Hormonal therapies for new onset and relapsed depression during perimenopause

[Features of the clinical picture of affective disorders in women during the menopausal transition and early postmenopause]

OBJECTIVE

To determine the clinical and psychopathological features of affective disorders in women in the perimenopausal and early postmenopausal periods.

MATERIAL AND METHODS

The study included 90 female patients receiving inpatient psychiatric care for affective disorders, among them 41 patients were perimenopausal (group 1) and 49 were early postmenopausal (group 2). Clinical and psychopathological, psychometric (the Hospital Anxiety and Depression Scale - HADS, the Hamilton Depression and Anxiety Scales - HAM-D and HAM-A, the Hypomania Checklist-32 - HCL-32, the Bipolarity Index (BI), the Insomnia Severity Index - ISI, the Pittsburgh Sleep Quality Index - PSQI) and statistical methods were used.

RESULTS

Symptoms of atypical (63.4%) and anxious (87.8%) depression predominated among perimenopausal patients, and melancholic depression (59.2%) prevailed in early postmenopause. Patients in group 1 had higher anxiety scores on HADS and HAM-A compared to group 2 (p=0.003 and p=0.01). At the same time, early postmenopausal women had higher depression scores on the HADS and HAM-D (p=0.001). ISI and PSQI scores in postmenopause were significantly higher than in perimenopause (p=0.001 and p=0.009).

CONCLUSION

The clinical features of affective disorders as well as severity and nature of the accompanying sleep disturbances vary depending on the stage of menopause, which must be considered when prescribing additional methods for examination and treatment of these disorders.

Scale development and validation of perimenopausal women disability index in the workplace

BACKGROUND

Menopausal disorders include obscure symptomatology that greatly reduce work productivity among female workers. Quantifying the impact of menopause-related symptoms on work productivity is very difficult because no such guidelines exist to date. We aimed to develop a scale of overall health status for working women in the perimenopausal period.

METHODS

In September, 2021, we conducted an Internet web survey which included 3,645 female workers aged 45-56 years in perimenopausal period. We asked the participants to answer 76 items relevant to menopausal symptomatology, that were created for this study and performed exploratory and confirmatory factor analyses for the scale development. Cronbach's alpha, receiver operating characteristic analysis, and logistic regression analysis were used to verify the developed scale.

RESULTS

Approximately 85% participants did not have menstruation or disrupted cycles. Explanatory factor analysis using the maximum likelihood method and Promax rotation identified 21 items with a four-factor structure: psychological symptoms (8 items, α = 0.96); physiological symptoms (6 items, alpha = 0.87); sleep difficulty (4 items, alpha = 0.92); human relationship (3 items, alpha = 0.92). Confirmatory factor analyses found excellent model fit for the four-factor model (RMSR = 0.079; TLI = 0.929; CFI = 0.938). Criterion and concurrent validity were confirmed with high correlation coefficients between each of the four factors, previously validated menopausal symptom questionnaire, and Copenhagen Burnout Inventory scales, respectively (all ps < 0.0001). The developed scale was able to predict absenteeism with 78% sensitivity, 58% specificity, and an AUC of 0.727 (95%CI: 0.696-0.757). Higher scores of each factor as well as total score of the scale were more likely to be associated with work absence experience due to menopause-related symptoms even after adjusting for Copenhagen Burnout Inventory subscales (all ps < 0.0001).

CONCLUSION

We found that the developed scale has high validity and reliability and could be a significant indicator of absenteeism for working women in perimenopausal period.

Severe mental illness and the perimenopause

Hormonal fluctuations in the perimenopause are associated with an array of physical and psychological symptoms. Those with pre-existing mental disorders may experience changes to their symptoms and response to treatment during the perimenopausal and postmenopausal periods and may also be at risk of poorer longer-term physical health outcomes in menopause. The transition towards menopause may be compounded by the oestradiol-suppressing effect of many psychotropics on the hypothalamopituitary-gonadal axis. A collaborative approach between primary care and secondary mental health services is an opportunity for proactive discussion of symptoms and support with management of the perimenopause. This may involve lifestyle measures and/or hormone replacement therapy, which can both lead to improvements in well-being and mental and physical health.

Pueratin improves diminished ovarian reserve by inhibiting apoptosis

Pueratin (Pue) is an extract from Pueraria lobata, and exhibits therapeutic effects for the treatment of inflammation. However, the beneficial effects and mechanisms underlying Pue in the treatment of diminished ovarian reserve (DOR) remains to be fully elucidated. The aim of the present study was to investigate the effect of Pue on Bcl-2 and Bax protein expression in rats with DOR, associated with infertility within clinical practice, induced by 4-vinylcyclohexene diepoxide (VCD). A model of DOR was established in female Sprague Dawley rats by an intraperitoneal injection of 80 mg/kg VCD daily for 45 days. From day 1, the Sprague Dawley rats were orally administered with drugs daily for 45 days. They were divided into normal, model, Pue-low dose (L), Pue-medium dose (M) and Pue-high dose (H) groups (50, 100 and 300 mg/kg Pue, respectively). Follicle-stimulating hormone (FSH), luteinizing hormone (LH) and estradiol (E₂) levels were subsequently detected using ELISA. H&E staining and TUNEL staining were used to evaluate histopathological changes and apoptosis levels in the ovary, respectively. Bcl-2 and Bax protein expression levels in rat ovaries were evaluated using immunohistochemistry and western blotting. Compared with those in the model group, FSH and LH levels in the Pue-L, -M and -H groups were significantly decreased, whilst E₂ levels were significantly increased (P<0.05). After intragastric administration, the volume of the ovaries and uteri of rats in the Pue groups was increased compared with the model group, and the numbers of primordial follicles and primary follicles were also increased. The number of apoptotic cells and the expression of Bax were significantly reduced in a dose-dependent manner (P<0.05), compared with the model group. In addition, Bcl-2 protein expression and the Bcl-2/Bax ratio were found to be significantly increased in the Pue-treated groups in a dose-dependent manner (P<0.05), compared with the model group. In conclusion, Pue treatment improved ovarian function by regulating hormone balance in addition to Bcl-2 and Bax expression.

Acupuncture as an Independent or Adjuvant Management to Standard Care for Perimenopausal Depression: A Systematic Review and Meta-Analysis

Background: Many women with perimenopausal depression (PMD) have sought alternative therapies such as acupuncture because of concerns about risks associated with antidepressant and hormone replacement therapy (HRT). This systematic review aimed to clarify if acupuncture is effective for PMD compared with waitlist control or placebo/sham acupuncture, and if acupuncture alone or combined with standard care (antidepressant and/or HRT) is more effective in ameliorating PMD in comparison with standard care alone. Methods: Randomized controlled trials (RCTs) of PMD treatment via acupuncture vs. waitlist control or placebo/sham acupuncture, and RCTs of PMD treatment via acupuncture alone or combined with Western pharmacotherapy vs. Western pharmacotherapy were searched for from seven databases from inception to December 2020. Cochrane criteria were followed. Results: Twenty-five studies involving 2,213 women were analyzed. Meta-analyses indicated that acupuncture significantly reduced the global scores of Hamilton Depression Scale (HAMD) [standardized mean difference (SMD) = -0.54, 95% CI (-0.91, -0.16), p < 0.01], compared with standard care. The therapeutic effect of acupuncture maintained at 2-, 4-, and 12-week follow-ups. Acupuncture combined with standard care was more effective than standard care alone in decreasing HAMD scores [SMD = -0.82, 95% CI (-1.07, -0.58), p < 0.01]. Too few RCTs were available to assess the clinical efficacy differences between acupuncture and placebo/sham acupuncture or HRT alone. Acupuncture also showed better effects in decreasing Kupperman index (KI) scores, whether compared with antidepressant alone [MD = -4.55, 95% CI (-8.46, -0.65), p = 0.02] or antidepressant combined with HRT [MD = -0.89, 95% CI (-1.34, -0.43), p < 0.01]. Conclusions: In comparison with standard care, acupuncture alone or combined with standard care was associated with significant improvements in PMD and reductions of other menopausal symptoms. This finding suggests that acupuncture may be a useful addition to treatment for PMD.

Estrogen receptors-β and serotonin mediate the antidepressant-like effect of an aqueous extract of pomegranate in ovariectomized rats

Pomegranate (Punica granatum) fruit is of particular interest because of its high nutritional value and therapeutic actions. Recently, we showed that an aqueous extract of pomegranate (AE-PG) given by oral route induced antidepressant-like actions mediated by estrogen receptors (ERs) suggesting its potential to function as an alternative to estrogen therapy replacement in menopause-related depression treatment. Orally administered AE-PG allows the biotransformation of ellagitannins into active estrogenic compounds through the intestinal microbiota. However, it is necessary to know if compounds that do not need to be biotransformed by the intestinal microbiota are involved in the antidepressant-like effects. Therefore, the first aim of this study was to determine if AE-PG produces an antidepressant-like effect when administered intraperitoneally. Also, to determine the participation of specific ER-subtypes (α or β) and to analyze the role of the serotonergic system. Young female Wistar rats were ovariectomized as a surgical model of menopause. The intraperitoneal administration of AE-PG (1 mg/kg; i. p.) was evaluated in the forced swimming test and open field tests. Also, the ERα antagonist (TPBM; 50 μg/rat; s. c.) or the ERβ antagonist (PHTPP; 25 μg/rat; s. c.) were administered with AE-PG to analyze the participation of the specific ERs. Finally, the effect of the serotonin neurotoxin 5,7-DHT (200 μg/rat; i. c.v.) on the antidepressant-like effect of the AE-PG was studied in independent experimental groups. RESULTS: showed that AE-PG administered by intraperitoneal route induced antidepressant-like effects. This result suggests that gut microbiota biotransformation is not necessary to exert its actions. The mechanism of action involves the activation of the ERβ and the serotonergic system. Altogether, this information contributes to the elucidation of the antidepressant action of the pomegranate fruit, which could be further considered as an alternative treatment for depression during menopause.

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.

Hormone-replacement therapy: current thinking

For several decades, the role of hormone-replacement therapy (HRT) has been debated. Early observational data on HRT showed many benefits, including a reduction in coronary heart disease (CHD) and mortality. More recently, randomized trials, including the Women's Health Initiative (WHI), studying mostly women many years after the the onset of menopause, showed no such benefit and, indeed, an increased risk of CHD and breast cancer, which led to an abrupt decrease in the use of HRT. Subsequent reanalyzes of data from the WHI with age stratification, newer randomized and observational data and several meta-analyses now consistently show reductions in CHD and mortality when HRT is initiated soon after menopause. HRT also significantly decreases the incidence of various symptoms of menopause and the risk of osteoporotic fractures, and improves quality of life. In younger healthy women (aged 50-60 years), the risk-benefit balance is positive for using HRT, with risks considered rare. As no validated primary prevention strategies are available for younger women (<60 years of age), other than lifestyle management, some consideration might be given to HRT as a prevention strategy as treatment can reduce CHD and all-cause mortality. Although HRT should be primarily oestrogen-based, no particular HRT regimen can be advocated.

Management of endometrial modifications in perimenopausal women

Perimenopause has a variable length and time of onset and is characterized by its variability in hormonal levels. The histological changes in the perimenopausal endometrium may be represented by nonproliferative or proliferative benign or malignant lesions. A commonly encountered manifestation of endometrium lesions during menopausal transition is the abnormal uterine bleeding (AUB). The clinical management of AUB must follow a standardized classification system for optimal results. The medical and surgical treatment must be adapted according to age, risk factors, symptoms, and cycle irregularities. Use of alternative therapies and proper diet may result in improved long-term outcomes.

Effects of a phyto complex on well-being of climacteric women

AIM

The aim of this study was to assess the effects of a phyto complex on menopausal symptoms.

MATERIAL AND METHODS

A total of 151 women aged 42-67 years were enrolled. They were in spontaneous or surgical menopause by at least 12 months, reporting symptoms referable to the climacteric syndrome. Two validated and standardized tests were given to the whole sample at the entrance of the study (T0) and after 6 months of treatment (T6): the Greene Climacteric Scale (GCS) and the Beck Depression Inventory (BDI). Interim evaluations were carried out at 1-3 months (T1 and T3) on five symptoms selected from the GCS. The phyto complex was given to each enrolled woman, from the T0 to T6 time-points, for a total of 180 days.

RESULTS

At the T0 time-point, the average scores were: GCS, 28.98 (standard deviation [SD] ± 10.71); BDI, 14.48 (SD ± 6.5). At the T1 time-point, five parameters of the GCS were assessed with a reduction of 36.25% in symptoms (5.69, SD ± 3.53). At the T6 time-point the assessment was completed: average GCS results were 11.54 (SD ± 8.01) with a 60.17% improvement; and average BDI results were 6.11 (SD ± 4.6) with a 58.91% improvement in the depressive symptoms.

CONCLUSIONS

The phyto complex under consideration is an effective tool to counter, in a quick and long-lasting manner, the most common and nagging symptoms of the climacteric syndrome, such as hot flushes, insomnia and depression.

The Antidepressant-like Effects of Estrogen-mediated Ghrelin

Ghrelin, one of the brain-gut peptides, stimulates food-intake. Recently, ghrelin has also shown to play an important role in depression treatment. However, the mechanism of ghrelin's antidepressant-like actions is unknown. On the other hand, sex differences in depression, and the fluctuation of estrogens secretion have been proved to play a key role in depression. It has been reported that women have higher level of ghrelin expression, and ghrelin can stimulate estrogen secretion while estrogen acts as a positive feedback mechanism to up-regulate ghrelin level. Ghrelin may be a potential regulator of reproductive function, and estrogen may have additional effect in ghrelin's antidepressantlike actions. In this review, we summarize antidepressant-like effects of ghrelin and estrogen in basic and clinical studies, and provide new insight on ghrelin's effect in depression.