HRT Should Be First Line Therapy For Perimenopausal Depression
John Studd, DSc,MD,FRCOG
The worst symptoms of the climacteric appear in the menopausal transition which is the two or three years before the periods cease. The most troublesome perimenopausal symptom is depression which is often linked to loss of energy, loss of libido, anxiety, panic attacks and headaches. These symptoms are often cyclical but can be continuous. Perimenopausal depression is part of the syndrome of Reproductive Depression where women have experienced premenstrual depression as a teenager, postnatal depression later on and subsequently perimenopausal depression. The first line therapy should be oestrogens with minimal progestogen.
Oestrogen therapy will also help any co-existent menopausal symptoms of flushes, sweats and vaginal dryness. Regrettably the discredited conclusions from the 2002 WHI study still influence the decision to treat women in this age group. The evidence now is clear that the side-effects occurred with oral oestrogens, with continuous progestogen in women above the age of sixty who mostly had pre-existing health problems. If there is a breast cancer risk and there probably is not, it is due to the administration of continuous progestogen as oestrogen without progestogen is associated with lower levels of breast cancer . Transdermal oestrogens do not produce any increase in liver coagulation factors and there is no increase in DVT, pulmonary embolus, strokes or heart attacks. In fact, there is good evidence that heart attacks and cardiac deaths are less common.
The obstacles to this logical and effective treatment are twofold. Firstly in spite of many of the authors of the 2002 study queuing up to apologise for their errors of selection, their conclusions and publicity and the realisation of the effect it has had on millions of women denied HRT, it has not been supported by the advisory bodies. This bad news is in the undergraduate textbooks and it will take a generation to get rid of it. Hence general practitioners and specialists feel justified in denying women oestrogens for perimenopausal depression.
The second problem is the refusal of psychiatrists to accept the notion that hormones are involved with the etiology and thus the cure for depression. Even premenstrual depression which occurs for ten days before a period, and every period, is regarded as a psychiatric condition. When it fails to respond to antidepressants (and why should it?) they are then misdiagnosed as bipolar disorder and this is followed by inappropriate mood stabilising drugs. This refusal to accept double blind trials in the literature is all the more surprising as the studies took place in conjunction with psychiatrists at the Maudsley Hospital and later repeated successfully by psychiatrists from Harvard.
It is too easy to prescribe antidepressants for this age group but they do not work. Similarly there is a move to give antidepressants for hot flushes and sweats rather than oestrogens. That is the level of clinical nihilism that has occurred following the WHI study. These woman with perimenopausal depression should be treated with oestrogens and remain on the treatment for many years for their mood, bone density, their hearts and general wellbeing. There really are no long term risks, only benefits.