Monthly Archives: May 2020

Benefits of HRT

I have often given women this list of reasons to continue taking HRT, and also why they should be taken long term. I reiterate this again, just to remind you of some of the reasons you take these hormones. This article comes from Professor John Studd, The leading expert in the world on the menopause and osteoporosis. His CV is very impressive, and more information can be found on his web-site


Many years ago I published a paper “10 reasons to be happy about HRT “ It can be found on my website but a brief summary is –

1. HRT will stop your hot flushes and sweats

2. HRT will stop vagina dryness and the many causes of painful intercourse and loss of libido

3. HRT increases bone density and prevents osteoporotic fractures

4. HRT protects the intervertebral discs

5. HRT does reduce the number of heart attacks

6. HRT helps depression in many women

7 HRT improves libido

8 HRT improves the texture and quality of the skin

9. ”I am a nicer person to live with “

10 HRT is safe The full text of this paper can be found can be found on my website There is perhaps another

#11 advantage to add to this list.

There is increasing evidence that HRT decreases the risk of Alzheimer’s disease. This is logical because the earlier the menopausal the greater the risk of Alzheimer’s in later life but it’s difficult to prove this to everybody’s satisfaction. Certainly, population studies particularly the huge Utah study suggest a decreased risk, but the demands of precise epidemiology insist that a randomised controlled trial with the placebo group is conducted. The problem is at what age should this huge study begin – at the age of 60 ,50, 40 or even earlier and what happens to the placebo group when the patient begins to suffer hot sweats insomnia and depression. She will then move on to estrogens. The problem will never be solved by a vastly expensive and impossible study, so we have to rely on the population data that we have at the moment. It is worth remembering that when Sir Richard Doll’s observation that lung cancer was 13 times more common in smoking doctors than non-smoking doctors was criticised for the absence of a trial, he famously replied that you don’t need a randomised trial to prove the bleeding obvious.

Prof. John Studd.

Miss hugs? Touch forms bonds and boosts immune systems. Here’s how to cope without it during coronavirus

Miss hugs? Touch forms bonds and boosts immune systems. Here’s how to cope without it during coronavirus

May 13, 2020 4.30pm AEST


  1. Michaela Pascoe Postdoctoral Research Fellow in Mental Health, Victoria University
  2. Alexandra Parker Professor of Physical Activity and Mental Health, Victoria University
  3. Glen Hosking Senior Lecturer in Psychology, Victoria University
  4. Sarah Dash Postdoctoral research fellow, Victoria University

Disclosure statement

Alexandra Parker receives funding from NHMRC.

Glen Hosking, Michaela Pascoe, and Sarah Dash do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.


Victoria University

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Don’t shake hands, don’t high-five, and definitely don’t hug.

We’ve been bombarded with these messages during the pandemic as a way to slow the spread of COVID-19, meaning we may not have hugged our friends and family in months.

This might be really hard for a lot of us, particularly if we live alone. This is because positive physical touch can make us feel good. It boosts levels of hormones and neurotransmitters that promote mental well-being, is involved in bonding, and can help reduce stress.

So how can we cope with a lack of touch?

Wes Mountain/The Conversation, CC BY-ND

Touch helps us bond

In humans, the hormone oxytocin is released during hugging, touching, and orgasm. Oxytocin also acts as a neuropeptide, which are small molecules used in brain communication.

It is involved in social recognition and bonding, such as between parents and children. It may also be involved in generosity and the formation of trust between people.

Touch also helps reduce anxiety. When premature babies are held by their mothers, both infants and mothers show a decrease in cortisol, a hormone involved in the stress response.

Positive touch can release oxytocin, which is involved in human bonding. Shutterstock

Touch promotes mental well-being

In adults with advanced cancer, massages or simple touch can reduce pain and improve mood. Massage therapy has been shown to increase levels of dopamine, a neurotransmitter (one of the body’s chemical messengers) involved in satisfaction, motivation, and pleasure. Dopamine is even released when we anticipate pleasurable activities such as eating and sex.

Read more: We need to flatten the ‘other’ coronavirus curve, our looming mental health crisis

Disruptions to normal dopamine levels are linked to a range of mental illnesses, including schizophrenia, depression and addiction.

Serotonin is another neurotransmitter that promotes feelings of well-being and happiness. Positive touch boosts the release of serotonin, which corresponds with reductions in cortisol.

Serotonin is also important for immune system function, and touch has been found to improve our immune system response.

Symptoms of depression and suicidal behaviour are associated with disruptions in normal serotonin levels.

Social distancing during the pandemic has meant we’re barely touching each other, so it’s not surprising we might feel desperate for a hug. Jesus Merida/Sipa USA

But what about a lack of touch?

Due to social distancing measures during the COVID-19 pandemic, we should be vigilant about the possible effects of a lack of physical touch, on mental health.

It is not ethical to experimentally deprive people of touch. Several studies have explored the impacts of naturally occurring reduced physical touch.

For example, living in institutional care and receiving reduced positive touch from caregivers is associated with cognitive and developmental delays in children. These delays can persist for many years after adoption.

Read more: Childhood deprivation affects brain size and behaviour

Less physical touch has also been linked with a higher likelihood of aggressive behaviour. One study observed preschool children in playgrounds with their parents and peers, in both the US and France, and found that parents from the US touched their children less than French parents. It also found the children from the US displayed more aggressive behaviour towards their parents and peers, compared to preschoolers in France.

Another study observed adolescents from the US and France interacting with their peers. The American kids showed more aggressive verbal and physical behaviour than French adolescents, who engaged in more physical touch, although there may also be other factors that contribute to different levels of aggression in young people from different cultures.

Maintain touch where we can

We can maintain touch with the people we live with even if we are not getting our usual level of physical contact elsewhere. Making time for a hug with family members can even help with promoting positive mood during conflict. Hugging is associated with smaller decreases in positive emotions and can lessen the impact of negative emotions in times of conflict.

In children, positive touch is correlated with more self-control, happiness, and pro-social skills, which are behaviours intended to benefit others. People who received more affection in childhood behave more pro-socially in adulthood and also have more secure attachments, meaning they display more positive views of themselves, others, and relationships.

Pets can help

Petting animals can increase levels of oxytocin and decrease cortisol, so you can still get your fill of touch by interacting with your pets. Pets can reduce stress, anxiety, depression and improve overall health.

In paediatric hospital settings, pet therapy results in improvements in mood. In adults, companion animals can decrease mental distress in people experiencing social exclusion.

Cuddling with pets is therapeutic and may help ease the mental health effects of social distancing. Shutterstock

Read more: Are people with pets less likely to die if they catch the coronavirus?

What if I live alone?

If you live alone, and you don’t have any pets, don’t despair. There are many ways to promote mental health and well-being even in the absence of a good hug.

The American College of Lifestyle Medicine highlights six areas for us to invest in to promote or improve our mental health: sleep, nutrition, social connectedness, exercise, stress management, and avoiding risky substance use. Stress management techniques that use breathing or relaxation may be a way to nurture your body when touch and hugs aren’t available.

Staying in touch with friends and loved ones can increase oxytocin and reduce stress by providing the social support we all need during physical distancing.

Why do women gain weight during menopause?

Why do women gain weight during menopause?

May 5, 2020 5.50am AEST


  1. Nicholas Fuller Charles Perkins Centre Research Program Leader, University of Sydney

Disclosure statement

Nicholas Fuller works for the University of Sydney and has received external funding for projects relating to the treatment of overweight and obesity. He is the author and founder of the Interval Weight Loss program.


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For most women, perimenopause – the transition to menopause – begins in their 40s. The entire menopause process typically lasts around four years and begins with the ovaries making less estrogen.

A woman is considered to be post-menopausal when she hasn’t experienced a menstrual period for 12 months. This usually occurs between the ages of 46 to 52 years.

Read more: How to make work menopause-friendly: don’t think of it as a problem to be managed

Symptoms of menopause can include irregular periods, hot flushes, fatigue, tender breasts, night sweats, vaginal dryness, difficulty sleeping, changes in mood and lower libido.

During menopause, hormonal changes can affect the way fat is distributed in the body, but ageing is more likely to be the cause of any weight gain associated with menopause.

Gaining weight isn’t inevitable, though. There’s plenty you can do to combat weight gain as you age.

Ageing is more likely to be the cause of any weight gain associated with menopause. Monkey Business Images/ Shutterstock

Hormonal changes alter where the body deposits fat

Certain areas such as your stomach are more prone to weight gain during menopause. This is because the change in hormones, which lead to a higher testosterone-to-estrogen ratio, alters where the body deposits fat. Fat comes off the hips and is deposited around the middle.

But the hormonal changes involved in menopause aren’t the reason you gain weight.

A higher testosterone-to-estrogen ratio resulting from menopause can restribute weight from the hips to the middle. Maridav/ Shuttertock

Ageing is the real cause

The weight gain that comes with menopause is a by-product of ageing.

As we age, our body stops working as efficiently as it did before. Muscle mass starts to decrease – a process known as “sarcopenia” – and fat begins to increase.

And because muscle mass is one of the determining factors of how fast your metabolism will run, when your muscle mass decreases, your body starts to burn fewer calories at rest. This might make it more challenging to maintain your weight.

Read more: Trick or treat? Alternative therapies for menopause

As we age, we tend to continue with our same food habits but don’t increase our activity. In fact, aches and pains can make some people actively decrease theirs.

Not compensating for the ageing process and the change in body composition can lead to weight gain.

And this applies to men too – they are just as likely to gain weight due to this process known as sarcopenia.

Menopause and weight gain take their toll

Due to a change in body fat distribution and increase in waist circumference, menopause can also increase your risk of other health conditions.

Read more: Hot flashes? Night sweats? Progesterone can help reduce symptoms of menopause

Following menopause, your ovaries make very little of the hormones estrogen and progesterone. Estrogen helps to keep your blood vessels dilated – relaxed and open – which helps keep your cholesterol levels down.

Without estrogen, or with lower quantities, your bad cholesterol (known as low-density lipoprotein or LDL-cholesterol) starts to build up in your arteries. This can increase your risk of heart disease and stroke.

Having less estrogen also results in a loss of bone mass, putting you at risk of the disease osteoporosis, which makes your bones more prone to fractures.

What can you do?

Weight gain associated with ageing is not inevitable. There are a number of things you can do to maintain your weight as you age.

1. Exercise

Incorporate regular daily exercise, with a mixture of intensities and variety of activities. Try to include body-strengthening exercises two days per week.

2. Weigh yourself – but not too much

Weigh yourself once a week at the same time and day to monitor the trend over time. Any more than this will only create a fixation with weight. Day-to-day fluctuations in weight are to be expected.

Regularly weighing yourself can help you monitor your weight over time. Stock-Asso/ Shutterstock

3. Create positive habits

Create positive habits by replacing negative behaviours. For example, instead of mindlessly scrolling through social media of an evening or turning on the TV and comfort-eating, replace it with a positive behaviour, such as learning a new hobby, reading a book or going for a walk.

Read more: How to beat weight gain at menopause

4. Eat more slowly

Eat food away from technological distractions and slow down your food consumption.

Try using a teaspoon or chopsticks and chew your food thoroughly as slowing down your food consumption reduces the quantity consumed.

5. Switch off from technology:

Turn off technology after dusk to improve your sleep. Blue light emission from phones, tablets and other devices tell your brain it’s day, instead of night, which will keep you awake.

Lack of sleep (less than six hours per night) can compromise your decision-making abilities which might lead you to make unhealthy choices that contribute to weight gain.

6. Curb sugar cravings naturally

If you’re craving sugar you’re better off reaching for foods naturally high in sugar and fat first. Some great options are fruits, nuts, avocado and 100% nut butters. These foods release the same feel-good chemicals in the brain as processed and fast food and leave us feeling full.

Allow yourself your favourite treats, but keep them to once per week.

5 reasons to stop prescribing vitamin D for bones

5 reasons to stop prescribing vitamin D for bones

Supplementation doesn’t prevent fractures, falls or improve bone density

There is little reason to continue prescribing vitamin D for bone health, because it doesn’t prevent fractures, falls or improve bone density.

The authors of a large meta-analysis published in Lancet Diabetes and Endocrinology say their findings show vitamin D supplementation has little justification — except in rare cases of rickets or osteomalacia where exposure to sunlight is a factor.

Since the last major review in 2014, more than 30 randomised controlled trials on bone health and vitamin D have been published, nearly doubling the evidence-base available.

“Our findings suggest that vitamin D supplementation does not prevent fracture or falls, or have clinically meaningful effects on bone mineral density,” say the researchers, led by Dr Mark Bolland, of the University of Auckland, New Zealand.

“There were no differences between the effects of higher and lower doses of vitamin D.

“There is little justification to use vitamin D supplements to maintain or improve musculoskeletal health. Guidelines should reflect this.”

Here are five key reasons to stop recommending vitamin D as a way of improving bone health:

  1. This is the largest meta-analysis to date, combining data from 81 randomised controlled trials, involving more 53,500 participants, with more than half the studies involving daily dosing.
  2. Vitamin D supplementation was shown to have no effect on total fracture, hip fracture or falls.
  3. For bone mineral density outcomes, the between-group differences were 0.25% for lumbar spine, 0.76% for femoral neck, and 0.13% for total body, none of which were clinically relevant.
  4. More than 90% of the trials reported achieving 25-hyroxyvitamin D concentrations of 50nmol/L or more and 58% reported achieving concentrations of 75nmol/L or more.
  5. Dr Bolland and colleagues are leaders in the field of meta-analysis and have taken great care to analyse the data in every way possible, according to a linked editorial in the same journal.

And what about the extra-skeletal benefits of vitamin D?

According to the editorial author, Professor Chris Gallagher, of Creighton University in the US, those results are coming soon, with studies on almost 100,000 participants currently enrolled in randomised controlled trials of vitamin D supplementation due to report within three years.

“I look forward to those studies giving us the last word on vitamin D,” Professor Gallagher concluded.

These 4 diets are trending. We looked at the science (or lack of it) behind each one

Thought Catalog/Unsplash

These 4 diets are trending. We looked at the science (or lack of it) behind each one

May 4, 2020 5.49am AEST


  1. Clare Collins Professor in Nutrition and Dietetics, University of Newcastle
  2. Lee Ashton Postdoctoral research fellow, University of Newcastle
  3. Rebecca Williams Postdoctoral Researcher, University of Newcastle

Disclosure statement

Clare Collins is affiliated with the Priority Research Centre for Physical Activity and Nutrition, the University of Newcastle, NSW. She is an NHMRC Senior Research and Gladys M Brawn Research Fellow. She has received research grants from NHMRC, ARC, Hunter Medical Research Institute, Meat and Livestock Australia, Diabetes Australia, Heart Foundation, Bill and Melinda Gates Foundation, nib foundation, Rijk Zwaan Australia and Greater Charitable Foundation. She has consulted to SHINE Australia, Novo Nordisk, Quality Bakers, the Sax Institute and the ABC. She was a team member conducting systematic reviews to inform the Australian Dietary Guidelines update and the Heart Foundation evidence reviews on meat and dietary patterns.

Lee Ashton is affiliated with the Priority Research Centre for Physical Activity and Nutrition at the University of Newcastle, NSW, Australia.

Rebecca Williams is affiliated with the Priority Research Centre for Physical Activity and Nutrition at the University of Newcastle, NSW, Australia.


University of Newcastle

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Diets claiming you’ll lose a huge amount of weight in next to no time pop up on social media relentlessly.

When a new diet promises dramatic results with little effort, or sells miraculous pills, potions or supplements guaranteed to melt body fat or speed a up sluggish metabolism – with testimonials touting success – then be sceptical.

We evaluated four current diet trends to see how their claims stack up against the science.

Read more: Health Check: six tips for losing weight without fad diets

Reverse dieting

Reverse dieting, referred to as “the diet after the diet”, involves increasing your energy intake in a gradual, step-wise way after you stop following a reduced energy diet.

The reverse diet is popular among bodybuilders and physique athletes trying to return to “normal” eating patterns without gaining extra weight.

The theory is that providing a small energy intake surplus may help restore circulating hormone levels and reverse any adverse change in the body’s energy expenditure, restoring it to pre-diet levels.

At the same time it tries to match energy intake to a person’s usual metabolic rate based on them being at a stable weight. The aim is to try not to store extra body fat due to consuming more kilojoules than are being used.

Diet trends are often not based on hard facts. i yunmai/Unsplash

Anecdotal reports of success using reverse dieting have seen it trending, but there are no studies specifically testing this diet for weight management.

Ideally, weight loss strategies should maximise any reduction in body fat stores while conserving or building muscle mass.

One review evaluated studies estimating the number of extra kilojoules needed daily to maximise muscles and minimise body fat stores, while also exercising to build muscles, called resistance training. They found limited evidence to guide recommendations.

Verdict? Fad diet.

The GAPS diet

The Gut And Psychology Syndrome (GAPS) diet starts with a strict elimination diet followed by maintenance and reintroduction phases that proponents suggest you follow over several years.

There is no scientific evidence to support the website claim that the diet could lift a “toxic fog off the brain to allow it to develop and function properly”.

The GAPS diet wasn’t specifically formulated for weight management; it’s rather promoted as a natural treatment for people with digestive problems or conditions that affect the brain, such as autism. But the blog reports some people have experienced positive weight changes, either weight loss or weight gain, as needed.

The diet recommends removing all grains, pasteurised dairy, starchy vegetables and refined carbohydrates and swapping these for fish, eggs, broths, stews and fermented foods.

The GAPS protocol also recommends a range of supplements including probiotics, essential fatty acids, digestive enzymes and cod liver oil which happen to be for sale on the website.

The GAPS diet says that increased intestinal permeability, or “holes in your gut” termed “leaky gut”, allow food components and bacteria to enter your blood, which it says then triggers neurological and psychological conditions including depression, autism and learning difficulties.

GAPS claims to heal a leaky gut by eliminating certain foods that trigger it and to improve digestive and psychological health.

While intestinal permeability is increased in some situations including pregnancy, during endurance exercise, or with the use of non-steroidal anti-inflammatory medication, there’s no evidence the GAPS diet regime resolves this.

Read more: The science behind diet trends like mono, charcoal detox, Noom and Fast800

Further, any bouts of diarrhoea experienced while following the GAPS diet are not “clearing you out”. There is no scientific evidence that any diarrhoea caused by following this diet is helpful.

Ultimately, this diet is extremely restrictive and puts you at risk of malnutrition. We strongly advise against it.

Verdict? Fad diet.

The HCG diet

Human chorionic gonadatropin (HCG) is a hormone produced during pregnancy and used in fertility treatments. HCG supplementation has also been used in athletes because it promotes testosterone production and builds muscle in males. It’s currently on the World Anti-Doping list of prohibited substances.

HCG is promoted as a weight loss supplement with older claims it could mobilise fat and suppress appetite. The original 1954 HCG trial had some positive results and triggered development of the current HCG diet.

The diet involves taking a HCG supplement, typically as liquid drops, while following a very low-energy diet of 2,000 kilojoules (500kcal) a day.

Since 1954, no studies have replicated the original findings. The conclusion? Weight loss is due to the large energy deficit. We don’t recommend this diet.

Verdict? Fad diet.

IIFYM (If It Fits Your Macros) diet

Instead of counting kilojoules, the IIFYM diet gets you to count your macronutrients (macros).

First you use their online calculator and fill in a range of questions related to your plans to manage your weight. You supply your email and it works out your daily macro needs and sends you a copy plus an “offer” for a personalised program with a money back guarantee.

You then monitor your daily intake of protein, carbohydrate and fat in grams coming from food and drinks (though you can count macros on any app).

Focus on where your macros are coming from rather than counting them. Shutterstock

Depending on a person’s goals, the diet may or may not include a daily kilojoule restriction.

There is no research specifically testing the IIFYM diet. But lots of research has tested whether certain macronutrient ratios are better for weight management. The short answer is no.

A review of 14 popular diets with varying macronutrient ratios found no specific diet was better than others in achieving weight loss over six months. Across all diets weight loss diminished by 12 months.

Read more: Health Check: ten ways to save 2,000 kilojoules and drop a clothes size

For weight loss, the key to success is achieving a total daily kilojoule restriction you can live with.

Focus on which foods your macros are coming from, rather than the ratio. Eating foods of higher nutritional quality, like vegetables, fruit, legumes and wholegrains, rather than energy-dense, nutrient-poor ultra-processed foods, means your total kilojoule intake will be lower.

Counting macros can inform food choices that boost diet quality and help lower kilojoule intake, but there’s no strong evidence behind this diet.

Verdict? Fad diet.

For personalised help to check whether you’re meeting your nutritional requirements, consult an Accredited Practising Dietitian. Due to COVID-19, Medicare have introduced rebated telehealth consultations for eligible people.

Read more: Health Check: what’s the best diet for weight loss?

If you’d like to learn more about weight loss, you can enrol in our free online course The Science of Weight Loss – Dispelling Diet Myths which begins on May 6.

6 Critical COVID-19 Questions We Must Answer to Move Past the Pandemic


6 Critical COVID-19 Questions We Must Answer to Move Past the Pandemic

By Jonathan Ford Hughes on May 15, 2020 FacebookTwitterLinkedInEmailShare

If there’s any cause for optimism over the response to COVID-19, it’s this: Every day, we learn a little bit more about the virus and how to put a stop to it. It’s actually quite remarkable if you think about where we were in February, compared to where we are now. Then, we weren’t even sure if survivors had immunity. Now, we’re rolling out new tests, we have a treatment option, and an accelerated vaccine timeline. 

However, we’re by no means on the other side of this pandemic. To get there, we’re going to need to come up with answers to these critical questions.

What is the actual mortality rate?

This is the literal trillion-dollar question, with the economy tanking and a record number of Americans out of work. The current mortality rates are accurate only to a degree. It’s a simple matter of data set size. The more tests we have, the more data we have, and the more accurate our projections about the infection and mortality rates become. Without knowing the actual mortality rate, how do we know if we’re overreacting, under-reacting, or getting the social distancing/shutdown response just right?

The only way to answer this question is to expand testing — a refrain that we’ve heard from researchers since day 1 of the epidemic. We’re making progress on that end. Rutgers University recently rolled out a saliva-based, rapid antigen detection test. But until we have something instant — something akin to a pregnancy test — can we safely allow people to return to work?

Furthermore, let’s say we know the actual death rate. This raises the king-kong ethical question of, how many deaths are acceptable? 

How serious is the risk to children?

Early in the response to the pandemic, many believed that children would largely be unscathed by COVID-19. And statistically, that does appear to be the case. However, the recent emergence of about 150 cases that look similar to Kawasaki disease, mostly clustered in New York, are cause for concern. Are these isolated incidences, or the early onset of a trend for the virus?

Again, knowing the answer to this question is critical for the reopening of America. Harried parents across the U.S. want their kids back in school so they can get some relief and get back to work, but is it safe for them to return? And what precautions might we have to take prior to widespread availability of a safe, effective vaccine?

Is an accelerated vaccine timetable safe?

Speaking of vaccines, we are heading into uncharted territory. President Trump’s Operation Warp Speed calls for 300 million vaccinations by January 1, 2021. For context, the record for bringing a vaccine to market is 4 years, held by the mumps shot. To hit that January 1 mark, we’re going to have to jump directly into human trials.

This raises a number of ethical questions, as well as technical ones. For one, is it right to inject millions of people with a vaccine that hasn’t been subjected to the usual rigorous FDA trial process? And more importantly, how will we be sure that it works and that there aren’t any adverse events without the usual trial phases? 

There’s a tradeoff to be made here: Save lives by bringing a vaccine to market quickly, or be methodical to minimize risk? Once again, knowing the actual death rate would make answering this question a bit easier.

What’s going on with remdesivir?

So, great. We have one effective COVID-19 drug. But just how effective is it? Unfortunately, as reported by STAT earlier this month, the jury’s out. NIH researchers elected to give patients earmarked for placebo the drug before the study was complete. The thinking was that from an ethical standpoint, carrying the study through to its designated length put more patients at risk of dying when early results seemed to indicate that remdesivir could help.

At the end of the trial, STAT notes, among those who received remdesivir, 8% died. In the placebo group, 11.6% died prior to the endpoint change. This, unfortunately, isn’t statistically significant. So, it looks like it’s back to the drawing board.

What is the extent of the mental health toll?

Are we ready for the mental health pandemic that’s likely to be on the heels of the COVID-19 pandemic? For months, people have been living in isolation, separated from their support networks of friends and families. Elements of everyday life — such as going for a walk or shopping for food — have become anxiety-provoking brushes with illness or death.

Nearly 100,000 are dead, and their friends and family haven’t had the chance to even properly grieve the loss of the people they love. Unlike cases of the virus, it isn’t as easy to measure the mental health impact. We’ll likely only gain a sense of the scope in the years to come. 

How are physicians and other healthcare workers holding up?

Burnout was a problem before COVID-19 hit. Now, many physicians have been working non-stop to keep patients alive. Others are watching their practices shrivel as elective procedures have been put on hold, and patients avoid seeking care out of fear of falling ill with the virus.

There’s been much focus on financial support for Americans at large, but little discussion about supporting American physicians and healthcare workers. We need to understand what their fiscal and emotional needs are to keep continuing their critical work.

Low mood and depressive symptoms during perimenopause

Low mood and depressive symptoms during perimenopause – Should General Practitioners prescribe hormone replacement therapy or antidepressants as the first-line treatment?

Mandy Leonhardt

First Published June 27, 2019 Research Article

Article information 

Free Access


Perimenopausal women have an increased risk of developing new onset and recurrent mental health conditions such as anxiety, low mood and depressive symptoms. General Practitioners frequently prescribe antidepressants as the first-line treatment for these symptoms, despite clear lack of evidence for their efficacy and their unfavourable side effect profile. This article, written by a General Practitioner, gives a practical overview of the mental health symptoms which women may report to their General Practitioners during the menopausal transition and discusses underlying causes, assessment, risk factors and treatment options based on current evidence.Keywords Antidepressants, anxiety, depression, hormone replacement therapy, menopause, perimenopause

Perimenopause and mental health

The perimenopause is defined as the transitional period prior to menopause and features clinical, biological and endocrinological changes. The perimenopause ends 12 months after the last menstrual period.1 The median age of onset of perimenopausal symptoms is 47.5 years.2 The average duration of the menopause transition is four years (defined by menstrual cycle irregularity), but the individual variation for this phase ranges from 0–11 years.3

The risk of depression increases during the menopause transition.4 In my own clinical practice as a General Practitioner (GP), I find that from the age of 40 onwards, even while periods are still regular, women may experience a variety of different mental health symptoms. These symptoms may be new and out of character, or they may be recurrent, or cyclical, such as exacerbated perimenstrual syndrome (PMS). Heightened anxiety, tearfulness, loss of confidence, low mood or mood swings are common symptoms perimenopausal women report in my day-to-day practice. Many women report that they don’t feel continuously depressed as such, but that they ‘just don’t feel like themselves anymore and don’t recognise the person they have become’. These mental health symptoms during the menopausal transition may occur with or without vasomotor symptoms (VMS). In the absence of VMS, irregular or missed periods, or in women deemed ‘too young’ for being menopausal, health care practitioners often don’t consider hormonal changes as a causative factor and this can affect the treatment options offered to these patients.

There is evidence that episodes of depression associated with reproductive events are triggered by hormonal fluctuations. Some authors have argued that hormone modulated reproductive affective disorders such as PMS, perimenstrual dysphoric disorder (PMDD), pre/postnatal depression and climacteric depression are distinct forms of depression and could be categorised as subtypes of Reproductive Depression.5,6 The term ‘Reproductive Depression’ was first introduced by Nappi et al.,7 and it implies that whilst symptoms may be similar, the underlying biological mechanisms differ from other forms of depression. The term helps to acknowledge that there are types of depression which are specifically linked to the biology of the female sex and this could lead to a more individualised approach to treatment. Currently, the term ‘Reproductive Depression’ is not yet widely acknowledged by the medical profession and it is not included in Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM 5) 5 or International Classification of Disease, Eleventh Revision (ICD-11).

Supporting the position that perimenopausal depression is a subtype of reproductive depression has important clinical implications for the treatment and/or prevention of perimenopausal depression.

Hormone replacement therapy (HRT) can be an effective and safe treatment for low mood that arises as a result of the menopause,810 but a recent survey has shown that more than half of the GPs questioned prescribed antidepressants instead of HRT for the management of mood-related menopausal symptoms,11 even though the NICE guidelines state that HRT and/or cognitive behavioural therapy (CBT) can be considered for low mood symptoms related to the menopause.12 The incorrectly interpreted Women’s Health Initiate Study (WHI) from 2002 may still be to blame for the reluctance of some health care practitioners to prescribe HRT.13 A Canadian Study from 2005, which looked at changes in prescribing patterns related to HRT/antidepressants in Canada, confirmed that a significant decrease in the number of HRT prescriptions after 2002 was associated with a statistically significant increase in prescriptions for selective serotonin reuptake inhibitors (SSRIs) during the years after the WHI was published. They concluded that women who were previously prescribed HRT to control their (physical and psychological) menopausal symptoms were now given SSRIs instead.14


Mental health-related symptoms during the perimenopause and the early menopausal years are common and particularly these symptoms and not necessarily VMS can be the main reason why women seek help from their GP. Epidemiological studies have shown that between 45% and 68% of perimenopausal women report elevated depressive symptoms.15 In 15%–30% of perimenopausal women, symptoms are severe enough to be regarded as a depressive disorder.16

It is important that GPs have an awareness about these symptoms (Table 1) and their possible underlying causes in women in this age group. Every woman will experience this time in her life differently and every woman has a different range and severity of symptoms at a different age, before her periods stop for more than 12 months and she is postmenopausal. From my own experience as a menopause care provider, I find that women from their early 40s onwards frequently report that they feel more anxious, irritable and insecure, that they feel easily irritated, angry and that there are times when they feel like they are losing control over their life. Some women say that they feel overall less confident, less resilient to stress and that they have become indecisive and insecure for no reason. These symptoms often come and go during the day or they can last continuously for extended periods of time. Frequently, women also report that symptoms are exacerbated during the days before their period start. Depending on the severity and frequency of these symptoms, they can have a major detrimental effect on the way women function at work, on their relationship with their partner and on their family.

Table 1. Mental health symptoms women report during the perimenopause.1719

Table 1. Mental health symptoms women report during the perimenopause.1719

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Animal studies have shown that ovarian steroids have a direct impact on neurotransmitter system activities, including regulation of metabolic enzyme production as well as receptor and transporter protein activity. The pattern of effects of ovarian steroids on the serotonin system in humans is similar to those observed in animals. There is also evidence that reproductive steroids influence the serotonergic regulation of the hypothalamic-pituitary-adrenal (HPA) axis.3 Neurobiological evidence indicates that estradiol has neuromodulary and neuroprotective effects in the hypothalamus, amygdala and the hippocampi, which are directly relevant to mood symptomatology. Estrogen acts as a serotonergic agonist and is implicated in multiple mood regulating mechanisms in different brain regions. It increases serotonergic postsynaptic responsivity, increases the number of serotonergic receptors and enhances serotonergic transport and uptake.20 A clinical study from 2015 demonstrated that the sudden (blinded) withdrawal of estradiol, which was given to participating perimenopausal women as a transdermal patch, precipitated depressive symptoms in those women who had a history of perimenopausal depression. The women in the control group, who also had a history of perimenopausal depression, but who continued to receive estradiol, had no recurrence of their depressive symptoms. The depression inducing effects of estradiol withdrawal in this study only affected women with a history of perimenopausal depression, which suggests that perimenopausal changes in estradiol levels can trigger depression in a susceptible subgroup of women.21 Results from another clinical trial suggest that estradiol variability in the menopause transition enhances emotional sensitivity to psychosocial stress and this increased sensitivity may contribute to the development of depressed mood. These effects of estradiol fluctuation on stress sensitivity and mood appear to be independent of estradiol levels and VMS.22 There is substantial evidence now that fluctuations of estradiol levels during the menopause transition trigger alterations in the HPA axis and changes in cortisol levels, which further supports the idea that perimenopausal depression is unique in its aetiology and that affected women could benefit from interventions to stabilize estradiol levels, such as HRT.23,24

Risk factors

There are risk factors which make a subgroup of women more vulnerable to developing depressive symptoms during the perimenopause (Table 2). Women who have a history of increased sensitivity to hormonal fluctuations and to reproductive endocrine changes, such as PMS/PMDD or postnatal depression (PD), but also women with a history of oral contraceptive-induced dysphoria have a higher risk of developing depressive symptoms during the perimenopausal years.3 Perimenopausal women with a history of PMS are three times more likely to report symptoms of depression during the menopausal transition compared to premenopausal women.17 But even in women with no history of depression, the risk of new onset depression during the perimenopausal years is still twice as high as in premenopausal women.3

Table 2. Factors which increase the risk for depressive symptoms during the perimenopause.25,26

Table 2. Factors which increase the risk for depressive symptoms during the perimenopause.25,26

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GPs have usually 10 min to take a history, make a diagnosis and discuss treatment options. It is not realistic to carry out a thorough mental health assessment during 10 min and often it requires several visits to enable the GP to make a diagnosis and for women to make an informed decision about the best possible treatment option. Blood tests such as FSH levels may be considered in symptomatic women aged 40–45 and of course if premature ovarian insufficiency is suspected in women below the age of 40.27 The GP should ask the patient about a history of depression including PD, PMS/PMDD, quality of sleep, periods (flooding, pain, frequency), contraception, as well as VMS (hot flushes, night sweats). Validated instruments such as the beck depression inventory, Hamilton Depression Rating Scale or the Patient Health Questionnaire-9 can be used to measure and monitor the severity of depressive symptoms. The Greene Climacteric Scale is a specific assessment tool for menopausal symptoms, which includes physical as well as psychological parameters.28 Another useful tool is the Meno-D questionnaire. This is a relatively new rating scale (2018), which was specifically developed and validated to assess the rate and severity of the characteristic symptoms of perimenopausal depression (Table 3). The concept of the Meno-D scale is based on a five-factor model: self; somatic; cognitive; sleep; sexual. It is designed to be used by clinicians, researchers and as a self-assessment tool for perimenopausal women. The questionnaire asks 12 questions and each question has five answer options, each graded from 0 to 4, according to severity.19 Unfortunately, the paper does not provide scoring thresholds which would help to practically define normal from abnormal results. It may therefore be more useful as a symptom monitoring tool rather than a diagnostic tool.

Table 3. Clinical areas which are assessed by the Meno-D questionnaire.19

Table 3. Clinical areas which are assessed by the Meno-D questionnaire.19

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Untreated depressive symptoms greatly affect the quality of life, relationships and the ability to function in the workplace. Depression is associated with an increased risk of heart disease, diabetes, osteoporosis and in the worst case, suicide.16 Treatment should be personalised and tailored to each individual woman and her needs. Treatment progress needs to be monitored, and women should be reviewed frequently. A careful risk assessment and history taking prior to starting treatment is essential. Personal health beliefs, ideas, concern and expectations should be considered, and doctors should work in partnership with the patient, giving relevant evidence-based information to help women to make an informed decision about the best treatment option. Advice about healthy lifestyle measures like smoking cessation, reducing alcohol intake, healthy eating, exercise and managing stress should be included during the discussion about treatment. CBT and mindfulness-based therapies can be offered in addition to medication depending on severity and preferences.29

Hormone replacement therapy

Fluctuating estradiol levels have been shown to contribute to the development of depressive symptoms and low mood during the perimenopause. Stabilising estradiol levels with HRT has been shown to be an effective treatment for mild to moderate depressive symptoms.9,30,31 One recent clinical study showed that the combination of transdermal estradiol in combination with micronized progesterone helped to prevent clinically significant depressive symptoms among initially euthymic perimenopausal and early postmenopausal women.8

The NICE guidelines state that HRT should be considered as a treatment for low mood that arises as a result of the menopause. The guidelines also state, that due to lack of evidence, SSRIs or serotonin norepinephrine reuptake inhibitors (SNRIs) are not recommended to treat low mood in menopausal women who have not been diagnosed with clinical depression.12 It is important that health care professionals who are involved in the care of menopausal women are mindful to distinguish between severe major depressive episodes and less severe depressive symptoms and low mood. Women who diagnostically fulfil the criteria for major depression and clinical depression should still be treated with antidepressants as the first-line treatment.

Beyond the stabilisation of estradiol fluctuations to treat low mood, HRT is also the first choice for the treatment of VSM in woman who don’t have contraindications. HRT improves overall quality of life, energy levels and sleep and it does not negatively affect libido or cause sexual dysfunction.32 In addition, HRT is licenced for the prevention and treatment of osteoporosis,32,33 and can help to prevent cardiovascular disease if started early enough.34 HRT, preferably transdermal estradiol (gel or patch) should be offered as the first-line treatment to women with mild perimenopausal depressive symptoms.35 Women with a uterus need endometrial protection when using estrogen replacement; however, many women with a history of PMS/PMDD and oral contraceptive-induced dysphoria are sensitive or even intolerant to synthetic progestins. Micronized progesterone (orally or vaginally) given continuously or cyclically or the Mirena coil (IUS) have been shown to be better tolerated than other progestogens with regard to mood-related side effects.36


In a large metanalysis, antidepressants have been shown to be more efficacious than placebo in adults with major depressive disorder, but this analysis did not specifically look at perimenopausal women.37 In 2018, the North American Menopause Society (NAMS) issued a consensus statement about the evaluation and treatment of perimenopausal depression. These guidelines recommend that antidepressants, CBT and other psychotherapies should remain the front-line treatments for major depressive episodes during the perimenopause, despite also stating that there is evidence that estrogen therapy has antidepressant effects of similar magnitude to that observed with classic antidepressant agents when administered to depressed perimenopausal woman with or without concomitant VMS.15 The NAMS statement does not provide a treatment recommendation for less severe menopause-related depressive symptoms or low mood, but focuses on major depressive episodes. The NICE menopause guideline on the other hand does make this recommendation by stating that there is no clear evidence for SSRIs or SNRIs to ease low mood in menopausal women who have not been diagnosed with clinical depression.12

With regard to the best choice of antidepressant, only Desvenlafaxine has been studied in two large randomised placebo controlled trials and proven efficacious in the treatment of depressed perimenopausal women. Most other antidepressants have been trialled in cohorts of younger premenopausal or older postmenopausal women.38,39 Clinical trials have shown that compared to placebo, antidepressants can help to reduce the frequency of VMS40,41; however, compared to HRT they are much less effective. HRT has been shown to reduce the severity and frequency of VMS by up to 83%, whereas antidepressants reduced the severity by up to 50%.42 In addition to that, only Paroxetine 7.5 mg (Brisdelle) has so far been approved by the FDA for the treatment of VMS, no other antidepressant is licenced for this purpose.43

Another very important consideration with regard to prescribing antidepressants in perimenopausal women is the unfavourable side effect profile. While HRT is licenced for the prevention and treatment of osteoporosis, SSRIs have been shown to significantly increase fracture risk in perimenopausal women if taken longer than five years.42 Menopausal symptoms can last much longer than five years and the long-term use of antidepressants can further add to an already increased risk of osteoporosis in women. In addition to an increased fracture risk, antidepressants are also associated with cardiovascular side effects, gastrointestinal side effects, increased risk of suicidal behaviour during the first weeks of treatment, weight gain, headache and insomnia.45 More than 50% of women who take SSRIs will experience sexual dysfunction, including low libido, anorgasmia and decreased arousal, which greatly affects quality of life.46

HRT in combination with antidepressants

What needs to be taken into consideration, is the range of severity of perimenopausal mental health symptoms from mild to moderate and severe which is different for each woman. The most severe symptoms may fulfil the criteria of a major depressive episode as diagnosed according to the DSM 5 criteria.47 Women are two to four times more likely to experience major depression during the perimenopausal or early postmenopausal phase.48 Women who fulfil the criteria for major depression should be offered antidepressants as the first-line treatment. In addition, they can be offered HRT if they also experience other menopause-related symptoms. In women with mild to moderate low mood who don’t achieve sufficient symptom control on HRT alone, antidepressants can be an important adjunct medication and there is some evidence that HRT can augment and enhance the efficacy of some antidepressants. HRT can be added to an antidepressant and vice versa.15,17,46 In women with a history of several depressive episodes, who have been stable for many years while taking antidepressants (SSRIs) and who are experiencing a worsening of depressive symptoms together with VMS, the antidepressant dosing may need to be adjusted and add-on hormone therapy should be considered.42 Clinical decisions about treatment should be made on a personalised case-by-case evaluation.


A growing body of research provides evidence that perimenopausal depression is a subtype of Reproductive Depression. Women with a history of depression or hormone-related mood changes seem to be particularly sensitive to perimenopausal estradiol fluctuations and have a higher risk of developing anxiety and depression. It is important that GPs have an awareness of Reproductive Depression and support women who enter and go through the menopausal transition appropriately and effectively. A thorough history of the woman’s mental health, which also includes questions about the menstrual cycle, PMS, PD and side effects to hormonal contraception should be taken. Women should be given relevant information about the benefits and side effects of HRT, as well as antidepressants, so that they can make an informed decision about the best treatment option. Those women who do not have contraindications, such as breast cancer and are not diagnosed with clinical depression, should be offered HRT as the first-line treatment for low mood during the perimenopause and GPs who practice in the UK should follow the NICE guidelines. In more severe cases, such as major depressive episodes, a combination of antidepressants and adjunct HRT should be considered.



Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

Not applicable.


ML is the sole author of this work.


1. Hillard, T, Abernethy, K, Hamoda, H, et al. Management of the menopause. 6th ed. UK: British Menopause Society, 2017, p.2.
Google Scholar
2. McKinlay, SM, Brambilla, DJ, Posner, J. The normal menopause transition. Maturitas 1992; 14: 103–115.
Google Scholar | Crossref | Medline | ISI
3. Schmidt, PJ, Rubinow, DR. Sex hormones and mood in the perimenopause. Ann N Y Acad Sci 2009; 1179: 70–85.
Google Scholar | Crossref | Medline | ISI
4. Cohen, LS, Soares, CN, Vitonis, AF, et al. Risk for new onset of depression during the menopausal transition: the Harvard study of moods and cycles. Arch Gen Psychiatry 2006; 63: 385–390.
Google Scholar | Crossref | Medline
5. Studd, J, Nappi, RE. Reproductive depression. Gynecol Endocrinol 2012; 28: 42–45.
Google Scholar | Crossref | Medline | ISI
6. Payne, JL, Teitelbaum-Palmer, J, Joffe, H. A reproductive subtype of depression: conceptualizing models and moving toward etiology. Harv Rev Psychiatry 2009; 17: 72–86.
Google Scholar | Crossref | Medline | ISI
7. Nappi, RE, Tonani, S, Santamaria, V, et al. Luteal phase dysphoric disorder and premenstrual syndrome. Ital J Psych 2009; 28: 27–33.
Google Scholar
8. Gordon, JL, Rubinow, DR, Eisenlohr-Moul, TA, et al. Efficacy of transdermal estradiol and micronized progesterone in the prevention of depressive symptoms in the menopause transition: a randomized clinical trial. JAMA Psychiatry 2018; 75: 149–157.
Google Scholar | Crossref | Medline
9. Soares, CN, Almeida, OP, Joffe, H, et al. Efficacy of estradiol for the treatment of depressive disorders in perimenopausal women: a double-blind, randomized, placebo-controlled trial. Arch Gen Psychiatry 2001; 58: 529–534.
Google Scholar | Crossref | Medline
10. Schmidt, PJ, Nieman, L, Danaceau, MA, et al. Estrogen replacement in perimenopause-related depression: a preliminary report. Am J Obstet Gynecol 2000; 183: 414–420.
Google Scholar | Crossref | Medline | ISI
11. Newson L, Mair R. and Lass A. Br J of Fam Med 2018, (accessed 30 December 2018).
Google Scholar
12. NICE . Menopause: diagnosis and management. UK: NICE, 2015.
Google Scholar
13. Writing Group for the Women’s Health Initiative Investigators . Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the women’s health initiative randomized controlled Trial. JAMA 2002; 288: 321–333.
Google Scholar | Crossref | Medline | ISI
14. McIntyre, RS, Konrski, JZ, Grigoriadis, S, et al. Hormone replacement therapy and antidepressant prescription patterns: a reciprocal relationship. CMAJ 2005; 4: 172.
Google Scholar
15. Maki, P, Kornstein, SG, Hadine, J, et al. Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. Menopause 2018; 25: 1069–1085.
Google Scholar | Crossref | Medline
16. Toffol, E, Heikinheimo, O, Partonen, T. Hormone therapy and mood in perimenopausal and postmenopausal women: a narrative review. Menopause 2015; 22: 564–578.
Google Scholar | Crossref | Medline
17. Parry, BL. Optimal management of perimenopausal depression. Int J Womens Health 2010; 2: 143–151.
Google Scholar | Crossref | Medline
18. Soares, CN, Frey, BN. Challenges and opportunities to manage depression during the menopausal transition and beyond. Psychiatr Clin N Am 2010; 33: 295–308.
Google Scholar | Crossref | Medline | ISI
19. Kulkarni, J, Gavrilidis, E, Hudaib, AR, et al. Development and validation of a new rating scale for perimenopausal depression – the Meno-D. Transl Psychiatry 2018; 8: 123–131.
Google Scholar | Crossref | Medline
20. Wharton, W, Gleason, CE, Olson, SR, et al. Neurobiological underpinnings of estrogen-mood relationship. Curr Psychiatry Rev 2012; 8: 247–256.
Google Scholar | Crossref | Medline
21. Schmidt, PJ, Ben, DR, Martinez, PE, et al. Effects of estradiol withdrawal on mood in women with past perimenopausal depression: a randomized clinical trial. JAMA Psychiatry 2015; 72: 714–726.
Google Scholar | Crossref | Medline | ISI
22. Gordon, JL, Rubinow, DR, Eisenlohr-Moul, TA, et al. Estradiol variability, stressful life events and the emergence of depressive symptomatology during menopause transition. Menopause 2016; 23: 257–266.
Google Scholar | Crossref | Medline | ISI
23. Gordon, JL, Eisenlohr-Moul, TA, Rubinow, DR, et al. Naturally occurring changes in estradiol concentrations in the menopause transition predict morning cortisol and negative mood in perimenopausal depression. Clin Psychol Sci 2016; 4: 919–935.
Google Scholar | SAGE Journals | ISI
24. Gupta, S, Mukherjee, A, Biswas, S, et al. Evaluation of endocrine parameters as predictor of major depressive disorder. Indian J Psychol Med 2017; 39: 766–769.
Google Scholar | Crossref | Medline
25. Freeman, EW, Sammel, MD, et al. Premenstrual syndrome as a predictor of menopausal symptoms. Obstet Gynecol 2004; 103: 960–966.
Google Scholar | Crossref | Medline | ISI
26. Bromberger, JT, Kravitz, HM. Mood and menopause: findings from the study of women’s health across the nation (SWAN) over 10 years. Obstet Gynecol Clin North Am 2011; 38: 609–625.
Google Scholar | Crossref | Medline | ISI
27. Hillard, T, Abernethy, K, Hamoda, H, et al. Management of the menopause. 6th ed. UK: British Menopause Society, 2017, p.36.
Google Scholar
28. Greene, J. A factor analytic study of climacteric symptoms. J Psychosom Res 1976; 20: 425–430.
Google Scholar | Crossref | Medline | ISI
29. Green, SM, Key, BL, McCabe, RE. Cognitive-behavioural, behavioural, and mindfulness-based therapies for menopausal depression: a review. Maturitas 2015; 80: 37–47.
Google Scholar | Crossref | Medline
30. Grazziottin, A, Serafini, A. Depression and the menopause: why antidepressants are not enough? Menopause Int 2009; 15: 76–81.
Google Scholar | SAGE Journals
31. Worsley, R, Davis, SR, Gavrilidis, E, et al. Hormonal therapies for new onset and relapsed depression during perimenopause. Maturitas 2012; 73: 127–133.
Google Scholar | Crossref | Medline
32. Newson, LR. Best practice for HRT: unpicking the evidence. Br J Gen Pract 2016; 66: 597–598.
Google Scholar | Crossref | Medline
33. Hillard, T, Abernethy, K, Hamoda, H, et al. Management of the menopause. 6th ed. UK: British Menopause Society, 2017, p.121.
Google Scholar
34. Newson, L. Menopause and cardiovascular disease. Post Reprod Health 2018; 24: 44–49.
Google Scholar | SAGE Journals
35. Soares, CN, Zitek, B. Reproductive hormone sensitivity and risk for depression across the female life cycle: a continuum of vulnerability? J Psychiatry Neurosci 2008; 33: 331–343.
Google Scholar | Medline | ISI
36. Panay, N, Studd, J. Progestogen intolerance and compliance with hormone replacement therapy in menopausal women. Hum Reprod Update 1997; 3: 159–171.
Google Scholar | Crossref | Medline | ISI
37. Cipriani, A, Furukawa, TA, Salanti, G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet 2018; 391: 1357–1366.
Google Scholar | Crossref | Medline
38. Clayton, AH, Kornstein, SG, Dunlop, BW, et al. Efficacy and safety of desvenlafaxine 50 mg/d in a randomized, placebo-controlled study of perimenopausal and postmenopausal women with major depressive disorder. J Clin Psychiatry 2013; 74: 1010–1017.
Google Scholar | Crossref | Medline | ISI
39. Kornstein, SG, Jiang, Q, Reddy, S, et al. Shortterm efficacy and safety of desvenlafaxine in a randomized, placebo-controlled study of perimenopausal and postmenopausal women with major depressive disorder. J Clin Psychiatry 2010; 71: 1088–1096.
Google Scholar | Crossref | Medline | ISI
40. Hickey, M, Szabo, RA, Hunter, M, Non-hormonal treatments for menopausal symptoms. BMJ 2017; 23: 359–366.
Google Scholar
41. Stubbs, C, Mattingly, L, Crawford, SA, et al. Do SSRIs and SNRIs reduce the frequency and/or severity of hot flashes in menopausal women. J Okla State Med Assoc 2017; 110: 272–274.
Google Scholar | Medline
42. Tan O, Pinto A and Carr BR. Hormonal and non-hormonal management of vasomotor symptoms: a narrated review. J Endocrinol Diabetes Obes 2013; 1: 1009–1024.
Google Scholar
43. Ronald, J, Li, L, Kim, MJ, et al. FDA approval of paroxetine for menopausal hot flushes. N Engl J Med 2014; 370: 1777–1779.
Google Scholar | Crossref | Medline
44. Sheu, Yi-han, Lanteigne, A, Stürmer, T, et al. SSRI use and risk of fractures among perimenopausal women without mental disorders. Inj Prev 2015; 21: 397–403.
Google Scholar | Crossref | Medline
45. Andrews, PW, Thomson, JA, Amstadter, A, et al. Primum non nocere: an evolutionary analysis of whether antidepressants do more harm than good. Front Psychol 2012; 3: 117–136.
Google Scholar | Crossref | Medline | ISI
46. Kim, D, Joffe, H. Use of antidepressants during perimenopause. Womens Health 2006; 2: 627–637.
Google Scholar | SAGE Journals
47. American Psychiatric Association . Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Association, 2013.
Google Scholar | Crossref
48. Bromberger, JT, Kravitz, HM, Chang, YF, et al. Major depression during and after the menopausal transition: study of women’s health across the nation (SWAN). Psychol Med 2011; 41: 1879–1888.
Google Scholar | Crossref | Medline | ISI

Women harmed, money wasted: Why breast screening needs a rethink

Australian Doctor News

Update on My Practice:

I am still doing mainly telephone appointments, but have relaxed that policy from next week and will see patients face-to -face for those who would prefer to actually see me. Otherwise, the system is working well.

The issue below is one I have discussed many times, and is something i feel strongly about this over treatment and over diagnosis. I have given a lot more information on my web-site under breast screening. It is a complex issue, but i believe in transparency and that women should be better informed about all sides of this debate.

Women harmed, money wasted: Why breast screening needs a rethink

ANALYSIS: Can we afford to screen as many women as we do, considering the cost and rate of overdiagnosis? 21st August 2019 By Jocelyn Wright6 Comments

If Australia’s breast cancer screening program was proposed today as a necessary intervention to protect women from the physical and emotional ravages of a disease that kills 3000 a year, would it be dismissed for the harms it causes and the costs it imposes?

Professor Alexandra Barratt

Professor Alexandra Barratt.

Put another way is it still worthwhile, fit-for-purpose?

Last month, researchers from Cancer Council NSW published the results of some rough calculations attempting to identify the current price of each single extra life-year generated. 

Their estimate was around $65,000. In terms of cost-benefit calculations in healthcare this is very high, higher than the $30,000-$50,000 threshold Australian governments apply when deciding whether interventions are worthwhile.

Such figures are an abstraction, but they suggest something is going wrong because the figures are a result of that clinical issue rumbling for the past 20 years about mass mammography screening driving unnecessary care and significant harms.

“This is a very heated argument around the world. There’s still a live question as to the extent to which it helps women, lengthens life or improves quality of life,” says Professor Alexandra Barratt, a professor of public health at Sydney University.

Read more: Is the breast screening program still value for money?

“The good news has always been that we have reduced breast cancer mortality — but we still don’t know how much of that is a result of new treatments and how much is due to screening.”

She says unlike HPV, the natural history of breast cancer remains something of a riddle. 

“With cervical cancer, we know how it progresses, when to screen and when to intervene. We haven’t got that level of understanding with breast cancer.

“One woman said to me she wishes she had never been screened. She doesn’t know whether the treatment matters, whether she may be in the 20% for whom the cancer doesn’t progress.

“However, she feels uncertain about whether she’s done the right thing and angry at not being better informed before.” 

Professor Barratt believes around 20% of all screen-detected cancers are overdiagnosed. A review in 2012 in Europe put that figure as low as 1-10%.

Read more: Q&A: How to help breast cancer survivors reduce CVD risk

But then within a year a Cochrane review of seven trials involving 600,000 women aged 39-74 randomly assigned to receive screening mammograms or not concluded the rate of overdiagnosis was 30%.

This means that for every 2000 women screened over 10 years, one will avoid dying of breast cancer, 10 healthy women will be treated unnecessarily and more than 200 women will experience anxiety and uncertainty for years because of false-positive findings.

The point now is that a wave of recent cost-effectiveness calculations on breast screening are including the consequences of overdiagnosis and that, according to Professor Barratt, “makes a huge difference” to whether breast screening appears worthwhile in terms of its financial cost.

The researchers from Cancer Council NSW are calling for Australia to conduct its own formal cost-benefit analysis of the program, which screens some 1.7 million women a year. They note that the last analysis was completed in 2009. 

Professor Barratt says in 2013, the Swiss Medical Board conducted its own review and recommended phasing out routine screening, determining that no new systematic program should be introduced.3  

Another review in 2013 in the UK made a “best estimate” that annually, 1300 breast cancer deaths are averted through its screening program — “a most welcome benefit.” However, it called for greater efforts to communicate the benefits and harms.4 

Read more: Consider breast density alongside cancer risk for further screening

The result is that today, detailed pamphlets are given to women each and every time they are invited to screen. Professor Barratt says if she could make one change overnight to Australia’s program, she’d do the same here. 

“There’s no downside to better informing women, only a small cost.”

But all the number crunching is probably a side issue.

The accountancy headaches will be soothed simply through better targeted screening, where high- and low-risk women are offered different screening intervals and protocols as determined by their individual risk profile, based on genetic mutations, ethnicity, age, breast density and positive family history. 

But we still need evidence to quantify what the risks are and it seems we are still only just at the beginning of a process to do that through the large scale randomised trials needed to provide robust answers.

There are two main contenders.

Video: Watch researchers behind the study discuss their hopes for the project.

The US is currently running its WISDOM study, involving 100,000 women.

This trial promises to ‘break the deadlock’ in a debate that has raged and boiled within the medical profession despite being rooted in trial data generated over 30 years ago at a time before personalised medicine was widely embraced, much talked about or even possible.

Under the WISDOM trial, women in the risked-based arm will be divided into four separate risk groups — high to low — and then compared with women offered annual screening (see box below for how women will be stratified by risk).

The researchers say the primary outcomes will be the number of stage IIb or higher cancers using personalised versus annual screening.

They will also be able to compare the morbidity of personalized vs annual screening based on the number of biopsy being performed

The other option began last year — a European trial called My Personalised Breast Screening (MyPeBS).

Some 85,000 women will be randomly assigned to either continue with standard screening while another group will be differentially screened for four years before returning to standard screening.

Like the WISDOM trial they will stratify their individual risk of developing breast cancer.

This study is due to end in 2025.

Read more: Implant ban to hit breast cancer survivors: surgeon

Professor Barratt is optimistic about what will emerge but she stresses “risk stratification is a big step from where we are at the moment”.

It will also bring with it that the vexed question of how easy it will be to scale back the reach of Australia’s program given the stubborn belief among the public that screening in any form can only be a good thing. 

What would happen if a woman deemed low risk is suddenly placed outside the program and loses her life to breast cancer?

It’s the PSA debate again. As with that debate, being told of the costs and benefits doesn’t lessen the anguish of hindsight for a patient and their family when things don’t turn out well

But at least now, while it is going to take time, there is push to make mammogram screening work better beyond the arguments over its rights and wrongs.

WISDOM US risk stratification and screening recommendations
RiskRisk factorsScreening recommendations
Highest risk BRCA1/2, TP53, PTEN, STK11, CDH1 mutation carrier (or) ATM, PALB2, or CHEK2 mutation carrier with positive family history of breast cancer (or) Women with a five-year risk of 6% or more (risk of an average BRCA carrier) (or) Women with a history of mantle radiation between ages 10 and 30 Annual mammogram + MRI
Elevated risk Women aged 40-49 with extremely dense breasts (or) Women with a five-year risk of 0.75% or more of developing ER-breast cancer based on susceptibility, age, and ethnicity (or) Women in top 2.5th percentile of risk by one-year age category (or) ATM, PALB2 or CHEK2 mutation carrier without a positive family history of breast cancer Annual mammogram
Average risk Women aged 50-74 (or) Women aged 40-49 with a five-year risk of more than 1.3% or more (risk of an average 50 year-old woman) Biennial mammogram
Lowest risk Women aged 40-49 with a more than 1.3% five-year risk of developing breast cancerNo screening until age 50

References on request from

Health benefits of taking a nap.

Featured Articles in Internal Medicine In the News

This simple indulgence once a day can help lower your blood pressure

Naveed Saleh, MD, MS, for MDLinx | April 30, 2020

Taking a nap could do more than just renew your energy levels and mood, according to emerging evidence. Several researchers have found that taking a siesta is not only linked to lower blood pressure levels, but also improved sleep quality and wake performance.

AdvertisementWoman reading positive blood pressure levels

Emerging research shows that naps are more than just a luxurious way to boost your energy levels.

People have been taking naps for thousands of years, with the practice dating back to ancient Muslim culture, where it takes a religious dimension for some practitioners. But, the concept of napping has perhaps become most popular through the practice of siestas, which originated in Spain but has become popular worldwide. Although siestas are now considered a luxury, they were once thought to be a necessity for physical health, particularly for farmers. The point of siestas was to sleep through the hottest part of the day and avoid the midday sun to restore energy levels. Now, researchers are finding that naps may offer other important health benefits—including improvements in cardiovascular health, sleep quality, and mental acuity. 

Here’s a detailed overview of some of the noteworthy evidence-based health benefits of napping.


In patients with controlled hypertension, naps could lead to drops in blood pressure comparable to those seen with other lifestyle changes, according to recent research presented at the American College of Cardiology’s 68th Annual Scientific Session, now published in the Journal of the American College of Cardiology. The study is the first to prospectively determine the impact of mid-day sleep on blood pressure levels among individuals with well-controlled hypertension. 

“Midday sleep appears to lower blood pressure levels at the same magnitude as other lifestyle changes. For example, salt and alcohol reduction can bring blood pressure levels down by 3 to 5 mmHg,” said cardiologist and study co-author Manolis Kallistratos, MD, Asklepieion General Hospital, Voula, Greece. 

“These findings are important because a drop in blood pressure as small as 2 mmHg can reduce the risk of cardiovascular events such as heart attack by up to 10%. Based on our findings, if someone has the luxury to take a nap during the day, it may also have benefits for high blood pressure. Napping can be easily adopted and typically doesn’t cost anything,” Dr. Kallistratos added.

In their study, Dr. Kallistratos and colleagues followed a cohort of 212 patients with well-controlled hypertension (mean blood pressure: 129.9/76.7 mmHg; 74.6% non-smokers; 74.6% without diabetes), among whom they assessed: mid-day sleep time (average: 49 minutes); lifestyle habits, such as alcohol, coffee, and salt consumption, as well as physical activity; body characteristics; blood pressure levels; pulse wave index (PWV), a measure of arterial stiffness; and augmentation index (AI). Participants underwent Doppler ultrasonography and echocardiography at enrollment, and wore an ambulatory blood pressure monitors to measure and track blood pressure levels at routine intervals during daily living.

In all, the researchers found that mean 24-hour systolic blood pressure readings were 5.3 mmHg lower among nappers vs non-nappers (127.6 mm Hg vs 132.9 mm Hg). Additionally, nappers exhibited better readings during the day compared with non-nappers (128.7/76.2 mmHg vs 134.5/79.5 mmHg). Dr. Kallistratos and fellow researchers noted a linear relationship between time spent asleep and blood pressure, with each hour of napping linked to a 3-mmHg drop in blood pressure.

“Mid-day sleep significantly decreases average and day [systolic blood pressure/diastolic blood pressure] in hypertensives,” concluded the authors. “Its effect is as potent as other well-established lifestyle changes and is independent of the dipping status of patients. It should be recorded in patients’ history and encouraged if applicable to their daily schedule.” (Here, dipping refers to natural drops in blood pressure that occur during nighttime sleep.)

Importantly, on analysis of data, the researchers adjusted for factors known to affect blood pressure levels, such as age, sex, lifestyle habits, and medication. Also of note: The quantity of antihypertensive medication taken, PWV tests, and echocardiograms were comparable between nappers and non-nappers.

“Even though both groups were receiving the same number of medications and blood pressure was well controlled, there was still a significant decrease in blood pressure among those who slept during midday,” Dr. Kallistratos said. “We obviously don’t want to encourage people to sleep for hours on end during the day, but on the other hand, they shouldn’t feel guilty if they can take a short nap, given the potential health benefits.

Other key health benefits

But napping isn’t just good for lowering your blood pressure. According to the findings of one review article published in the Journal of Sleep Research, napping enhances various aspects of waking performance—particularly vigilance, logical reasoning, reaction time, alertness. It also decreases sleepiness, sleep latency, and fatigue. 

Napping may also improve your disposition, lower tension, and decrease the risk of heart disease, according to The National Sleep Foundation

“Regular, short naps can help lower tension, which decreases your risk of heart disease. Get the most health benefits out of your nap by doing it right. Stick to a regular napping schedule during optimal hours, which are between 1:00 p.m. and 3:00 p.m. This timeframe is optimal, since that’s usually after lunchtime, when your blood sugar and energy starts to dip. Keep shut-eye short; and nap in a dark room so that you’ll fall asleep faster.

“As anyone who has suffered from a sleepless night knows, it’s hard to be chipper the next day. Sneaking in a nap can help erase that sleep-deprived irritability. Keep in mind, a short snooze is a wiser choice than sipping espresso if you need a mid-day reboot, since consuming caffeine in the afternoon or evening can negatively affect your nighttime slumber. Napping is a natural way to revive your energy.”

Coronavirus: how worried should I be about the shortage of face masks? Or can I just use a scarf?

Coronavirus: how worried should I be about the shortage of face masks? Or can I just use a scarf?

January 31, 2020 4.21pm AEDT


  1. C Raina MacIntyre Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, Kirby Institute, UNSW
  2. Abrar Ahmad Chughtai Epidemiologist, UNSW

Disclosure statement

C Raina MacIntyre receives funding from NHMRC (Centre for Research Excellence and Principal Research Fellowship) and Sanofi currently. She has received funding from 3M more than 5 years ago for face mask research. She has worked with Paftec on research in respirators (no funding was involved).

Abrar Ahmad Chughtai had testing of filtration of masks by 3M for his PhD. He also has worked with Paftec on research in respirators (no funding was involved).



UNSW provides funding as a member of The Conversation AU.

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The World Health Organisation (WHO) has just declared the coronavirus outbreak a public health emergency of international concern.

There have been nearly 10,000 cases of the so-called 2019-nCoV in China, 23 countries affected and more than 213 deaths globally.

China, Germany, the US and several other countries confirmed the virus can spread person to person, even from people without any symptoms.

Now there are reports of face mask shortages around the world, including Australia, the US and in many cities of China.

How concerned should we be about these shortages? Or can we just wrap a scarf or piece of cloth around our face to protect against infection?

Read more: How contagious is the Wuhan coronavirus and can you spread it before symptoms start?

How important are face masks?

For a disease with no drug or vaccine yet, non-pharmaceutical measures are the mainstay of control. This includes personal protective equipment, such as face masks.

But the type of face masks we typically see (surgical masks) do not provide a seal around the face or filtration of airborne particles, like those that may carry coronavirus.

They do however provide a limited physical barrier against you transferring the virus from your hand to the face, or from large droplets and splashes of fluid.

You also need to put on and remove your mask properly, as this advice from the World Health Organisation shows. Make sure your face mask is the right way round, says the World Health Organisation.

Disposable respirators reduce the risk of respiratory infections. They are designed to fit around the face and to filter 95% of airborne particles. However, these should be reserved for health workers, who need them most.

Do we really need these masks anyway?

In the disease epicentre, Wuhan, or on an evacuation flight out of Wuhan, face masks are a sensible precaution. They are also needed in other Chinese cities that are affected by the outbreak and where transmission is ongoing.

However, in countries where transmission is not widespread and there are only a handful of cases being treated in hospital isolation rooms, masks serve no purpose in the community.

For example, there is no need for the general public to use face masks in Australia, US and other counties where a few imported cases are reported, and the risk of catching the virus is low.

Read more: The Wuhan coronavirus is now in Australia – here’s what you need to know

Panic buying will result in a lack of supplies when we need them most, for instance, if the number of cases escalates dramatically. During the H1N1 influenza pandemic in 2009, the WHO did not recommend the general public use face masks.

Residents of Nanning, China, lining up to buy face masks this week. Peng Huan/EPA/AAP

The case is different for health workers, who face greater risks. It is essential we provide health workers with the best protection, because if they get sick or die, we lose our ability to fight the epidemic. During the SARS epidemic, 21% of all cases globally were health workers.

Read more: SARS, MERS …? Preparing for the next coronavirus pandemic

How concerned should we be about the shortage of face masks?

This is a concern, especially if people hoard or stockpile face masks when there is no need. We saw a shortage of masks early during the 2009 influenza pandemic. The surge in demand during such events also results in higher prices.

Countries have started releasing stockpiles of masks and other personal protective equipment to the health system. For example, the Australian government this week released one million masks for general practices and pharmacists from the national medical stockpile.

There is also an existing shortage of masks in some areas of Australia due to the bushfire response and face masks from the national stockpile have mainly been released in those areas.

What happens if the situation gets worse?

The number of cases is expected to increase and a large quantity of face masks may be needed.

If the current situation becomes a pandemic (an epidemic that goes global), we could be facing a much greater demand for personal protective equipment in the health sector alone.

In a modelled serious epidemic in Sydney of smallpox, if health workers use two disposable respirators a day for 6 months, over 30 million respirators will be needed for 100,000 clinical health workers.

Read more: What is a super spreader? An infectious disease expert explains

China is the largest producer of face masks globally and it has already stepped up production to meet the high demand.

If large outbreaks happen in other countries, China may not be able to meet the demand of face masks, respirators and other medical supplies.

Not all face masks are up to the job

Another problem is the sale of low-quality face masks due to a shortage of products on the market, as has been reported in China and Hong Kong.

Face masks are not regulated, may not filter the air, and also typically allow large amounts of air in through the sides. With a shortage of masks, low-quality masks could be exported to other countries.

Read more: I’ve always wondered: why many people in Asian countries wear masks, and whether they work

If I can’t get hold of a mask, can I wrap a scarf around my face?

Wrapping cloth around your face probably will not protect you. That’s because a scarf or a hanky does not provide a tight fit around the face, isn’t designed to filter out air and may be contaminated.

However, during the Ebola epidemic, a woman nursed her entire family through the illness using home-made protective equipment and did not get infected.

In Asia, cloth masks are popular because they are cheap and re-usable. But they don’t protect you. Cloth masks may even increase your risk of infection, especially if you don’t wash them regularly. They may absorb moisture and provide a breeding ground for bugs.

So, ideally, people shouldn’t be using them. However, people may resort to cloth if there is no other choice.

In a nutshell

While news of mask shortages might sound scary, if you are in a country with few isolated cases, you don’t need one anyway as the risk of infection is very low for the general public.

Panic buying or stockpiling also means there won’t be enough to go round should the situation worsen.

Even if you do use a face mask, they may protect against large droplets (ones you can feel on your skin when someone sneezes) and self-contamination from your hands, but not against smaller airborne particles.

Don’t forget, hand-washing is also very effective in preventing infection.