Hormones and Depression in Women
John Studd, DSc,MD,FRCOG
It has been known for more than a century that depression is more common in women that man. Suicide attempts are more common and prescriptions for antidepressants are more common in women. The question is why. This excess of depression occurs at times of hormonal change such as in the days before a period as premenstrual depression or in the weeks after pregnancy as postnatal depression and the years approaching the menopause. This group of depressive disorders are called Reproductive Depression and is the subject of this review.
Very often women with Reproductive Depression will have a history of having severe PMS as a teenager which becomes worse with age. Almost invariably this depression improves during pregnancy but then reoccurs as postnatal depression some weeks after delivery because when the periods and cycles return it becomes premenstrual depression again and this becomes worse with age. It is often badly treated with antidepressants and the woman then develops a history of recurrent depression that does not respond to antidepressants. As the depression is cyclical it is often misdiagnosed as Bipolar disorder and hence patients are given quite the wrong treatment in the form of mood stabilising drugs antidepressants or worse…
Diagnosis of hormone responsive depression.
The diagnosis is made by the history and not from blood tests.Most of these women are premenopausal and will have normal oestradiol and FSH levels.These 2 hormones have a wide normal range and the levels may not be optimal for the individual.Certainly it is wrong to exclude an endocrine component to the depression and deny women effective hormone therapy. Relevent clues in the history are
- the monthy cyclicity, now or in the past, of the depression
- PMS as a teenager
- a good mood with no depression during pregnancy
- Postnatal depression
- Depression becoming cyclical as periods return after pregnancy
Very often when these perimenopausal women with longstanding depression will state that they last felt well during pregnancy many years ago. These are the women whose depression responds to oestrogen.
What is the correct treatment for Reproductive Depression?
It is important to realise that Reproductive Depression is an endocrine problem and not a psychiatric problem. Antidepressants may be required later but initially the correct treatment is by oestrogens. Oral oestrogens probably work but all of the scientific data concerns transdermal hormones in the form of gels, patches or implants. Not only are transdermal gels effective buth they avoid the liver circulation and hence do not produce the same coagulation factors that are induced by oral oestrogens.Thus there is no increased risk of deep vein thrombosis or pulmonary embolus.
The role of testosterone is mainly for women who also complain of loss of energy and loss of libido. Testosterone supplementation will usually sort out this problem and also in combination with oestrogen improve mood. Testosterone is not available by the oral route and testosterone patches have recently been discontinued therefore it is usual to give testosterone by transdermal gel or even by an implant although the availability of testosterone implants at the moment is very intermittent.
The role of Progestogen
Patients with a uterus who are having transdermal oestrogens for mood swings and depression should have monthly progestogen to protect the endometrium. Unfortunately these women with PMS are usually progestogen intolerant and even a low dose of a low potency progestogen for only seven days (the orthodox duration is fourteen days) may produce a minor reoccurrence of PMS type symptoms. These patients may respond to change of gestogen or taking the seven day course alternate months but this they usually hate they symptoms that reoccur with even a mild progestogen. Many will opt for a Mirena IUS. This usually works but there do remain a small group of women who still have progestogen intolerance and do not want to try progestogen by any route or any dose and instead will opt for a laparoscopic hysterectomy and bilateral salpingo oophorectomy with replacement oestradiol and testosterone. This intervention produces a 90% ‘cure’ of Reproductive Depression.
What is the wrong treatment?It is commonplace for perimenopausal women to visit their GP complaining of depression with loss of energy, self confidence and libido only to be prescribed antidepressants. This is usually the worst treatment for symptoms which can be quickly solved with HRT. There has even been an astonishing recent development of treating hot flushes and sweats with antidepressants rather than the rapidly effective oestrogen. Psychiatrists almost never use hormones no doubt because they are not trained to do so but GPs do understand the use and side effects of HRT and oral contraceptives so it is difficult to understand their reluctance