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

Sleep quality in late pregnancy is associated with maternal mental health in the early postpartum period

OBJECTIVE

Several studies suggest an association between poor sleep quality during late pregnancy and postpartum depressive symptoms. However, so far no studies have comprehensively examined how sleep quality during pregnancy might impact overall mental well-being postpartum. This study aimed to investigate if sleep quality in pregnancy is associated with postpartum mental well-being, and/or with hormonal fluctuations, immune status, and parity.

METHODS

We used data from 56 healthy women acquired in late pregnancy and five weeks postpartum. Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI), and mental well-being was measured with the World Health Organization Well-Being Index (WHO-5) as the primary outcome. Secondary outcomes included the Total Mood Disturbance (TMD) Score of the Profile of Mood States (POMS) and the Edinburgh Postnatal Depression Scale (EPDS) sum score. Blood samples for estradiol and high-sensitivity C-reactive protein (hsCRP) analysis were taken on the day of delivery and five weeks postpartum.

RESULTS

We found a significant association between poor sleep quality in late pregnancy and lower levels of mental well-being five weeks postpartum (p = 0.02). Post hoc analyses showed a significant interaction with parity in this association (p = 0.016) such that multiparous women appeared more affected by poor sleep quality in late pregnancy. Sleep quality pre- and postpartum were highly correlated (p > 0.001). Meanwhile, hormonal and inflammatory markers did not significantly interact with sleep quality and postpartum well-being.

CONCLUSION

Sleep quality in late pregnancy is associated with maternal mental health early postpartum and this phenomenon appeared to be most pronounced for multiparous women.

Menopause and mental health

PURPOSE OF REVIEW

This review discusses mental health changes commonly experienced by individuals during the menopause transition (MT). The pathophysiology of the MT, the chronology and type of mental health symptoms arising from this pathophysiology, and evidence-based options for treating midlife patients are discussed. This review concludes with treatment options to enable clinicians to more effectively counsel, recognize and treat symptoms during the MT.

RECENT FINDINGS

The MT begins earlier than previously understood with mood and cognitive issues as common initial mental health symptoms significantly impacting quality of life. These symptoms are due to profound changes in the brain's structure, connectivity, energy metabolism, and inflammation linked to perimenopausal hormone shifts. Hormone therapy, psychiatric medication, psychotherapy, and lifestyle adjustments all play a role in the management of mental health symptoms arising during the MT. Lack of both obstetrician and gynecologist and mental health clinician awareness can leave patients undertreated and vulnerable to nonevidence-based approaches.

SUMMARY

Patients in the MT are at increased risk for mental health issues, both preexisting and new onset. The OB/GYN clinician plays a key role in recognizing and addressing these conditions to improve health outcomes in midlife women.

The trajectory of depressive symptoms and the association with quality of life and suicidal ideation in patients with major depressive disorder

BACKGROUND

Major depressive disorder (MDD) is the most prevalent mental health disorder globally. However, the association between depressive symptom trajectories in the early period and subsequent mental health outcomes remains not fully elucidated. This study aimed to delineate the depressive symptom trajectories during the initial phase of treatment, identify baseline characteristics associated with these trajectories, and explore the association of trajectories with subsequent quality of life and suicidal ideation.

METHODS

Participants were from the Depression Cohort in China. The diagnosis of MDD was assessed using the Mini-International Neuropsychiatric Interview (M.I.N.I.). Information on depressive symptom severity, quality of life, suicidal ideation and other demographics were collected. Latent class trajectory modeling was used to identify distinct classes of depressive symptom trajectories.

RESULTS

A total of 566 patients with MDD were included, and we identified 3 categories with differential trajectories characterized by improving class (66.7%), moderate decreasing class (27.7%), and persistent high class (5.6%). Compared to the improving class, severer anxiety and depressive symptoms at baseline increased the odds of belonging to the moderate decreasing class and persistent high class. Both moderate decreasing class and persistent high class were associated with increased risks of subsequent diminished quality of life. Additionally, only persistent high class was associated with a higher risk of subsequent suicidal ideation.

CONCLUSION

Severe baseline anxiety and depressive symptoms identify a subpopulation of persons living with MDD who evince a greater likelihood of symptom worsening over time as well as greater decrements in quality of life and worsening measures of suicidality.

Sex Differences in the Neurobiology of Fear and Anxiety

Although women are diagnosed with anxiety and stress-related disorders at twice the rate of men, there remains a lack of clarity around how to enhance treatment within each sex to reduce disparate rates of anxiety. However, in recent years, a growing literature has identified neural, cognitive, and physiological mechanisms that contribute to sex differences in fear and anxiety, with the promise of informing tailored treatment approaches. Here, we review recent findings, focusing on human studies among healthy populations as well as among patients with generalized anxiety, social anxiety disorder, post-traumatic stress disorder, and panic disorder. The literature reveals nuanced differences in the types of stimuli that preferentially evoke anxiety and stress responses in women and men, as well as sex differences in threat neurocircuitry that mediates the behavioral, physiological, and subjective components of fear and anxiety.

Biopsychosocial factors intersecting with weekly sleep difficulties in the menopause transition

OBJECTIVES

Sleep difficulties are common in the menopause transition and increase risk for a variety of physical and psychological problems. The current study investigated potential interactions between psychosocial variables and within-person changes in ovarian hormones in predicting perimenopausal sleep problems as well as the potential interactions between poor sleep and psychosocial factors in predicting worsened mood, affect, and attention.

STUDY DESIGN

The sample included 101 perimenopausal individuals. Participants completed 12 weekly assessments of self-reported sleep outcomes, depressive mood and affect, and attention function, and of estrone glucuronide (E1G) and pregnanediol glucuronide (PdG) levels (urinary metabolites of estradiol and progesterone, respectively); they also had 24-h tracking of vasomotor symptoms. Other psychosocial variables such as trauma history and stressful life events were assessed at baseline.

RESULTS

A history of depression, baseline depressive symptoms, trait anxiety, and more severe and bothersome vasomotor symptoms predicted worsened sleep outcomes. Recent stressful life events, trauma history, and person-centred E1G and PdG changes did not predict sleep outcomes. However, there was an interaction whereby person-centred E1G decreases predicted lower sleep efficiency in those with higher baseline depressive symptoms. Higher baseline depression and trauma history also amplified the effect of vasomotor symptoms on sleep outcomes. In evaluating the effect of poor sleep on psychological and cognitive outcomes, stressful life events emerged as a moderating factor. Finally, trauma history and poor sleep interacted to predict worsened attention function.

CONCLUSIONS

The current study suggests that certain individuals may be at greater risk of perimenopausal sleep problems and the resulting negative effects on mood and cognition.

Cumulative stressor exposure predicts menstrual cycle affective changes in a transdiagnostic outpatient sample with past-month suicidal ideation

BACKGROUND

Affective responses to the menstrual cycle vary widely. Some individuals experience severe symptoms like those with premenstrual dysphoric disorder, while others have minimal changes. The reasons for these differences are unclear, but prior studies suggest stressor exposure may play a role. However, research in at-risk psychiatric samples is lacking.

METHODS

In a large clinical sample, we conducted a prospective study of how lifetime stressors relate to degree of affective change across the cycle. 114 outpatients with past-month suicidal ideation (SI) provided daily ratings (n = 6187) of negative affect and SI across 1-3 menstrual cycles. Participants completed the Stress and Adversity Inventory (STRAIN), which measures different stressor exposures (i.e. interpersonal loss, physical danger) throughout the life course, including before and after menarche. Multilevel polynomial growth models tested the relationship between menstrual cycle time and symptoms, moderated by stressor exposure.

RESULTS

Greater lifetime stressor exposure predicted a more pronounced perimenstrual increase in active SI, along with marginally significant similar patterns for negative affect and passive SI. Additionally, pre-menarche stressors significantly increased the cyclicity of active SI compared to post-menarche stressors. Exposure to more interpersonal loss stressors predicted greater perimenstrual symptom change of negative affect, passive SI and active SI. Exploratory item-level analyses showed that lifetime stressors moderated a more severe perimenstrual symptom trajectory for mood swings, anger/irritability, rejection sensitivity, and interpersonal conflict.

CONCLUSION

These findings suggest that greater lifetime stressor exposure may lead to heightened emotional reactivity to ovarian hormone fluctuations, elevating the risk of psychopathology.

Estradiol and progesterone from pregnancy to postpartum: a longitudinal latent class analysis

Introduction

During the peripartum, women undergo significant hormonal changes that are crucial for fetal development and a healthy pregnancy and postpartum period for mother and infant. Although several studies have determined healthy norm ranges of estradiol and progesterone, there are discrepancies among the reports, rendering it unclear which hormone levels are linked to adverse health outcomes. To account for the impact of sex steroid patterns on health outcomes in mothers and children, a longitudinal assessment of different parameters is needed.

Materials and methods

We longitudinally assessed a cohort of 130 women over five months during pregnancy and postpartum. The women provided saliva samples and completed psychosocial questionnaires. Hormone analyses were conducted using enzyme-linked immunosorbent assay (ELISA). Different parameters of estradiol and progesterone were analyzed and evaluated in relation to psychometric variables. To examine the presence of heterogenous hormonal trajectories in the peripartum, we applied group-based trajectory modelling as a special case of latent-class group analysis.

Results

Estradiol and progesterone levels rose towards the end of pregnancy and dropped sharply after birth, with considerable individual variation, particularly during pregnancy. However, their ratio remained stable. We identified three estradiol trajectory subgroups and two progesterone subgroups. Age influenced progesterone levels, with older pregnant women having higher levels than younger women. Anxiety and depressive symptoms had a predictive value for trajectories of specific subgroups of women. The study also revealed two distinct subgroups regarding the course of estradiol and progesterone fluctuations as well as their ratio.

Conclusion

This study provides insights into the course and fluctuation of salivary estradiol and progesterone levels among healthy women during the peripartum period, highlighting significant variations in hormone levels but stability in their ratio during this time. The finding of distinct sex steroid courses in the peripartum is new and suggests the need for further research to explore their impact on health outcomes. Our preliminary results suggest that hormonal fluctuations at the end of pregnancy appear to be a normal occurrence and might even be a protective factor for associated psychological symptoms and sleep disturbances in women.

Antidepressant- and Anxiolytic-like Effects of Pomegranate: Is It Acting by Common or Well-Known Mechanisms of Action?

The pharmacological effects of pomegranates have been described considering metabolic aspects such as hypoglycemic and hypolipidemic activities. The pomegranate extract has activity on the central nervous system (CNS) as a natural antidepressant and anxiolytic. The chemical composition of pomegranates is complex since the bioactive compounds are multiple secondary metabolites that have been identified in the extracts derived from the peel, seed, flowers, leaves, or in their combination; so, it has not been easy to identify an individual compound as responsible for its observed pharmacological properties. From this point of view, the present review analyzes the effects of crude extracts or fractions of pomegranates and their possible mechanisms of action concerning antidepressant- and anxiolytic-like effects in animal models. Serotonin receptors, estrogen receptors, the peroxisome proliferator-activated receptor gamma (PPARγ), or monoamine oxidase enzymes, as well as potent antioxidant and neuroplasticity properties, have been described as possible mediators involved in the antidepressant- and anxiolytic-like behaviors after pomegranate treatment. The pharmacological effects observed on the CNS in experimental models associated with a specific stress level suggest that pomegranates could simultaneously modulate the stress response by activating several targets. For the present review, scientific evidence was gathered to integrate it and suggest a possible pathway for mediators to be involved in the mechanisms of action of the pomegranate's antidepressant- and anxiolytic-like effects. Furthermore, the potential benefits are discussed on comorbid conditions with anxiety and depression, such as perimenopause transition and pain.

Life stress influences the relationship between sex hormone fluctuation and affective symptoms in peripubertal female adolescents

Female adolescents have a greatly increased risk of depression starting at puberty, which continues throughout the reproductive lifespan. Sex hormone fluctuation has been highlighted as a key proximal precipitating factor in the development of mood disorders tied to reproductive events; however, hormone-induced affective state change is poorly understood in the pubertal transition. The present study investigated the impact of recent stressful life events on the relationship between sex hormone change and affective symptoms in peripubertal female participants. Thirty-five peripubertal participants (ages 11-14, premenarchal, or within 1 year of menarche) completed an assessment of stressful life events, and provided weekly salivary hormone collections [estrone, testosterone, dehydroepiandrosterone (DHEA)] and mood assessments for 8 weeks. Linear mixed models tested whether stressful life events provided a context in which within-person changes in hormones predicted weekly affective symptoms. Results indicated that exposure to stressful life events proximal to the pubertal transition influenced the directional effects of hormone change on affective symptoms. Specifically, greater affective symptoms were associated with increases in hormones in a high stress context and decreases in hormones in a low stress context. These findings provide support for stress-related hormone sensitivity as a diathesis for precipitating affective symptoms in the presence of pronounced peripubertal hormone flux.

Depressed, stressed, and inflamed: C-reactive protein linked with depression symptoms in midlife women with both childhood and current life stress

To determine whether the relationship between inflammatory factors and clinically significant depression symptoms is moderated by high exposure to adverse childhood experiences and current life stressors in a longitudinal community cohort of midlife women. Methods: Participants from the Penn Ovarian Ageing Study community cohort (age at baseline: M = 45.3 [SD = 3.8]) were included in analyses if they had a blood sample measuring basal inflammatory markers during at least one visit where depression symptom severity and current stressful life events were also assessed (N = 142, average number of visits per participant = 1.75 [SD = 0.92]). Approximately annually over the course of 16 years, participants self-reported depression symptom severity using the Centre for Epidemiologic Studies Depression (CESD) Scale, provided menstrual diaries to determine menopause stage, and contributed blood samples. Residual blood samples were assayed for interleukin (IL)-6, IL 1-beta (IL-1β), tumour necrosis factor alpha (TNF-α), and high sensitivity C-reactive protein (hsCRP). Early life stress was quantified using the Adverse Childhood Experiences questionnaire (low [0-1 experience(s)] versus high [≥ 2 experiences]). Current stressful life events were assessed using a structured interview (low [0-1 events] vs. high [≥ 2 events]). Generalised estimating equation models were used to model associations with the outcome of interest-clinically significant depression symptoms (CESD ≥16)-and risk factors: inflammatory marker levels (log transformed), adverse childhood experiences group, and current life stressors group. Covariates included menopause stage, age at study baseline, body mass index, race, and smoking status. We found a significant three-way interaction between log hsCRP levels, adverse childhood experiences group, and current life stressors group on likelihood of experiencing clinically significant depression symptoms (OR: 4.33; 95% CI: 1.22, 15.46; p = 0.024) after adjusting for covariates. Solely for women with high adverse childhood experiences and with high current life stressors, higher hsCRP was associated with higher odds of having clinically significant depression symptoms (OR: 1.46; 95% CI 1.07, 1.98; p = 0.016). This three-way interaction was not significant for IL-6, IL-1β, or TNF-α. For women in midlife with exposure to high adverse childhood experiences and multiple current life stressors, elevated levels of CRP were uniquely associated with clinically significant depression symptoms. Early life adversity and current life stressors represent identifiable individual risk factors whose negative impact may be curtailed with inventions to target inflammation in midlife women.

Promoting good mental health over the menopause transition

The potential risk for mental health conditions over the menopause transition shapes women's expectations and informs putative physiological mechanisms regulating women's mental health. We review evidence from prospective studies reporting on associations between mental health conditions and the menopause transition. Major depressive disorder and the more prevalent subthreshold depressive symptoms are the most common conditions studied. We reviewed 12 prospective studies reporting depressive symptoms, major depressive disorder, or both over the menopause transition and found no compelling evidence for a universal increased risk for either condition. However, specific subgroups of participants, primarily defined by menopause-related risk factors (ie, vasomotor symptoms that are severe or disturb sleep, a long duration of the transition, or reproductive hormone dynamics) and psychosocial risk factors (eg, stressful life events), were vulnerable to depressive symptoms. The increased risk of major depressive disorder over the menopause transition appears predominantly in individuals with previous major depressive disorder. Greater focus on recognising risk factors in primary care is warranted. On the basis of scarce data, we found no compelling evidence that risk of anxiety, bipolar disorder, or psychosis is universally elevated over the menopause transition. Potential misattribution of psychological distress and psychiatric disorders to menopause could harm women by delaying accurate diagnosis and the initiation of effective psychotropic treatments, and by creating negative expectations for people approaching menopause. A paradigm shift is needed. We conclude with recommendations for the detection and treatment of depressive symptoms or major depressive disorder and strategies to promote good mental health over the menopause transition, while responsibly preparing and supporting those at risk.

The role of the hypothalamic-pituitary-adrenal axis in depression across the female reproductive lifecycle: current knowledge and future directions

The aim of this narrative review is to consolidate knowledge on the role of the hypothalamic-pituitary-adrenal (HPA) axis in depression pathophysiology at different reproductive stages across the female lifespan. Despite growing evidence about the impact of gonadal hormones on mood disorders, no previous review has examined the interaction between such hormonal changes and the HPA axis within the context of depressive disorders in women. We will focus on HPA axis function in depressive disorders at different reproductive stages including the menstrual cycle (e.g., premenstrual dysphoric disorder [PMDD]), perinatally (e.g., postpartum depression), and in perimenopausal depression. Each of these reproductive stages is characterized by vast physiological changes and presents major neuroendocrine reorganization. The HPA axis is one of the main targets of such functional alterations, and with its key role in stress response, it is an etiological factor in vulnerable windows for depression across the female lifespan. We begin with an overview of the HPA axis and a brief summary of techniques for measuring HPA axis parameters. We then describe the hormonal milieu of each of these key reproductive stages, and integrate information about HPA axis function in depression across these reproductive stages, describing similarities and differences. The role of a history of stress and trauma exposure as a contributor to female depression in the context of HPA axis involvement across the reproductive stages is also presented. This review advances the pursuit of understanding common biological mechanisms across depressive disorders among women. Our overarching goal is to identify unmet needs in characterizing stress-related markers of depression in women in the context of hormonal changes across the lifespan, and to support future research in women's mental health as it pertains to pathophysiology, early diagnosis, and treatment targets.

Menopause-Biology, consequences, supportive care, and therapeutic options

Menopause is the cessation of ovarian function, with loss of reproductive hormone production and irreversible loss of fertility. It is a natural part of reproductive aging. The physiology of the menopause is complex and incompletely understood. Globally, menopause occurs around the age of 49 years, with geographic and ethnic variation. The hormonal changes of the menopause transition may result in both symptoms and long-term systemic effects, predominantly adverse effects on cardiometabolic and musculoskeletal health. The most effective treatment for bothersome menopausal symptoms is evidence-based, menopausal hormone therapy (MHT), which reduces bone loss and may have cardiometabolic benefits. Evidence-based non-hormonal interventions are also available for symptom relief. Treatment should be individualized with shared decision-making. Most MHT regimens are not regulator approved for perimenopausal women. Studies that include perimenopausal women are needed to determine the efficacy and safety of treatment options. Further research is crucial to improve menopause care, along with research to guide policy and clinical practice.

Menopause and Mood: The Role of Estrogen in Midlife Depression and Beyond

Depression is a disabling condition that often leads to significant burden. Women are more vulnerable to depression during reproductive-related "windows of vulnerability" such as the menopause transition and early postmenopausal years. This heightened vulnerability can be attributed, at least in part, to the neuromodulatory effects of estrogen on mood and cognition and the exposure to rapid fluctuations of estradiol levels during midlife years. The management of midlife depression can be challenging due to the presence and severity of other complaints such as vasomotor symptoms and sleep disturbances. Psychopharmacologic, behavioral, and hormonal interventions should be part of the treatment armamentarium.

Biobehavioral mechanisms underlying testosterone and mood relationships in peripubertal female adolescents

The pubertal transition is characterized by pronounced sex hormone fluctuation, refinement of affective neural circuitry, and an increased risk of depression in female adolescents. Sex hormones, including testosterone, exert modulatory effects on frontal-limbic brain networks and are associated with emotion dysregulation and depressive symptoms. Weekly changes in hormones predict affective symptoms in peripubertal female adolescents, particularly in the context of stress; however, the biobehavioral mechanisms underlying hormone change and mood relationships during the pubertal transition have yet to be determined and was the objective of the present study. Forty-three peripubertal female adolescents (ages 11-14) collected 8-weekly salivary hormone (estrone, testosterone) samples and mood assessments to evaluate hormone-mood relationships, followed by a biobehavioral testing session with psychosocial stress and EEG. Within-person correlations between weekly hormone changes and corresponding mood were performed to determine individual differences in mood sensitivity to weekly hormone change. Increased frontal theta activity indexing emotion reactivity, reduced cortisol reactivity, and reduced vagal efficiency predicted the strength of the relationship between testosterone and mood. Further, testosterone-sensitivity strength was associated with the enhancement of negative affect following stress testing. Results identify divergent frontal theta and stress responses as potential biobehavioral mechanisms underlying mood sensitivity to peripubertal testosterone fluctuation.

The COVID-19 Pandemic Impact on the Psychophysical Health of Post-Menopausal Women: A Cross-Sectional Study

Background and Objectives: The aim of this study was to investigate lifestyle, menopausal symptoms, depression, post-traumatic stress disorder (PTSD) and sleep disorders in post-menopausal women throughout the first wave of the COVID-19 pandemic, including the impact of menopause hormonal therapy (HT). Materials and Methods: Post-menopausal women were given the following questionnaires: socio-demographic characteristics; lifestyle; history of COVID-19; menopause-specific quality of life (MENQOL), the first part of which refers to the pre-pandemic period ("pre COVID-19") and the second refers to the current period ("during COVID-19"); Beck's depression inventory (BDI); the impact of event scale-revised (IES-R); and the Pittsburgh sleep quality index (PSQI). Results: One hundred and twenty-six women completed all questionnaires, with a mean age of 55.5 ± 6.0 years. The mean menopause duration was 5.7 ± 5.6 years. Twenty-four women were taking HT. A significant mean weight gain, a reduction in physical activity (respectively p < 0.001) and worsened quality of romantic relationships (p = 0.001) were reported during the pandemic. Menopausal symptoms did not vary significantly throughout the pandemic; however, women taking menopausal HT had lower physical (p = 0.003) and sexual (p = 0.049) MENQOL domain scores, lower depressive symptoms (p = 0.039) and better romantic relationships (p = 0.008). Conclusions: The COVID-19 pandemic caused reduced physical activity, worsened food habits and weight gain in post-menopausal women. They also reported a high rate of severe-moderate PTSD and a negative influence on their romantic relationships. Menopausal HT seems to be a potential protective factor for sexual and physical status and for symptoms of depression.

Associations of stressful life events with subthreshold depressive symptoms and major depressive disorder: The moderating role of gender

BACKGROUND

Stressful life events (SLEs) are high-risk factors for subthreshold depressive symptoms (SDS) and major depressive disorder (MDD). This study sought to assess the association of SLEs with SDS and MDD, with a focus on gender effects.

METHODS

A total of 4132 participants were recruited from 34 primary health care settings. The Stressful Life Events Screening Questionnaire (SLESQ) was used to measure SLEs that participants had experienced in the past time. The Patient Health Questionnaire 9 (PHQ-9) was used to assess SDS, and the Mini-International Neuropsychiatry Interview (MINI) depression module was used to assess the diagnosis of MDD by trained psychiatrists.

RESULTS

In our sample (N = 4132), exposure to any SLEs was more common in individuals with SDS and MDD than in non-depressed population, and the proportion of emotional abuse was relatively high (SDS: 10.6 %; MDD: 33.9 %). After adjusting for control variables, people who experienced SLEs were at a higher risk of SDS and MDD. For males, those experiencing only one event were not at a higher risk of SDS (P = 0.061). For individuals who had experienced multiple SLEs, the association between SLEs and SDS was stronger in females than males. However, the association between SLEs and MDD was stronger in males than females.

LIMITATIONS

The cross-sectional study design and self-reported SLEs.

CONCLUSIONS

SLEs were associated with the increased risks of SDS and MDD. The associations of SLEs with SDS were more robust for females than males. In contrast, the association between SLEs and MDD was stronger in males than females.

Perimenopausal Effects of Estradiol on Anhedonia and Psychosis Study (PEEPs): study protocol for a neural and molecular mechanistic clinical trial

BACKGROUND

The perimenopausal transition is accompanied by psychiatric symptoms in over 10% of women. Symptoms commonly include depressed mood and anhedonia and less commonly include psychosis. Psychiatric symptoms have been linked to the depletion and/or variability of circulating estradiol, and estradiol treatment reduces perimenopausal anhedonia and psychosis in some women. Estrogen fluctuations may disrupt function in the mesolimbic reward system in some women, leading to psychiatric symptoms like anhedonia or psychosis. The Perimenopausal Effects of Estradiol on Anhedonia and Psychosis Study (PEEPs) is a mechanistic clinical trial that aims to (1) identify relationships between perimenopausal-onset anhedonia and psychosis and neuromolecular markers of mesolimbic reward responses and (2) determine the extent to which estradiol treatment-induced changes in mesolimbic reward responses are associated with alleviation of perimenopausal onset anhedonia or psychosis.

METHODS

This study will recruit 100 unmedicated women ages 44-55 in the late-stage perimenopausal transition, sampling across the range of mild-to-high anhedonia and absent-to-moderate psychosis symptoms. Patients will be randomized to receive either estradiol or placebo treatment for 3 weeks. Clinical outcome measures will include symptoms of anhedonia (measured with Snaith-Hamilton Pleasure Scale; SHAPS) and psychosis (measured with Brief Psychiatric Rating Scale; BPRS psychosis subscale) as well as neural markers of mesolimbic reward system functioning, including reward-related fMRI activation and PET-derived measure of striatal dopamine binding. Pre-treatment associations between (1) SHAPS/BPRS scores and (2) reward-related striatal dopamine binding/BOLD activation will be examined. Furthermore, longitudinal mixed models will be used to estimate (1) symptom and neuromolecular trajectories as a function of estradiol vs. placebo treatment and (2) how changes in reward-related striatal dopamine binding and BOLD activation predict variability in symptom trajectories in response to estradiol treatment.

DISCUSSION

This clinical trial will be the first to characterize neural and molecular mechanisms by which estradiol treatment ameliorates anhedonia and psychosis symptoms during the perimenopausal transition, thus laying the groundwork for future biomarker research to predict susceptibility and prognosis and develop targeted treatments for perimenopausal psychiatric symptoms. Furthermore, in alignment with the National Institute for Mental Health Research Domain Criteria initiative, this trial will improve our understanding of a range of disorders characterized by anhedonia, psychosis, and reward system dysfunction.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05282277.

[Cognitive and psychoemotional changes in menopausal transition: The possibility of medical correction]

The increasing of older age group in the population determines studying of age related diseases and emergence of new investigations in this area. In Female body, entering the menopausal transition is the start of «aging» of reproductive function and linked with decreasing of sex hormons levels. A direct connection between changes of estrogen, progesterone, androgen ratios and cognitive function of women was revealed. The anatomical localization of sex hormone receptors, the mechanisms of interaction of hormones with these receptors determine the ways of implementing biological effects of steroids on the CNS. Modern theories of «healthy nerve cells» and «eu-estrogenemia» explains the role of additional criteria, such as the absence of neurological diseases history and the duration of hypoestrogenia, to the outcome of menopausal hormone therapy. Additional factors that can affect to MHT action include: the composition of hormone therapy, administration methods, regimens (cyclic, continuous), duration of treatment, history of endocrine diseases, diabetes mellitus, gynecological history (parity, menarche age, COC use), heredity. The sections present the effect of menopausal transition on the development of depression, mood changes, sleep disturbances and mental disabilities. The explanation of negative effects of menopausal hormone therapy to cognitive health is also described by modern point of view. The ambivalent opinions of researchers, the potential of new reading of the results of earlier studies, confirms the necessity of continuing study of this topic.

Anxiety-like behavior and GABAergic system in ovariectomized rats exposed to chronic mild stress

Stress or low level of estrogen could promote anxiety and depression; thus, it is of interest to investigate the combined effect of mild stress and the lack of estrogen on mental disorders by utilizing an animal model. This study was conducted to assess anxiety- and depressive- like behaviors in ovariectomized (Ovx) rats exposed to chronic mild stress (CMS) and determine the alteration in gamma-aminobutyric acid (GABA)-related transmission. Ovx rats were randomly assigned into four groups: (1) estrogen replacement (E2-NoCMS), (2) estrogen replacement and exposure to CMS (E2-CMS), (3) vehicle (VEH-NoCMS), and (4) vehicle and exposure to CMS (VEH-CMS). Following 4-week CMS, VEH groups (VEH-NoCMS and VEH-CMS) showed a similar level of anxiety-like behavior in elevated T-maze, whereas E2-CMS, VEH-NoCMS and VEH-CMS showed anxiety-like behavior in open field. The depressive-like behavior in the force swimming test tended to be affected by estrogen deprivation than CMS. The alteration of the GABAergic system as determined from the GABA level and mRNA expression of GABA-related transmission (i.e., glutamic acid decarboxylase, GABA transporter and GABA_A subunits) showed that the GABA level in the amygdala and frontal cortex was affected by CMS. For mRNA expression, the mRNA profile in the amygdala and hippocampus of VEH-NoCMS and E2-CMS was the same but different from those of VEH-NoCMS and E2-CMS. In addition, compared with E2-NoCMS, the mRNA profile in the frontal cortex was similar in VEH-NoCMS, E2-CMS, and VEH-CMS. These findings indicated that the underlying mechanism of the GABAergic system was differently modified, although VEH-NoCMS and VEH-CMS showed anxiety-like behavior. The findings of this study may provide a comprehensive understanding of the modulation of the GABAergic system during estrogen deprivation under CMS, as observed in menopausal women who were daily exposed to stress.

Effects of nutritional interventions on the severity of depressive and anxiety symptoms of women in the menopausal transition and menopause: a systematic review, meta-analysis, and meta-regression

IMPORTANCE

Depression and anxiety may significantly affect women during the menopausal transition. In addition to traditional treatment strategies such as hormone therapy, antidepressants, and psychotherapy, nutritional interventions have been increasingly studied, but there is no consensus about their role in this patient population.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the effect of nutritional interventions on the severity of depressive (DS) and anxiety (AS) symptoms in women during the menopausal transition or menopausal years.

EVIDENCE REVIEW

Electronic search using databases PubMed, Cochrane, and Embase to identify articles indexed until January 31, 2021, focusing on randomized placebo-controlled trials documenting the effect of diet, food supplements, and nutraceuticals on DS and AS.

FINDINGS

Thirty-two studies were included (DS, n = 15; AS, n = 1; DS and AS combined, n = 16). We found two studies that demonstrated data combined with other interventions: one with lifestyle interventions (vitamin D plus lifestyle-based weight-loss program) and another with exercise (omega 3 plus exercise). The pooled effect size favored the intervention group over placebo for both DS and AS (DS: standardized mean difference, -0.35 [95% confidence interval, -0.68 to -0.03; P = 0.0351]; AS: standardized mean difference, -0.74 [95% CI, -1.37 to -0.11; P = 0.0229]). There was significant heterogeneity in the pooled results, which can be attributed to differences in assessment tools for depression and anxiety as well as the variety of nutritional interventions studied. The subgroup analysis showed a statistically significant effect of menopausal status (perimenopausal or menopausal) but not the type or duration of nutritional intervention. Older age was the only significant predictor of the effect size of nutritional interventions in the meta-regression.

CONCLUSIONS AND RELEVANCE

Nutritional interventions are promising tools for the management of mood/anxiety symptoms in women during the menopausal transition and in postmenopausal years. Because of significant heterogeneity and risk of bias among studies, the actual effect of different approaches is still unclear.

Mood disorders and hormonal status across women's life: a narrative review

Depressive disorders and anxiety states represent one of the most frequent psychiatric pathologies occurring transiently in vulnerable women throughout their life, from puberty to menopause. It is now known that sex hormones play a key role on the nervous system, interfering with neuronal plasticity and enhancing the processes of learning, memory, cognition, and mood. Numerous mechanisms are at the base of these processes, displaying interactions between estrogen and serotoninergic, dopaminergic, and GABAergic receptors at the central level. Therefore, given the sexual steroids fluctuations throughout the entire female lifespan, and considering the role played by sex hormones at the central level, it is not surprising to observe the onset of mood or neurodegenerative disorders over time. This is especially true for women in hormonal transition phase, such as puberty, postpartum and the menopausal transition. Moreover, all these conditions are characterized by hormone withdrawal, imbalance, or modifications due to menopausal hormone therapies or contraceptives which could prompt to a deterioration of mood and cognition impairment or to an improvement in the quality of life. More studies are needed to better understand the hormone-related effects on the nervous system, and the underlying pathways involved in transitional or chronic mood disorders, to promote new patient-specific therapeutic strategies more effective than the current ones and tailored according to the individual need and women's life period.

Strategies to cope with stress and anxiety during the menopausal transition

The menopausal transition is often accompanied by psycho-vegetative symptoms, including stress and anxiety symptoms. Identifying stress and anxiety and intervening early can have an enormous public health impact. Health care practitioners like obstetrician-gynecologists or family doctors play a critical role in the diagnosis, prevention and treatment of stress and anxiety symptoms or disorders, as they often represent women's primary medical contact during the menopausal transition. However, they frequently do not feel confident in identifying and treating mental health problems. The aim of this review was to summarize current (since 2010) knowledge from randomized controlled trials, systematic reviews, and meta-analyses on diagnostics and treatment options, and to provide clinical decision-making algorithms. The recent literature suggests pharmacological, (cognitive) behavioral, and complementary treatments. The choice about which one to use should be discussed with the patient.

Biopsychosocial risk factors of depression during menopause transition in southeast China

Objective

More than 2 billion women are experiencing menopause transition in China and some of them suffered from depression; while the risk factors of depression during menopause transition were still unclearin China. We aimed to investigate the risk factors in mid-life women in Southeast China.

Method

This study included 1748 Chinese women aged 40–65 years-old who visited gynecology outpatient department of Women’s hospital School of Medicine, Zhejiang University during 2010–2018. Demographic information was collected, and the modified Kupperman Menopausal Index (mKMI) and Hamilton Rating Scale for Depression were assessed. Circulating levels of sex hormones were tested. Ordinal logistic regression analysis was performed to identify risk factors for depression.

Results

The prevalence of depression symptoms was 47.43%. The majority of women had mild (38.56%) or moderate depressive symptoms (8.00%); only 0.86% had severe depressive symptoms. Compared with perimenopausal women, postmenopausal women had increased risks of more severe depression. The associations between menopausal syndromes and the intensity of depression were strongly positive (OR 6.69, 95% CI 5.39–8.29). Elder age, higher follicle stimulating hormone levels, lower estradiol levels, and fewer parity were positively related with the intensity of depression. Among postmenopausal women, underweight, mKMI > 14, earlier age at menopause, shorter reproductive period, and longer duration after menopause were risk factors for incresed intensity of depression.

Conclusions

The results demonstrated a high proportion of depression in women complaining of menopause. Menopausal symptoms were strongly related to the intensity of depression. In postmenopausal women, estrogen related events are associated with the intensity of depression. Gynecological endocrinologists in China should consider screening for depression in high-risk women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01710-4.

Effects of estrogen receptor β or G protein-coupled receptor 30 activation on anxiety-like behaviors in relation to GABAergic transmission in stress-ovariectomized rats

For mental disorders such as anxiety and depression, stress and stressful events are considered as precipitating causes that may be enhanced by estrogen variability. This condition is proven by the higher vulnerability of women than men. Despite the complexity of underlying mechanisms, the gamma-aminobutyric acid (GABA) system piques interest as its receptor contains multiple psychoactive modulatory sites including neurosteroids. Moreover, according to clinical and experimental reports, GABA-associated genes can be altered by stress and hormonal status. Therefore, this study investigated the effects of estrogen receptor β (ERβ) or G protein-coupled receptor 30 (GPR30) activation on anxiety/depression-like behaviors and the alterations in the GABA-associated gene of ovariectomized rats under chronic mild stress (CMS). Mild stressors were focused on because they represent a realistic simulation of daily life stress. In this study, ovariectomized rats were treated with vehicle, estradiol (E2), diarylpropionitrile (DPN; ERβ agonist) or G1 (GPR30 agonist) and exposed to 4-week CMS. The results showed that E2, DPN, and G1 treatments reduced anxiety-like behaviors without affecting depression-like behaviors. Concurrently, the GABA level and most GABA- and neurosteroid-associated mRNAs were altered by E2. Similar mRNA profiles were observed in DPN- and E2-administrations but not in G1 treatment. Collectively, these data suggest that estrogen exerts an anxiolytic-like action through either ERβ and/or GPR30 activation, and the modulatory effects of estrogen on GABAergic system are likely to be modulated through ERβ. The findings of this study therefore further provide insights into the roles of estrogen and daily mild stressors in GABA-related activity and behavioral responses, especially anxiety.

Baseline anxiety-sensitivity to estradiol fluctuations predicts anxiety symptom response to transdermal estradiol treatment in perimenopausal women - A randomized clinical trial

BACKGROUND

The menopausal transition (perimenopause) is associated with an increased risk of major depression, characterized by anxiety and anhedonia phenotypes. Greater estradiol (E2) variability predicts the development of perimenopausal depression, especially within the context of stressful life events (SLEs). While transdermal E2 (TE2) reduces perimenopausal depressive symptoms, the mechanisms underlying TE2 efficacy and predictors of TE2 treatment response remain unknown. This study aimed at determining relationships between E2 fluctuations, mood symptoms, and physiologic stress-reactivity (cortisol and interleukin-6) and whether differences in mood-sensitivity to E2 fluctuations predict mood responses to TE2 treatment.

METHODS

This randomized, double-blind, placebo-controlled trial investigated medically healthy women (46-60 years) in the early or late menopause transition. Baseline E2-sensitivity strength was calculated from eight weekly individual correlations between week-to-week E2 change and index week anxiety (State-Trait Anxiety Inventory) and anhedonia (Snaith-Hamilton Pleasure Scale). Women then received eight weeks of TE2 or transdermal placebo.

RESULTS

Analyses included 73 women (active TE2 n = 35). Greater baseline E2 fluctuations predicted greater anhedonia (p = .002), particularly in women with more SLEs. Greater E2 fluctuations also predicted higher cortisol (p = .012) and blunted interleukin-6 (p = .02) stress-responses. Controlling for baseline symptoms, TE2 was associated with lower post-treatment anxiety (p < .001) and anhedonia (p < .001) versus placebo. However, the efficacy of TE2 for anxiety (p = .007) and also for somatic complaints (p = .05) was strongest in women with greater baseline E2 sensitivity strength.

CONCLUSIONS

TE2 treatment reduced perimenopausal anxiety and anhedonia. The ability of baseline mood-sensitivity to E2 fluctuations to predict greater TE2 efficacy has implications for individualized treatment of perimenopausal anxiety disorders.

Hippocampal volume changes in a pharmacological sex-hormone manipulation risk model for depression in women

Hormone transition phases may trigger depression in some women, yet the underlying mechanisms remain elusive. In a pharmacological sex-hormone manipulation model, we previously reported that estradiol reductions, induced with a gonadotropin-releasing hormone agonist (GnRHa), provoked subclinical depressive symptoms in healthy women, especially if neocortical serotonin transporter (SERT) binding also increased. Within this model, we here evaluated if GnRHa, compared to placebo, reduced hippocampal volume, in a manner that depended on the magnitude of the estradiol decrease and SERT binding, and if this decrease translated to the emergence of subclinical depressive symptoms. Sixty-three healthy, naturally cycling women were included in a randomized, double-blind, placebo-controlled GnRHa-intervention study. We quantified the change from baseline to follow-up (n = 60) in serum estradiol (ΔEstradiol), neocortical SERT binding ([¹¹C] DASB positron emission tomography; ΔSERT), subclinical depressive symptoms (Hamilton depression rating scale; ΔHAMD-17), and hippocampal volume (magnetic resonance imaging data analyzed in Freesurfer 7.1, ΔHippocampus). Group differences in ΔHippocampus were evaluated in a t-test. Within the GnRHa group, associations between ΔEstradiol, ΔHippocampus, and ΔHAMD-17, in addition to ΔSERT-by-ΔEstradiol interaction effects on ΔHippocampus, were evaluated with linear regression models. Mean ΔHippocampus was not significantly different between the GnRHa and placebo group. Within the GnRHa group, hippocampal volume reductions were associated with the magnitude of estradiol decrease (p = 0.04, Cohen's f² = 0.18), controlled for baseline SERT binding, but not subclinical depressive symptoms. There was no ΔSERT-by-ΔEstradiol interaction effects on ΔHippocampus. If replicated, our data highlight a possible association between estradiol fluctuations and hippocampal plasticity, adjusted for serotonergic contributions.

Examining negative affect, sleep duration, and using food to cope as predictors of weight in midlife women

Midlife women are vulnerable to developing obesity. Behavioral and psychosocial factors including sleep duration, stress eating, and negative emotionality are risk factors. However, little is known about the complex daily interplay between sleep, eating, emotion, and weight among midlife women. The current study examined how daily sleep, using food to cope, and negative emotionality are associated with weight using a daily process research design. An archival analysis was performed using the Midlife in the United States-II study (MIDUS II). The sample consisted of 489 midlife women (40-64 years of age). Variables included ecological momentary assessments of daily sleep duration, using food to cope, and negative affect (means and intraindividual variability) and a standardized measurement of BMI. Sleep duration variability was a significant predictor of BMI, albeit the model only accounted for .8% of the variance in BMI (b = .019, p < .05). In the final adjusted model, sleep duration variability, using food to cope, age, and physical activity were all significant predictors of BMI F(5, 559) = 21.503, p < .001, R² = .161, ⨂R² = .024, p = .001. Variability in negative affect, mean sleep duration or negative affect and the interactions between sleep duration (mean, variability) and negative affect (mean, variability) were not significant. Greater variability in sleep duration and greater use of food to cope predicted higher BMI in this sample across age and physical activity levels. Results highlight that daily health and psychosocial factors play an important role in weight.

Sex hormones and physical function among the Chinese oldest-old and centenarian women

Background

Physical independence is crucial for overall health in the elderly individuals. The life expectancy of women has been shown to be higher than that of men, which is also known as the “male–female health-survival paradox”. Sex hormones may be one of the explanations. However, the relationships between sex hormones and physical function remain unclear in the elderly females. This study was designed to explore these relationships among the Chinese oldest-old and centenarian women.

Methods

Data from 1226 women were obtained from the China Hainan Centenarian Cohort Study. Home interviews, physical examinations and blood analyses were conducted using standardized procedures. Variables including age, Han ethnicity, illiteracy, smoker, drinker, estradiol (E2), testosterone (T), follicle-stimulating hormone, and luteinizing hormone were used in the multivariate logistic and linear regression analyses.

Results

In all the participants, age [beta (95% confidence interval): − 0.84 (− 0.98, − 0.71)] and E2 levels [beta (95% confidence interval): − 0.22 (− 0.28, − 0.17)] were negatively associated with activities of daily living (ADLs) in the multivariate linear regression analyses (P < 0.05 for all). We also observed significantly negative associations of age [odds ratio (95% confidence interval): 0.90 (0.88, 0.91)] and E2 levels [odds ratio (95% confidence interval): 0.98 (0.98, 0.99)] with physical normality in the multivariate logistic regression analyses (P < 0.05 for all). Age and E2 levels gradually decreased with increases in the ADL quartiles across all the participants (P < 0.05 for all).

Conclusions

This study demonstrated that E2 levels were negatively associated with physical function among the Chinese oldest-old and centenarian women.

Methods for characterizing ovarian and adrenal hormone variability and mood relationships in peripubertal females

Peripubertal females are at elevated risk for developing affective illness compared to males, yet biological mechanisms underlying this sex disparity are poorly understood. Female risk for depression remains elevated across a woman's reproductive lifespan, implicating reproductive hormones. A sensitivity to normal hormone variability during reproductive transition events (e.g., perimenopause) precipitates affective disturbances in susceptible women; however, the extent of hormone variability during the female pubertal transition and whether vulnerability to peripubertal hormone flux impacts affective state change in peripubertal females has not been studied. 52 healthy peripubertal females (ages 11-14) provided 8 weekly salivary samples and mood ratings. 10 salivary ovarian and adrenal hormones (e.g., estrone, testosterone, dehydroepiandrosterone (DHEA)) were analyzed weekly for 8 weeks using an ultrasensitive assay to characterize the female peripubertal hormone environment and its association with affective state. Hormone variability indices, including standard deviation, mean squared and absolute successive differences of the 8 weekly measurements were analyzed by menarche status. Within-person partial correlations were computed to determine the strength of the relationship between weekly change in hormone level and corresponding mood rating for each participant. As expected, results indicated that hormone variability was greater for post- relative to pre-menarchal females and with advancing pubertal development, yet pregnenolone-sulfate and aldosterone did not differ by menarche status. Mood sensitivity to changes in estrone was exhibited by 57% of participants, whereas 37% were sensitive to testosterone and 6% were sensitive to DHEA changes. The present results offer novel evidence that a substantial proportion of peripubertal females appear to be mood sensitive to hormone changes and may inform future investigations on the biological mechanisms underlying hormone-induced affect dysregulation in peripubertal females.

Estrogen, the Peripheral Immune System and Major Depression – A Reproductive Lifespan Perspective

Major depression is a significant medical issue impacting millions of individuals worldwide. Identifying factors contributing to its manifestation has been a subject of intense investigation for decades and several targets have emerged including sex hormones and the immune system. Indeed, an extensive body of literature has demonstrated that sex hormones play a critical role in modulating brain function and impacting mental health, especially among female organisms. Emerging findings also indicate an inflammatory etiology of major depression, revealing new opportunities to supplement, or even supersede, currently available pharmacological interventions in some patient populations. Given the established sex differences in immunity and the profound impact of fluctuations of sex hormone levels on the immune system within the female, interrogating how the endocrine, nervous, and immune systems converge to impact women’s mental health is warranted. Here, we review the impacts of endogenous estrogens as well as exogenously administered estrogen-containing therapies on affect and immunity and discuss these observations in the context of distinct reproductive milestones across the female lifespan. A theoretical framework and important considerations for additional study in regards to mental health and major depression are provided.

Depression in midlife women attending a menopause clinic is associated with a history of childhood maltreatment

A growing body of literature has suggested that the perimenopause and the early postmenopausal years are associated with an increased risk of experiencing symptoms of depression and the development of first-onset and recurrent episodes of major depressive disorder. Multiple risk factors have been identified, including stressful life events and lower socioeconomic status, as well as early life adversity. The objective of the current study was to characterize the influence of early life childhood maltreatment and incident depression among women experiencing bothersome menopausal symptoms. Participants were recruited from two university-affiliated specialty clinics caring for women with bothersome menopausal symptoms. Assessments included the Childhood Trauma Questionnaire (CTQ), the Center for Epidemiological Studies - Depression (CES-D) scale and the Greene Climacteric Scale. Findings from this cross-sectional study indicate that adverse childhood experiences, as measured using the CTQ, were highly prevalent among women seeking care for bothersome menopausal symptoms (66%). Further, a greater score on the CTQ was significantly associated with higher CES-D scores, as well as with a greater burden of menopausal symptoms, after adjusting for confounding. Our findings lend support to the growing body of literature suggesting that early life stress affects mental health well into adulthood.

Ongoing tobacco use in women who experience homelessness and unstable housing: A prospective study to inform tobacco cessation interventions and policies

BACKGROUND

Tobacco use is common in people who experience homelessness. However, despite biological differences in use by sex and lower quit rates in women, research in homeless and unstably housed (HUH) women is sparse. We identified correlates of use specific to this population, with the goal of informing tobacco cessation programs tailored for HUH women.

METHODS

We conducted a prospective study among HUH women recruited from San Francisco homeless shelters, street encampments, free meal programs and low-income hotels. Between June 2016 and January 2019, study participants completed six monthly interviews to examine factors associated with tobacco use, defined as urinary cotinine >10 pg/mL or self-reported prior 30-day use.

RESULTS

Among 245 participants, 40% were Black, the median age was 53, 75% currently used tobacco and 89% had ≥one 24-hour quit attempt in the prior year. Tobacco use was more common in women with PTSD (66% vs. 48%) and depression (54% vs. 35%) compared to women without these conditions. Adjusted odds of tobacco use decreased significantly with increasing age (OR_{/5 yrs}: 0.81; 95% CI:0.68, 0.96) and increased with an increasing number of additional substances used (OR: 2.52; 95% CI: 1.88, 3.39).

CONCLUSION

Outside of a treatment setting and within a community-recruited sample population composed of HUH women, the number of additional substances used is a primary correlate of ongoing tobacco use. Tailored cessation interventions that prioritize the issue of multiple substance use, and public health policies that allocate funding to address it, may increase tobacco cessation in this population.

Steroid Hormone Secretion Over the Course of the Perimenopause: Findings From the Swiss Perimenopause Study

Background: Perimenopause is characterized by a decline in the steroid hormones, estradiol, and progesterone. By contrast, the steroid hormone cortisol, a marker of the hypothalamic–pituitary–adrenal (HPA) axis, increases. Recent longitudinal studies reported fluctuations in steroid hormone levels during perimenopause, and even increases in estradiol levels. To understand these confounding results, it is necessary to conduct a longitudinal, highly standardized assessment of steroid hormone secretion patterns in perimenopausal women.

Methods: This longitudinal study investigated 127 perimenopausal women aged 40–56 years for 13 months. Estradiol, progesterone, and cortisol were assessed using saliva samples, which were collected for two (during months 2 and 12 for estradiol and progesterone) or three (during months 2, 7, and 12 for cortisol) non-consecutive months over the course of the study. A total of 14 saliva samples per participant were analyzed to investigate the courses of estradiol and progesterone. Cortisol awakening response and fluctuations of cortisol throughout the day were measured using a total of 11 saliva samples per participant (on awakening, +30 min, +60 min, at 12:00 p.m., and before going to bed) for months 2, 7, and 12.

Results: Multilevel analyses revealed variance in intercept and slope across participants for estradiol [intercept: SD = 5.16 (95% CI: 4.28, 6.21), slope: SD = 0.50 (95% CI: 0.39, 0.64)], progesterone [intercept: SD = 34.77 (95% CI: 25.55, 47.31), slope: SD = 4.17 (95% CI: 2.91, 5.99)], and cortisol (intercept: SD = 0.18 (95% CI: 0.14, 0.23), slope: SD = 0.02 (95% CI: 0.01, 0.02)]. Time predicted cortisol levels [b = −0.02, t₍₉₇₉₎ = −6.63, p < 0.0001]. Perimenopausal status (early vs. late) did not predict estradiol [b = −0.36, t₍₁₆₀₈₎ = −0.84, p = 0.400], progesterone [b = −4.55, t₍₁₇₂₃₎ = −0.87, p = 0.385], or cortisol [b = 0.01, t₍₁₁₂₄₎ = 0.61, p = 0.542] scores over time.

Discussion: Our results are consistent with previous findings emphasizing highly individual fluctuations of estradiol and progesterone levels during perimenopause. However, our findings do not suggest a continuous decline during the observed transition phase, implying relatively stable periods of fluctuating hormone levels. Furthermore, given the lack of significant group differences, it may not be necessary to differentiate between early and late perimenopause from the standpoint of hormonal progression.

Guideline No. 422c: Menopause: Mood, Sleep, and Cognition

OBJECTIVE

Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence.

TARGET POPULATION

Perimenopausal and postmenopausal women.

BENEFITS, HARMS, AND COSTS

Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment.

EVIDENCE

Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002-2020, and MeSH search terms were specific for each topic developed through the 7 chapters.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population.

SUMMARY STATEMENTS

RECOMMENDATIONS.

The role of estradiol fluctuation in the pathophysiology of perimenopausal depression: A hypothesis paper

The menopause transition, which constitutes the five or so years surrounding the final menstrual period, has been established as a time of increased risk for depressive symptoms. While mounting research suggests that exposure to more extreme and fluctuating levels of estradiol (E2) plays a role, it remains unclear which specific trigger is most strongly implicated in the development of depressive mood: acute E2 withdrawal or extreme increases in E2. The current review summarises the literature supporting the role of each, considering research pertaining to perimenopausal depression as well as other reproductive mood disorders in which ovarian hormone change is believed to play a key role, namely premenstrual dysphoric disorder and postpartum depression. Taking together the available research pertaining to the various reproductive mood disorders, we propose that women may exhibit one of four E2 sensitivity profiles, each of which may have important implications for the expected timing and severity of depressive mood during the menopause transition: the E2-increase sensitive profile, developing depressive mood in response to elevations in E2, the E2-decrease sensitive profile, for whom E2 withdrawal triggers negative mood, the E2-change sensitive profile, characterised by mood sensitivity to E2 change in either direction, and the E2 insensitive profile for whom changes in E2 have negligible psychological effects. The evidence supporting the existence of such profiles are summarised, potential biological mechanisms are briefly highlighted, and implications for future research are discussed.

The Cortisol and ACTH Response to Dex/CRH Testing in Women With and Without Perimenopausal Depression

CONTEXT

Abnormalities in the hypothalamic-pituitary-adrenal (HPA) axis are frequent accompaniments of depression, and studies have documented the role of stress and stressful life events in the ontogeny of perimenopausal depressions (PMD). Because HPA axis function in women is further modulated both by aging and ovarian steroids, it is possible that a dysregulated HPA axis contributes to the increased risk of PMD.

OBJECTIVE

We examined HPA axis function in perimenopausal women with and without depression using the combined dexamethasone-corticotropin-releasing hormone (Dex/CRH) test.

METHODS

Dex/CRH tests were performed on 20 women with PMD and 20 women who were also perimenopausal but without current or past depression (control women). Main outcome measures were plasma levels of cortisol and adrenocorticotropin (ACTH) and 24-hour urinary free cortisol (UFC). Five women took chronic stable medications, otherwise all women were medically healthy, and both groups were comparable with respect to reproductive stage and age. Standardized symptom rating scales were administered to each woman prior to Dex/CRH testing.

RESULTS

No group differences were present in either baseline or stimulated ACTH and cortisol secretion. Baseline plasma measures of estradiol, progesterone, and 24-hour UFC levels similarly did not differ in PMD and control women.

CONCLUSION

Despite reports of increased stress responsiveness in PMD, we observed no abnormalities of HPA axis activity associated with PMD compared with women without depression. These findings suggest that PMD is not uniformly associated with HPA dysregulation and could reflect underlying pathophysiologic processes that are distinct from women with nonreproductive-related depressions.

Directive clinique n° 422c : Ménopause : Humeur, sommeil et cognition

OBJECTIF

Proposer des stratégies fondées sur les plus récentes données publiées pour améliorer les soins aux femmes ménopausées ou en périménopause.

POPULATION CIBLE

Les femmes ménopausées ou en périménopause. BéNéFICES, RISQUES ET COûTS: La population cible bénéficiera des plus récentes données scientifiques publiées communiquées par leurs fournisseurs de soins de santé. Aucun coût ni préjudice ne sont associés à cette information, car les femmes seront libres de choisir parmi les différentes options thérapeutiques, y compris le statu quo, pour la prise en charge des symptômes et morbidités associés à la ménopause. DONNéES PROBANTES: Les auteurs ont interrogé les bases de données PubMed, MEDLINE et Cochrane Library pour extraire des articles publiés entre 2002 et 2020 en utilisant des termes MeSH spécifiques à chacun des sujets abordés dans les 7 chapitres. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant l'approche d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: gynécologues, obstétriciens, médecins de famille, internistes, urgentologues, infirmières (autorisées et praticiennes), pharmaciens, stagiaires (étudiants en médecine, résidents, moniteurs cliniques) et autres fournisseurs de soins de santé pour la population cible. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Orcinol glucoside improves the depressive-like behaviors of perimenopausal depression mice through modulating activity of hypothalamic-pituitary-adrenal/ovary axis and activating BDNF- TrkB-CREB signaling pathway

Orcinol Glucoside (OG), a phenolic glucoside isolated from C. orchioides, showed the antidepressant-like effect on chronic unpredictable mild stress (CUMS)-induced rats previously. This study was designed to determine whether OG could improve the depressive-like symptoms of perimenopausal depression (PMD) and the possible mechanisms involved. This research was performed on a PMD mice model established by a two-steps method of ovariectomy (OVX) followed CUMS. OG treatment effectively improved the depressive-like behaviors of OVX-CUMS mice, as indicated by increased sucrose intake in sucrose preference test (SPT), reduced immobility time in forced swimming test (FST), and tail suspension test (TST), lower frequency of grooming and defecation, increased actions of rearing, and prolonged duration in the center in open field test (OFT). OG treatment alleviated the OVX-CUMS induced dysfunction of hypothalamic-pituitary-ovarian (HPO) axis by increased serum estradiol (E2) and decreased ovarian hormones follicle stimulating hormone (FSH), luteinizing hormone (LH), and gonadotropin-releasing hormone (GnRH) in serum. Meanwhile, OG reversed the hyperactivity of hypothalamic-pituitary-adrenal (HPA) axis as evidenced by decreased CORT and ACTH in serum, reduced as well as the mRNA and protein expression of corticotropin-releasing hormone (CRH) in hypothalamus and hippocampus. Moreover, OG up-regulated the protein expression of BDNF, TrkB, and phosphorylation level of CREB and ERK1/2 in hippocampus. These findings demonstrated that OG improves depressive behaviors of OVX-CUMS mice by modulating of HPO/HPA axis dysfunction, and activating BDNF-TrkB-CREB signaling pathway.

Endocrine and psychosocial moderators of mindfulness-based stress reduction for the prevention of perimenopausal depressive symptoms: A randomized controlled trial

BACKGROUND

The menopause transition is associated with an increased risk of depressive symptoms. The current study aimed to test whether Mindfulness-Based Stress Reduction, an 8-week group intervention involving meditation and yoga, might reduce the risk of depressive symptoms among perimenopausal women. A secondary aim was to examine baseline characteristics, including sensitivity to estradiol fluctuation, as a moderator of treatment effects.

METHODS

104 healthy women from the community in the menopause transition were enrolled and randomized to MBSR (n = 52) or a waitlist control condition (n = 52). Randomization was carried out using a random number generator and opaque sealed envelopes. Depressive symptoms, the main outcome, were assessed every two weeks for 6 months using the Center for Epidemiologic Studies Depression Scale (CES-D). The occurrence of an elevated CES-D score (≥16) and of a major depressive episode were pre-identified secondary outcomes. The following surveys were used to assess additional outcomes of interest every two months: the Perceived Stress Scale, Spielberger Trait Anxiety Inventory, Connor-Davidson Resilience Scale, and Pittsburgh Sleep Quality Index. Baseline characteristics examined as potential moderators of treatment benefit included: baseline CES-D score, past depressive episodes, recent stressful life events, a history of physical or sexual abuse, and emotional sensitivity to reproductive hormone fluctuation. Outcome assessors were blinded to the participants' assigned treatment arm.

RESULTS

Outcome data were available for 44 women assigned to MBSR and 51 women in the waitlist condition. Women randomized to MBSR reported fewer depressive symptoms, less perceived stress, less anxiety, increased resilience, and improved sleep (ps < 0.001). Furthermore, several baseline characteristics predicted a greater mood benefit of MBSR, including: a history of major depression (p for the interaction <0.001), a greater number of recent stressful life events (p < .001), being in the early menopause transition (p = .002), and an increased emotional sensitivity to reproductive hormone fluctuation (p = .004). There were no group differences in the occurrence of major depressive episodes (p > .05).

CONCLUSIONS

MBSR appears to be an effective intervention for the prevention of depressive symptoms in the menopause transition.

The Midlife Transition, Depression, and Its Clinical Management

The World Health Organization estimates that more than 260 million people are affected by depression worldwide, a condition that imposes a significant burden to individuals, their families, and society. Women seem to be disproportionately more affected by depression than men, and it is now clear that some women may experience windows of vulnerability for depression at certain reproductive stages across their life span, including the midlife transition. For some, age, the presence of cardiovascular or metabolic problems, and the emergence of significant, bothersome vasomotor symptoms and sleep problems may result in a compounded, deleterious impact on well-being and overall functioning.

Mood sensitivity to estradiol predicts depressive symptoms in the menopause transition

BACKGROUND

The risk for depression markedly rises during the 5-6 years leading up to the cessation of menstruation, known as the menopause transition. Exposure to extreme estradiol levels may help explain this increase but few studies have examined individual sensitivity to estradiol in predicting perimenopausal depression.

METHOD

The current study recruited 101 perimenopausal women. During Phase 1, we quantified each woman's sensitivity to changes in estradiol using 12 weekly measures of estrone-3-glucuronide (E1G), a urinary metabolite of estradiol, and concurrent depressive symptoms. The weekly cortisol awakening response was measured to examine the hypothalamic-pituitary-adrenal (HPA) axis in mediating mood sensitivity to estradiol. In Phase 2, depressive symptoms and major depression diagnoses were assessed monthly for 9 months. The relationship between Phase 1 E1G sensitivity and Phase 2 depressive symptoms and major depressive episodes was examined. Several baseline characteristics were examined as potential moderators of this relationship.

RESULTS

The within-person correlation between weekly E1G and mood varied greatly from woman to woman, both in strength and direction. Phase 1 E1G mood sensitivity predicted the occurrence of clinically significant depressive symptoms in Phase 2 among certain subsets of women: those without a prior history of depression, reporting a low number of baseline stressful life events, and reporting fewer months since their last menstrual period. HPA axis sensitivity to estradiol fluctuation did not predict Phase 2 outcomes.

CONCLUSION

Mood sensitivity to estradiol predicts risk for perimenopausal depression, particularly among women who are otherwise at low risk and among those who are early in the transition.

Simvastatin mitigates depressive-like behavior in ovariectomized rats: Possible role of NLRP3 inflammasome and estrogen receptors' modulation

It is well known that females are more vulnerable than males to stress-related psychiatric disorders, particularly during perimenopausal and postmenopausal periods. Hormone replacement therapy (HRT) has been widely used for the management of postmenopausal depression. However, HRT could be associated with severe adverse effects, including increased risk for coronary heart disease, breast cancer and endometrial cancer. Thus, there is a pressing demand for novel therapeutic options for postmenopausal depression without sacrificing uterine health. Simvastatin (SIM) was proven to have neuroprotective activities besides its hypocholesterolemic effect, the former can be attributed to its, antioxidant, anti-apoptotic and anti-inflammatory activities. Moreover, many reports highlighted that SIM has estrogenic activity and was able to induce the expression of estrogen receptors in rats. The present study showed that SIM (20 mg/kg, p.o.) markedly attenuated depressive-like behavior in ovariectomized (OVX) rats. Moreover, SIM prohibited hippocampal microglial activation, abrogated P2X7 receptor, TLR2 and TLR4 expression, inhibited NLRP3 inflammasome activation, with subsequent reduction in the levels of pro-inflammatory mediators; IL-1β and IL-18. Furthermore, a marked elevation in hippocampal expression of ERα and ERβ was noted in SIM-treated animals, without any significant effect on uterine relative weight or ERα expression. Taken together, SIM could provide a safer alternative for HRT for the management of postmenopausal depression, without any hyperplastic effect on the uterus.

Depression, hormone therapy, and the menopausal transition among women aged 45 to 64 years using Canadian Longitudinal Study on aging baseline data

OBJECTIVE

To investigate the association between menopausal status, hormone therapy (HT) use and the presence of depressive symptoms among middle-aged women in Canada.

METHODS

Cross-sectional baseline data from 13,216 women aged 45 to 64 years from the Canadian Longitudinal Study on Aging (CLSA) was used. The association between menopausal status (pre- vs postmenopausal) and self-reported symptoms of depression based on a score of 10 or more on the Center for Epidemiologic Studies Short Depression Scale-10 was assessed using logistic regression. Use and duration of use of HT, time since menopause, age at onset of menopause, and socioeconomic status and other contextual variables were explored for the association with depression.

RESULTS

Overall, 18.4% of middle-aged women in the CLSA data were identified as depressed using the Center for Epidemiologic Studies Short Depression Scale-10. Based on the logistic regression models, women reporting premature menopause (before the age of 40 years) and postmenopausal women currently using HT had 1.45 (1.07-1.97) and 1.21 (1.02-1.44) greater odds of having depression. Chi-square analyses showed that women with depressive symptoms were more likely to have low education, low household incomes, live alone, be nulliparous, and have low social support.

CONCLUSIONS

Our findings highlight the association between depression and premature menopause among midlife women. Current HT use may be a proxy for more severe menopausal vasomotor symptoms, a known risk factor for depressive symptoms. Identification of risk factors, including social determinants of health, age at menopause, and menopausal symptoms can help guide clinicians when assessing mental health. : Video Summary:http://links.lww.com/MENO/A576.

Predictors of irritability symptoms in mildly depressed perimenopausal women

OBJECTIVE

Irritability is a highly burdensome complaint, commonly, but not universally, linked with depressive symptoms. While increased variability in estradiol has been associated with depressive symptoms during perimenopause, more insight is needed into reproductive hormone dynamics and other factors that predispose perimenopausal women to irritable mood.

METHODS

Among 50 mildly depressed perimenopausal women (mean (SD) age 48.4 (3.9) years), severity of irritability symptoms (on Symptom Questionnaire Hostility subscale, range 0-23) was assessed weekly for eight weeks, concurrent with potential predictors. Associations between these were examined using generalized estimating equating models.

RESULTS

Most women (82.0%) reported having moderate to severe irritability at least once. However, the severity of irritability was highly variable from week-to-week (between-subject mean coefficient of variation [CV] 72.9% and within-subject mean CV 63.7%). In multivariate analyses, less variable serum estradiol levels (standardized β within-person CV -0.23 95%CI [-0.32, -0.14], p < 0.001), greater depression severity (0.45 [0.35, 0.56], p < 0.001), younger age (-0.23, [-0.28, -0.09], p < 0.001), and more frequent vasomotor symptoms (0.14 [0.05, 0.23], p = 0.002) were associated with more irritability. Depression severity explained the largest portion of the variance in irritability, but still not more than 20.3%. Neither crude values, weekly change in, or variability of progesterone or FSH levels were associated with irritability.

CONCLUSIONS

Irritability was highly prevalent among mildly depressed perimenopausal women. In contrast to depressive symptoms, decreased rather than increased variability in estradiol levels was associated with more irritability. This highlights that irritable mood can be disentangled from depressive symptoms in perimenopausal women and might be linked with different estradiol dynamics.

Cognitive profiles in perimenopause: hormonal and menopausal symptom correlates

OBJECTIVE

Perimenopause is associated with declines in attention, working memory and verbal memory; however, there are significant individual differences. Further, the contributions of hormones and menopausal symptoms to domain-specific cognitive functions remain unknown. This longitudinal study aimed to determine whether there were distinct cognitive profiles in perimenopause and to identify factors associated with each profile.

DESIGN

In a sample of 85 women evaluated over 400 bi-annual visits, we administered a comprehensive neuropsychological battery, assessed menopausal symptoms and measured 17β-estradiol and follicle stimulating hormone. Multilevel latent profile analysis was used to identify cognitive profiles. Regressions were conducted to determine differences in hormones and symptoms by profile after adjusting for Stages of Reproductive Aging Workshop + 10 (STRAW + 10) stage and demographic factors.

RESULTS

Perimenopausal cognitive profiles consisted of cognitively normal (Profile 1; n = 162), weaknesses in verbal learning and memory (Profile 2; n = 94), strengths in verbal learning and memory (Profile 3; n = 98) and strengths in attention and executive function (Profile 4; n = 61). Profile 2 was differentiated by less hormonal variability and more sleep disturbance than Profile 1 (p < 0.05).

CONCLUSIONS

There is significant heterogeneity in cognition during perimenopause. While most women do not develop impairments, a significant minority experience weaknesses in verbal learning and memory. Profile analysis may identify at-risk populations and inform interventions.

Disinhibition of right inferior frontal gyrus underlies alpha asymmetry in women with low testosterone

Asymmetrical expression of alpha oscillations in the frontal cortex, increased left relative to right, is a phenotype associated with increased behavioral inhibition and mood-related psychiatric illnesses. However, investigations of frontal alpha asymmetry in mood-disorders have yielded inconsistent findings. A better understanding of factors that contribute to individual differences is required to establish a useful biomarker for the diagnosis and treatment of mood and stress related disorders. A novel factor is hormone concentration, as steroid hormones play a prominent role in regulating mood and stress. To investigate this question, concentrations of testosterone and estradiol were sampled. Multiple linear regression revealed that low levels of testosterone correlated with greater frontal alpha asymmetry in women. Source localization found that frontal asymmetry was driven by decreased alpha power in right inferior frontal gyrus that correlated with increased behavioral inhibition in women. Together, these findings might explain inconsistencies in previous investigation on frontal alpha asymmetry.

Steroid Hormone Sensitivity in Reproductive Mood Disorders: On the Role of the GABAA Receptor Complex and Stress During Hormonal Transitions

Women worldwide are two to three times more likely to suffer from depression in their lifetime than are men. Female risk for depressive symptoms is particularly high during the reproductive years between menarche and menopause. The term “Reproductive Mood Disorders” refers to depressive disorders triggered by hormonal fluctuations during reproductive transitions including the perimenarchal phase, the pre-menstrual phase, pregnancy, the peripartum period and the perimenopausal transition.

Here we focus on reproductive mood disorders manifesting in adult life. We propose a research agenda that draws together several reproductive mood disorders and investigates which genetic, endocrinological, neural, and psychosocial factors can explain depressive symptoms during phases of hormonal transitions in women. Based on current research it is assumed that some women experience an increased sensitivity to not only fluctuations in reproductive steroids (estrogen and progesterone), but also stress-related steroids. We integrate both dynamics into the concept of “steroid hormone sensitivity,” expanding on the concept of “reproductive hormone sensitivity.” We suggest that a differential response of the stress steroid system including corticosteroids, neurosteroids, like allopregnanolone and the GABA-A Receptor complex, as well as a differential (epi)genetic risk in serotonergic and GABAergic signaling, are moderators or mediators between changes in the reproductive steroid system and the physiological, affective, and cognitive outcomes manifesting in reproductive mood disorders. We point to the lack of research on the role of psychosocial factors in increasing a woman's stress level and at some point also the sensitivity of her stress steroid system within the etiology of Reproductive Mood Disorders.

Drawing together the evidence on various reproductive mood disorders we seek to present a basis for the development of more effective pharmacological, social, and psychological treatment interventions and prevention strategies for women susceptible to these disorders. This could pave the way for new research as well as medical and psychological teaching and practice- such as a new type of Practice for Gynecological Psychoneuroendocrinology- with the aim of working on and ultimately offering more integrative forms of support not yet available to women suffering from depression during hormonal transitions. In medical history women have been left alone with this integrative challenge.

The short-term effects of estradiol, raloxifene, and a phytoestrogen in women with perimenopausal depression

OBJECTIVE

We examined the short-term efficacies of three estrogen-like compounds under placebo-controlled conditions in women with perimenopause-related depression (PMD).

METHODS

Women with PMD were randomized in a double-blind parallel design to one of four treatments: transdermal 17-beta estradiol (TE) (100 mcg/d); oral raloxifene (60 mg/d); a proprietary phytoestrogen compound, Rimostil (1,000 mg twice/d); or placebo for 8 weeks. The main outcome measures were the Center for Epidemiology Studies Depression Scale, 17-item Hamilton Rating Scale for Depression (HRSD), and the Beck Depression Inventory completed at each clinic visit. Secondary outcomes included a visual analogue self-rating completed at each clinic visit, and daily self-ratings of hot flush severity. Cognitive tests were performed at pretreatment baseline and at the end of the trial. In the primary analysis, we obtained four repeated measures in each woman in the four treatment arms. Analyses were done with SAS Version 9.4 software (SAS Institute, Inc, Cary, NC), using PROC MIXED (for mixed models). All models included the following four explanatory variables, regardless of whether they were statistically significant: 1) treatment group (TE, raloxifene, Rimostil, placebo); 2) week (W2, W4, W6, W8); 3) treatment group-by-week interaction; and 4) baseline value of the measure being analyzed. The inclusion of additional variables was evaluated individually for each outcome measure.

RESULTS

Sixty-six women were randomized into the trial, four women dropped out of the trial, and 62 women were included in the final data analysis. No effect of treatment group was observed in either the Center for Epidemiology Studies Depression Scale (P = 0.34) or Beck Depression Inventory (P = 0.27) scores; however, there was a difference in HRSD scores between treatment groups (P = 0.0037) that pair-wise comparisons of the combined weekly scores in each treatment demonstrated TE's beneficial effects on HRSD scores compared with Rimostil (P = 0.0005), and less consistently with placebo (P = 0.099). The average (SD) of the baseline scores for each treatment group on the HRSD was as follows: TE-15.3 (4.5), raloxifene-16.0 (3.7), Rimostil-14.0 (2.7), and placebo-15.2 (3.0). Whereas the HRSD scores after 8 weeks of treatment (least-square means) were TE-5.2(1.1), raloxifene-5.8(1.2), Rimostil-11.2(1.4), and placebo-7.8(1.1). No differences were observed between raloxifene and either TE or placebo in any scale score. HRSD scores in women assigned to TE were improved compared with those on Rimostil during weeks 6 and 8 (P values = 0.0008, 0.0011, respectively). Cognitive testing at week 8 showed that none of the three active treatment groups performed better than placebo.

CONCLUSIONS

This study did not identify significant therapeutic benefits of TE, Rimostil, or raloxifene compared with placebo in PMD. However, improvements in depression ratings were observed between TE compared with Rimostil. Thus, our findings do not support the role of ERbeta compounds in the treatment of PMD (and indeed could suggest a more important role of ERalpha).

How to study the menstrual cycle: Practical tools and recommendations

Despite decades of research on the physiological and psychological effects of the menstrual cycle, studies have not sufficiently adopted consistent methods for operationalizing the menstrual cycle. This has resulted in substantial confusion in the literature and limited possibilities to conduct systematic reviews and meta-analyses. In order to facilitate more rapid accumulation of knowledge on cycle effects, the present paper offers a set of integrative guidelines and standardized tools for studying the menstrual cycle as an independent variable. We begin with (1) an overview of the menstrual cycle and (2) premenstrual disorders, followed by (3) recommendations and tools regarding data collection in cycle studies. These recommendations address selecting the appropriate study design and sampling strategy, managing demand characteristics, identifying a sample of naturally-cycling individuals, and measuring menstrual bleeding dates, ovarian hormones, and ovulation. We proceed with suggestions for (4) data preparation and coding of cycle day and phases, as well as (5) data visualization, statistical modeling, and interpretation of menstrual cycle associations. We also provide (6) recommendations for using menses start day and ovulation testing to schedule visits in laboratory studies and end with a (7) comprehensive summary and conclusion. Regardless of whether the influence of the menstrual cycle is of central interest in a study or should be controlled to accurately assess the effects of another variable, the use of these recommendations and tools will help make study results more meaningful and replicable.