings provide evidence that HPA axis dysregulation, correlated with E2 fluctuation, may be implicated in the pathophysiology of perimenopausal depression.

INFLUENCE OF VAGINAL ADMINISTRATION OF GLUCOSAMINE HYDROCHLORIDE TO PSYCHO-EMOTIONAL AND LOCOMOTOR ACTIVITY OF SPAY FEMALE RATS

The significant place in the menopausal syndrome and deficiency of estrogens takes psycho-emotional disorders. Psychosomatic disorders, difficulty of adequate evaluation and correction in menopausal women evidence the fact that this issue is important today. Severe symptoms of menopausal syndrome at violation of psycho-vegetative sphere appear in the early post-menopause, due to final termination of ovarian function and sharply deficiency of estrogens during this period. Intravaginal administration of glucosamine hydrochloride to spay female rats has moderate anti-depressant and anxiolytic effects, accompanied by reduction of the psycho-emotional behavioral reactions, normalization of locomotor activity of animals. As of totality of effects, the estriol reference drug is better than glucosamine hydrochloride. The data reveal prospects of vaginal gel glucosamine hydrochloride in the treatment of menopausal disorders of various origins.