更年期抑郁的治疗经验

MenopauseandDepression

ExperienceinTreatmentObjectivesMenopauseassociatedpsychologicalchangesandsymptomsPathophysiologyinMenopauseDepressionAlternativeTreatmentoptionsforbothersomesymptoms(Medications)MedicationforthewomenwhoisContraindicatedforHormoneDepressioninMenopauseTrendofSuicideinawoman’sLifeTwopeakinalllifeofwomenAdolescenceandMenopauseMenopausesymptomrelatedpsychoticdisease(Depression)Metabolism,Volume54,Issue5,Supplement,May2005,Pages49–52EstrogenwithSerotonin1.InhibittheMonoamineOxidase(MAO)function2.Moderatetheserotonin(alpha1)receptoreffectDarleneDeechera,Frommenarchetomenopause:Exploringtheunderlyingbiologyofdepressioninwomenexperiencinghormonalchanges,Psychoneuroendocrinology,Volume33,Issue1,January2008,Pages3–17

SerotonininMenopauseSerotonindecreaseitamountSerotonindecreaseiteffectEstrogenandDepressionPremenstrualDysphoricDisorder(PMDD)PostPartumDepressionPostmenopauseDepression

SixWomenand

TheirNightmaresCase#135yoG1P0femalepresentswithc/ohotflashesandamenorrheafor12months.Shedoesn’tknowwhythisishappening,hersexareworsening.Dailyworkisbothered.Suicideintentionandconflictwithherhusbandoccurred.Shewantsyourhelp.Case#1DDxPrematureMenopausePituitaryTumorsOvarianFailureCerebellumAtrophyIatrogenicEffectCase#1TestLH,FSH,E2andTestosteroneSonoExaminationBrainComputerTomographyCase#1TreatmentHormone(E+P)(Angeliq)HotFlushPersistentSSRI(SelectiveSerotoninReuptakeInhibitors)ClonidineCase#245yoG2P2femalepresentswithc/ohotflashesandirregularmenses(q3-5mos)forthepast9months.Bodyweightgainedinrecent.Hermoodandbehaviorchange.FamilyAbuseinrecent21yodaughterrefusedtolivewithher.DDxTestsCase#2DDxSchizophreniaTransitionalMenopauseCase#2TestFSH,E2andTestosteronePsychologicalConsultationCase#2TreatmentSNRIforherschizophreniaHormoneReplacementCase#365yoWFpresentstostartHRT.Shehearditwouldhelpprotectherheart,makeherfeelyoungerandhelphermemory.Shewentthroughmenopause10yearsagoandhasnothadanyproblemsexceptanrecurrentdepression.Sheis5’4”,108lbs.Bytheway,shehadawristfx2yrsagotakesherevistafaithfully.Case#3TreatmentProzacornot?Tricyclicantidepresents?Case#449yoWFpresenceb/cshecan’tstandherhotflashesanymore.Shecan’tsleepverywellb/cshewakesup3timesanightdrenchedwithsweat.SheisanexecutiveatFirstNationalBank.Shehasahistoryofbreastcancer2yearsago.“PleaseDr.Linn,Ineedsomehormonesorsomething.”Case#4TreatmentBenzodiazepineBarbiturateHormoneReplacementTomoxifen?Case#555yoBFreturnstodiscussstoppingherHRT.Shehasbeentakingitfor5yearsnowwithgoodreliefofhervasomotorandsexs.AfterdiscontinuingherHRT,shewasinvolvedwithslightdepressionandchronicpain.Case#653yobreatcancerwomanstage1begancontinuoustomoxifenfor4years.Sheisnowhavingsomevaginalspotting.Afterusingthearomataseinhibit,severeinsomniaanddisorderbotherher.Case#6TreatmentHystectomyRegainTomoxifenStopAromataseInhibitorSSRIorSNRIHRTorSSRI(1)Postmenopausalwomenwithdepressionrespondbettertoselectiveserotoninreuptakeinhibitors(SSRIs)iftheyarealsotakinghormonaltherapy(HT),Italianresearcherssuggest.EHall,BNFrey,CNSoares-Drugs,2011-HRT&SSRI(2)RandomControl,NoresponsetoSSRIsin170postmenopausalwomenwithadepressiveepisode,asdefinedbytheDSM-IVcriteria,47ofwhomwereonHT.EHall,BNFrey,CNSoares-Drugs,2011-

HRT&SSRI(3)AmongpatientswhowerenotalsotakingHT,theresponseratetoSSRIswasonly63.2%,comparedwith83.7%amongpatientstakingHT.Furthermore,theratesofremissionweresimilarforthetwogroups,at52.63%and79.07%,respectively.SRDavis,FJane-ExpertOpiniononPharmacotherapy,2010HRT&SSRI(4)Theyalsofoundthatlevelsofluteinizinghormone(LH)mayprovideameansofpredictingwhichwomenarelikelytorespondSSRI&PlaceboSSRIarealsosuperiortoPlaceboClinicalimprovementatweek8(decreaseof50percentormorefrombaselineinhotflashfrequency)wassignificantlygreaterintheescitalopramgroupthanintheplacebogroup(55percentvs.36percent).Menopause:September/October2006-Volume13-Issue5-pp780-786SNRI

serotoninandnorepinephrinereuptakeinhibitorsOff-LabelUseinPostmenopauseSyndromesuchasinsomnia,anxietyanddepressionThecaseofmenopausalsymptoms,nervepain,hotflashesandemotionalstressarerelieved.DavidF.Archer,Volume200,Issue3,March2009,Pages238.e1–238.e10

MenopauseTerminology:

STRAW*StagingSystem*STRAW=StagesofReproductiveAgingWorkshop.†Stagesmostlikelytobecharacterizedbyvasomotorsymptoms.SoulesMR,etal.Menopause.2001;8:402-7.Stages:-2-1+1+2Terminology:Duration

ofStage:MenstrualCycles:MenopausalTransitionPostmenopauseEarlyEarly†Late†LatePerimenopauseVariableVariable

cyclelength

(>7days

different

fromnormal)2skipped

cyclesandan

intervalof

amenorrhea

(60days)4yrsUntil

demiseNone0FinalMenstrualPeriod1yrAmen.×12mos.abVasomotorsymptoms:

Whydon’twetreateverywomenwithhormones?MenopausalComplaints:

TreatmentsHormonesvsnon-hormonesvsherbalsWhatkindofherbaldrugiseffective?Efficacy?ClinicalEventHazardRatio,95%confidenceintervalHERSE+PWHIE+PWHIEaloneCHDEvents0.99(0.80-1.22)1.29(1.02-1.63)0.91(0.75-1.12)Stroke1.23(0.89-1.70)1.41(1.07-1.85)1.39(1.10-1.77)Pulm.Embolism2.79(0.89-8.75)2.13(1.39-3.25)1.34(0.87-2.06)BreastCancer1.30(0.77-2.19)1.26(1.00-1.59)0.77(0.59-1.01)ColonCancer0.69(0.32-1.49