HRT should be considered as first line therapy for perimenopausal depression
I have been away for the last 2 weeks celebrating 50 years of marriage. Our 4 children 4 spouses, 6 grandchildren were all there for the occasion. My son came from Tokyo to be with us, so it was wonderful to see them all and our friends and relatives. I am back to work next Monday,
BJOG Debate: HRT should be considered as first line therapy for perimenopausal depression Free Access
HRT should be considered as first line therapy for perimenopausal depression: FOR: Estrogens are the first line treatment for perimenopausal women
Perimenopausal women with depression (PMD) suffer the many symptoms of the menopausal transition before the cessation of periods, together with anxiety, poor concentration and loss of libido. These women often have a continuum of depression from an early age with a history of hormone‐related depression of premenstrual depression (PMS) and a history of postnatal depression (PND). The PND then becomes cyclical with the return of periods, becoming worse with age until the mid‐forties. These women are then denied hormone therapy because they are not post‐menopausal. This pattern of depression in women is best called reproductive depression (RD) and cannot be diagnosed or excluded by blood tests because the hormone levels will usually be in the premenopausal range (Studd & Nappi. Gynecol Endocrinol 2012;28:42–5).
Transdermal estrogens are safer than oral estrogens in that they do not carry any extra risk of thrombosis and also have been reported as more effective in the treatment of depression. This should be by patches or gels giving a reasonably high dose using estrogen patches of 100 mcg twice weekly (Soares et al. Arch Gen Psychiatry 2001;58:529–34). A similar dose of gels should be used. There is often a loss of libido and loss of energy at the same time and these women will benefit from transdermal testosterone. Although it is unlicensed in women, it can be achieved by testosterone gel, Testim or Testogel using approximately one‐tenth of the licensed male dose (Studd. Climacteric 2011;14:637–42). Those women with a uterus have to have cyclical progestogen but as these women are progesterone‐intolerant it is justifiable to use a shortened course of Norethisterone, Provera or Utrogestan for 7–10 days each month.
Not all women will have the depression removed by hormone therapy and there will be a case for the use of antidepressants in a few women, but I believe this is second line treatment for these patients who do not respond to the more logical transdermal estrogens. I have tried to arrange a lecture for years at the RCPsych but I am informed that there is no interest in this treatment among senior psychiatrists. Is it a territorial issue? Possibly. Is it a safety objection? This is unlikely as transdermal estradiol is safer than long‐term antidepressants (Smoller et al. Arch Int Med 2009;169:2128‐39). Essentially, the problem is the failure to recognise the hormonal component of perimenopausal depression. This failure leads to an interesting catalogue of explanations: treatment resistant depression (wrong treatment); borderline personality disorder (a familiar DSM V diagnosis); bipolar disorder (it is cyclical after all!); premorbid history of depression (depression also occurred before the current PMD; it was PMS or PND—usually both). Most psychiatrists are not effective when treating depression in women. I hope Michael Craig will be able to instruct them. I have failed.
Disclosures of interests
None declared. Completed disclosure of interests form available to view online as supporting information.