Analysis of Menopause and its Effects Essay
Despite having biological origins, menopause including the public expressions of the women going through it as well as the majority of the research conducted on it seem to be almost entirely socially constructed. Furthermore, menopause is typically cast, both societal and culturally in a negative light because of its implications of the ending reproductive processes in women which implies that society/culture seems to place a higher value on fertility and reproduction.
If this is true, it would serve to illustrate why so many societies are tipped in favor of male eminence as males do not undergo menopause as they can continually reproduce throughout most, if not all, of their entire life span thus males are valued higher than women assuming society is assigning value using a reproductive standard. Analysis of Menopause and its Effects Essay. The biological purpose of menopause has long been up for debate among scholars.
From a purely intuitive biological standpoint, the act of terminating a female’s ability to reproduce seems to hobble that species’ very survival as now reproduction can only occur during a specified window in which a female has the willingness and the ability o reproduce. Essentially, menopause can be viewed as a ticking clock” on reproductive success of a particular individual which in turn can affect the reproductive success of that individual’s species as a whole.
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From a more academic standpoint, according to current evolutionary theories of senescence, there should be no selection for post reproductive individuals” which renders menopause as a biological function counterproductive. (Piece 2001 p. 43). Several theories attempt to explain why menopause occurs but the most widely accepted of which is known as
The Grandmother Hypothesis which states that menopause is an adaptation that facilitates grandfathering” as well as sustaining longevity essentially allowing a postmenopausal women to focus on her now fertile daughter(s) and to provide assistance to their offspring instead of directing time and energy in efforts to produce entirely new offspring however new revisions of the theory are now suggesting that menopause is only a byproduct” of the women’s increased longevity. (Piece 2001 p. 44). Analysis of Menopause and its Effects Essay.
Despite the existence of numerous theories, the exact purpose f menopause has yet to be specified and this may play into why it is cast in such a negative light on the societal level. The very notion of a ticking clock bearing down upon reproductive success seems counterintuitive to the laymen. Coupled with humankind’s instinctual fear of the unknown and the fact the very reasons behind menopausal occurrence are not yet known, this allows societies and culture to harbor a psychological portrait that paints menopause as some nefarious, almost evil occurrence that rids women of their ability to reproduce.
This reproductive ability, on historical level, has been one of the foundational aspects of classifying womanhood” in any culture. Thus any element that would serve to destroy this essence, logically should be and must be deemed evil so it should come as no surprise that the overwhelming majority of cultures located in a wide array of socio- economic climates, all seek to vilify the occurrence of menopause. Archeological evidence seems to support the fact the one of the foundational beliefs of almost every prehistorically society is the value placed on fertility and reproductive success.
Fertility Idols and Venus figurines show status and command a historical ideal of how women should be with their shapely fugue that exudes health and thus better reproductive success. So much emphasis was placed on these sexual and secondary sexual characteristics of the female human… To the point of leaving the rest of the fugue-face, feet, arms, and so forth-either abstract or absent altogether” (Advisor, Softer, Page, 2007 p. 67). These second sexual characteristics are not Just present but rather dramatically, almost obtusely showcased. One of the toneless of Paleolithic elision is the emphasis placed on fertility.
Of course, the exact reason behind the carving of Venus figurines may never be acutely known however Just because additional research is being presented that may illustrate some of these figures may have had other uses (perhaps acting as an instructional model for basketry), they do offer a glimpse into the potential social norms that were at play during the figurine’s construction as the desires and a sense of both personal and communal identity can be found in the artistic choices that the carver chose to express in the figurines. Other societies have exhibited this innate sense of value of fertility.
Sumerian poetry expressing desire over their fertile mother goddess, the famous image of the Egyptian goddess Isis nursing her son as well as other examples clearly illustrate society’s age old obsession with fertility. It is then logically valid to assume that because it is a cultural and societal norm to value fertility there should exist another norm to look down and even curse the occurrence of menopause. Analysis of Menopause and its Effects Essay. These basic notions of typically negatively viewing menopause are not recent developments but ether the result of deeply ingrained cultural ideals that may have existed from the earliest formations of prehistoric humans.
Many of the experiences brought on by menopause in women are experienced as a result of cultural norms as opposed to biological processes. Cultural seems to not only view the experience differently but also attempts to dictate how women choose to express their symptoms which may, in turn, affect biology of the women experiencing them. In a study conducted with 75 women in different coloratura settings (Tunisia and France), researcher found that experiences were linked to social, not biological factors which implies that symptoms of menopause are not biologically determined (Delano et al 2012 up. 08-409). Additionally, most of the research conducted on menopause may also be socially constructed as well which provides testament to how culturally ingrained views can seep in and affect the initially objective scientific approaches of scientists. A large bulk of the research being conducted on the assumption that menopause is a time of negative physical, emotional sexual change” with only a fraction of researchers ever sousing on any positive aspects of menopausal occurrence. (Wintering, 2003 p. 627).
These biases are often exemplified by the types of questions asked by the researchers with negative connotations (vaginal dryness, irritation, lack of sexual arousal) with surveys relying on outlaying factors and statistics that often paint a skewed picture of how menopause actually occurs and what the changes associated with it really are. These very biases are acting in accordance with the cultural expectations laid down by society which in turn affects the biological changes for ex” (Wintering, 2003 p. 628) illustrating how overpowering culture can be if it can affect the very biology of the subject. Analysis of Menopause and its Effects Essay.
In the final analysis, the occurrence of menopause has been constrained, on a societal and cultural level, as an act that renders any women essentially worthless if their worth is viewed through a reproductive lens. If female’s sole biological purpose is reproduction, the occurrence of menopause destroys that forcing her into a position of subservience to males because they never lose their supposed biological purpose. This is a rather ugly and anorak assumption on society part that stems from long standing psychological notions of fearing that which society does not understand as well as assuming biology is the sole director of life.
Through this assumption, it is apparent that many cultural norms are not based on informed rationality but rather a perceived rationality. This is no better explained by the fact that post-menopausal women still live incredibly productive lives. Some would argue that there does not exist an actual intrinsic change between pre and post-menopausal women and that any difference s only an intangible, psychological one created by societal and cultural norms. So, what does this say about society is women are Judged using these norms? The question asked can only be answered by a self-reflexive look into ourselves.
Just because some of these cultural norms have weathered years of evolution and socio- political change does not mean they should be perpetuated into the future. If negative views of menopause really stem from our inner psychologists tendencies, the real challenge lies not in diagnosing the problem but in actually discovering a solution. Perhaps the best solution to help dispel these notions is to showcase studies that illustrate that post-menopausal women participate Just as actively on every level, both publicly and privately, as pre-menopausal women.Analysis of Menopause and its Effects Essay.
The menopause transition is experienced by 1.5 million women each year and often involves troublesome symptoms, including vasomotor symptoms, vaginal dryness, decreased libido, insomnia, fatigue, and joint pain.1–3
In one population-based assessment of 386 Australian women, 86% consulted a clinician at least once to discuss menopausal symptoms.4 Several symptoms bear an obvious relationship to the changing hormonal milieu associated with menopause, and most women make direct linkages between menopause and the common symptoms of hot flashes, vaginal dryness, and disrupted sleep (with or without associated night sweats). In addition, during menopause, women may develop depressive symptoms and cognitive difficulties, which are more subtly and inconsistently linked to hormones. Depression and cognitive impairment can be burdensome for women and also compound the burden of medical illness for the aging female population. As postmenopausal women are already at risk for osteoporosis and cardiovascular disease, it is important to address potentially changeable psychiatric issues that may make medical issues more difficult to treat. An understanding of the risk factors, clinical presentation, and management of these common menopausal symptoms allows for improved patient care and health outcomes for older female patients.
THE CORE 4 SYMPTOMS: VASOMOTOR, VAGINAL, INSOMNIA, AND MOOD
Epidemiology
Population-based, epidemiologic studies of menopausal women have recently been conducted and are yielding reliable and consistent information about the incidence, prevalence, and severity of several menopausal symptoms. However, the field is relatively new, and it is likely that there are subsets of women who are more or less vulnerable to particular symptoms or sets of symptoms. In 2005, a state-of-the-science conference on menopausal symptoms was convened, with a worldwide panel of expert evaluators who were tasked with determining which among the large set of midlife symptoms are most likely to be due to menopause. Symptoms were evaluated for their proximity to menopause, apart from the aging process, and the likelihood that estrogen is effective in relieving symptoms.2 Based on this evidence review, 3 symptoms emerged as having good evidence for linkage to menopause: vasomotor symptoms, vaginal dryness/dyspareunia, and difficulty sleeping/insomnia. After this conference and based on 3 seminal studies,3,5,6 adverse mood/depression was added to the list. Adequate longitudinal studies on cognitive function during the menopause were not yet available but have also become subsequently widely reported.2,3,5,7,8
It is clear that there are many other symptoms that are reported by menopausal women. These include joint and muscle aches, changes in body contour, and increased skin wrinkling.1 Several studies have examined the associations between these symptoms and menopause.Analysis of Menopause and its Effects Essay. Given the methods of ascertainment, the subjective nature of the complaints, the likelihood that there is publication bias (wherein positive studies demonstrating linkage to menopause are more likely to be published than negative studies), and their variation over time, it has been difficult to establish a true relationship between these symptoms and menopause. Other symptoms, such as urinary incontinence (UI) and sexual function, have mixed data for efficacy of estrogen treatment and linkage to menopause, apart from the aging process. For these reasons, this article addresses the core 4 symptoms and includes cognitive issues because they are of great importance and concern to aging women.
Vasomotor symptoms
Vasomotor symptoms afflict most women during the menopausal transition, although their severity, frequency, and duration vary widely between women. Hot flashes are reported by up to 85% of menopausal women.7 Hot flashes are present in as many as 55% of women even before the onset of the menstrual irregularity that defines entry into the menopausal transition9 and their incidence and severity increases as women traverse the menopause, peaking in the late transition and tapering off within the next several years.10–12 The average duration of hot flashes is about 5.2 years, based on an analysis of the Melbourne Women’s Health Project, a longitudinal study that included 438 women.11 However, symptoms of lesser intensity may be present for a longer period. Approximately 25% of women continue to have hot flashes up to 5 or more years after menopause. Analysis of Menopause and its Effects Essay. A meta-analysis of 35,445 women taken from 10 different studies confirmed a 4-year duration of hot flashes, with the most bothersome symptoms beginning about 1 year before the final menstrual period and declining thereafter.10
The exact cause of the hot flash has not been elucidated. The most accessible theory purports that there is a resetting and narrowing of the thermoregulatory system in association with fluctuations in or loss of estrogen production. In the past, hot flashes were thought to be related solely to a withdrawal of estrogen; however, there is no acute change in serum estradiol during a hot flash. Others have related hot flashes to variability in both estradiol and follicle-stimulating hormone (FSH) levels.6 It is thought that decreased estrogen levels may reduce serotonin levels and thus upregulate the 5-hydroxytryptamine (serotonin) (5-HT2A) receptor in the hypothalamus. As such, additional serotonin is then released, which can cause activation of the 5-HT2A receptor itself. This activation changes the set point temperature and results in hot flashes.13Regardless of the exact cause of the hot flash, both hormone therapy and nonhormonal regimens can help to relieve vasomotor symptoms (Table 1).
Table 1
Trade Name | Estrogen | Progestin | FDA Approved |
Dose |
---|---|---|---|---|
Hormonal Therapies | ||||
Premarin | CEE | — | Yes | 0.3–1.25 mg po daily |
Cenestin | Synthetic CE | — | Yes | 0.3–1.25 mg po daily |
Menest | Esterified estrogen | — | Yes | 0.3–1.25 mg po daily |
Estrace | 17β-estradiol | — | Yes | 1–2 mg po daily |
Estinyl | Ethinyl estradiol | — | Yes | 0.02–0.05 mg po 1–3 times daily |
Evamist | 17β-estradiol | — | Yes | 1–3 sprays daily |
Alora, Climara, Esclim, Menostar, Vivelle, Vivelle- Dot, Estraderm |
17β-estradiol | — | Yes | 1 patch weekly to twice weekly |
EstroGel | 17β-estradiol | — | Yes | 1.25 g daily transdermal gel (equivalent to 0.75 mg estradiol) |
Estrasorb | 17β-estradiol | — | Yes | 2 foil pouches daily of transdermal topical emulsion |
Activella | Estradiol 1 mg | NETA 0.5 mg | Yes | 1 tablet po daily |
Femhrt | Ethinyl estradiol 5 µg |
NETA 1 mg | Yes | 1 tab po daily |
Ortho-Prefest | 17β-estradiol 1 mg | Norgestimate 0.09 mg |
Yes | First 3 tablets contain estrogen, next 3 contain both hormones; alternate pills every 3 d |
Premphase | CEE 0.625 mg | MPA 5 mg | Yes | First 14 tablets contain estrogen only and remaining 14 tablets contain both hormones. 1 tab po daily |
Prempro | CEE 0.625 mg | MPA 2.5 or 5 mg |
Yes | 1 tab po daily |
CombiPatch | 17β-estradiol | NETA | Yes | 1 patch transdermal twice weekly |
Climara Pro | 17β-estradiol | LNG | Yes | 1 patch weekly |
Estrace | 17β-estradiol vaginal cream |
— | Yes | 2–4 g daily for 1 wk, then 1 g 3 times weekly |
Femring | Estradiol vaginal ring |
— | Yes | 1 ring inserted vaginally every 3 mo |
Duavee | CEE 0.45 mg/ bazedoxifine 20 mg |
— | Yes | 1 tablet daily |
Nonhormonal Therapies | ||||
Brisdelle | Paroxetinea 7.5 mg | — | Yes | 7.5 mg daily |
Effexor | Venlafaxine 36.5–300 mg |
— | No | 37.5–75 mg daily |
Pristiq | Desvenlafaxine | — | No | 50–100 mg daily |
Lexapro | Escitalopram | — | No | 10–20 mg daily |
Celexa | Citalopram | — | No | 10 mg daily |
Prozac | Fluoxetinea | — | No | 10–20 mg daily |
Zoloft | Sertraline | — | No | 50–100 mg daily |
Neurontin | Gabapentin | — | No | 300–900 mg up to tid |
Lyrica | Pregabalin | — | No | 50–10 mg tid |
Abbreviations: CE, conjugated estrogen; CEE, conjugated equine estrogen; LNG, levonorgestrel; MPA, medroxyprogesterone acetate; NETA, norethindrone acetate.
Vulvovaginal atrophy
Urogenital tissues are exquisitely sensitive to estrogen, and the fluctuations in estrogen that occur during the menopausal transition, followed by sustained low levels after menopause, can render these tissues fragile and cause distressing symptoms. Multiple population- and community-based studies confirm that about 27% to 60% of women report moderate to severe symptoms of vaginal dryness or dyspareunia in association with menopause.14,15 In addition to vaginal atrophy, narrowing and shortening of the vagina and uterine prolapse can also occur, leading to high rates of dyspareunia. Furthermore, the urinary tract contains estrogen receptors in the urethra and bladder, and as the loss of estrogen becomes evident, patients may experience UI. Unlike vasomotor symptoms, vulvovaginal atrophy does not improve over time without treatment. Analysis of Menopause and its Effects Essay.
Menopausal hormone therapy (MHT) is an effective treatment of vaginal atrophy and dryness. For this purpose, systemic or vaginal estrogen can be used, although locally applied estrogen is recommended and can be administered in very low doses (Table 2). These low doses are believed to be safe for the uterus, even without concomitant use of a progestin. Data are currently insufficient to define the minimum effective dose, but vaginal rings, creams, and tablets have all been tested and demonstrated to reduce vaginal symptoms.16
Table 2
Trade Name | Hormone | FDA Approved |
Dose |
---|---|---|---|
Premarin vaginal 0.625 gm | Conjugated equine estrogens |
Yes | 0.5–2 gm qd × 2–3 wk, off 1 wk, repeat prna |
Estrace vaginal 0.01% cream |
Estradiol | Yes | 1 gm biweekly to triweekly |
Estring 2 mg | Estradiol | Yes | One ring every 3 mo |
Osphena | Ospemifene | Yes | 60 mg po qd |
Although MHT is effective in reversing changes associated with vaginal atrophy,17,18 it is not beneficial for UI. The Women’s Health Initiative Hormone Trial found that women who received MHT and who were continent at baseline had an increase in the incidence of all types of UI at 1 year. The risk was highest for women in the conjugated equine estrogens (CEE)-alone arm. Among women experiencing UI at baseline, the frequency of symptoms worsened in both arms, and these women reported that UI limited their daily activities. This evidence clearly shows that the use of MHT increases the risk of UI among continent women and worsened the characteristics of UI among symptomatic women after 1 year of use.19
Women who have urogenital atrophy symptom require long-term treatments. Over-the-counter lubricants and moisturizers may have some effectiveness for milder symptoms; however, for those with severe symptoms, hormonal treatment is the mainstay. Vaginal estrogen can be given locally in very small doses (see Table 2). Until recently, there were no alternatives available. However, the FDA approved ospemifene, a systemically administered selective estrogen receptor modulator, for vulvovaginal atrophy in 2013. Dehydroepiandrosterone vaginal preparations are also being tested for effectiveness in treating menopausal urogenital atrophy.20 These 2 compounds may be particularly helpful for women who have estrogen-sensitive cancers, such as breast cancer, in whom exogenous estrogen use is contraindicated. It is too early to evaluate the comparative effectiveness of these treatments.
Sleep disturbances and insomnia
Sleep quality generally deteriorates with aging, and menopause seems to add an additional, acute layer of complexity to this gradual process. Analysis of Menopause and its Effects Essay. Women report more trouble sleeping as they enter into the menopausal transition, and sleep has been shown to be worse around the time of menses, both by self-report as well as by actigraphy.21,22Actigraphy studies indicate that as much as 25 minutes of sleep per night can be lost when a woman is premenstrual in her late reproductive years.21
Women report sleep difficulties approximately twice as much as do men.23 Further compromise in sleep quality is associated with the hormonal changes associated with the menopausal transition and with aging, apart from hormones. Over time, reports of sleep difficulties increase in women such that by the postmenopause more than 50% of women report sleep disturbance.2 Women seem to experience more detrimental effects on sleep in association with aging, when compared with men.24
Hormonal changes alone are not likely to provide the complete explanation for the relationship between sleep difficulty and menopause. Consistent with this concept is the fact that hormones are not always successful in treating sleep problems in midlife and beyond.25 Chronic poor sleep hygiene habits and mood disorders contribute further to sleep problems.
The nature of the sleep disturbance can help guide the clinician to appropriate treatment. Women who report nighttime awakening in association with night sweats are candidates for hormone therapy. However, the clinical history is not often so simple. Women with mood disorders, particularly anxiety and depression, may experience difficulty falling asleep and/or early awakening. Women aged 40 years and older also frequently report difficulty staying asleep. Lower socio-economic status (SES), white race, and low marital happiness are social factors that have all been associated with worse sleep.26Disorders such as sleep apnea and restless leg syndrome need to be considered. The clinical consequences of a poor night’s sleep include daytime fatigue and sleepiness, which can be subjectively measured and form the basis for a referral for a sleep study. Table 3 displays a clinically useful scale that can help the clinician estimate the daytime impact of the sleep complaint. Analysis of Menopause and its Effects Essay.
Table 3
Situation | Chance of Dozing |
---|---|
Sitting and reading | |
Watching television | |
Sitting inactive in a public place (eg, a theater or meeting) | |
As a passenger in a car for an hour without a break | |
Lying down to rest in the afternoon when circumstances permit | |
Sitting and talking to someone | |
Sitting quietly after a lunch without alcohol | |
In a car, while stopped for a few minutes in traffic |
Responses are recorded on a 4-point scale of 0 to 3 (0, no; 1, light; 2, moderate; 3, high chance of dozing). A total score of greater than 9 merits further evaluation.
Adapted from Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991;14:541; with permission.
Polysomnography has become a clinically useful tool for assessing sleep complaints.26When polysomnography is not available, clinicians can use sleep questionnaires to ascertain the principal issues surrounding the sleep complaint. Using polysomnography, investigators in the Study of Women’s Health Across the Nation (SWAN) study observed 20% of women with clinically significant apnea/hypopnea and 8% with periodic leg movements.26
Treatment of sleep complaints depends on the clinical findings. For insomnia, the reader is referred to the practical clinical review by Buysse.27 Sleep apnea is often treated with continuous positive airway pressure devices. Restless leg syndrome can be treated with dopamine agonists, gabapentin, and opioids.28 Hormone therapy can be considered for women with difficulty maintaining sleep because of vasomotor symptoms but seems to be effective mostly in postmenopausal women with surgically induced menopause.
Adverse mood
One-fifth of the US population will have an episode of depression in their lifetime, and women are twice as likely to be affected.29 Although depression is more likely to occur in young adults, with peak onset in the fourth decade of life, there is evidence that the perimenopause represents another period of vulnerability for women. Analysis of Menopause and its Effects Essay. Several large prospective cohort studies have shown an increased risk of depressed mood during the menopause transition and an approximately 3-fold risk for the development of a major depressive episode during perimenopause compared with premenopause.3,5,30,31Although a previous episode of depression has been shown to confer an increased risk, women with no previous episode of depression are still 2 to 4 times more likely to experience a depressive episode during the menopause transition compared with the premenopause. Anxiety symptoms have been found to precede depression in some instances, and anxiety may also be viewed as increasing a woman’s vulnerability to a midlife depressive episode.32
Other independent risk factors for the development of depressed mood during the menopause transition include poor sleep, stressful or negative life events, lack of employment, higher body mass index, smoking, younger age, and race (African Americans twice as likely to have depressive symptoms). In addition, there is evidence that hormonal changes occurring during menopause play a role, as evidenced by increased risk for depression in association with variability in estradiol levels, increasing FSH levels, surgical menopause, the presence of hot flashes, and a history of premenstrual syndrome. Contrary to prior belief, hot flashes are not necessary to the development of depression. Some have proposed the cascade theory, in which hot flashes lead to sleep disturbance and then to daytime fatigue, poor quality of life, and then depressive symptoms. Research instead shows that depressive symptoms more often precede hot flashes when they co-occur.33
There may also be significant environmental stressors present at the time that a woman reaches menopause. During midlife, a woman may be faced with changes in her marriage and family structure, with children no longer living in the home. She may experience changes in her career path, possibly returning to work or retiring. She may be taking on new responsibilities as a caregiver to her parents or in-laws, a well-known risk factor for depression. Although these factors do not likely cause depression on their own, they can certainly contribute and should be considered, particularly if supportive resources may be of help (Box 1). Analysis of Menopause and its Effects Essay.
As the menopause transition involves significant instability in estrogen levels, with intense irregular fluctuations, many researchers have focused on understanding the association between estrogen level and mood changes. As stated above, in longitudinal prospective studies, women who developed depression were more likely to have increased variability in estrogen levels, particularly in the early to midperimenopause.30The absolute level of estrogen is not associated with risk, however. Some studies have used gonadotropin-releasing hormone (GnRH) agonists in order to induce menopausal changes in premenopausal women, so that measurement of hormones, evaluation for mood symptoms, and response to add-back hormone therapy can be more easily determined.35 In a group of healthy premenstrual women, without a psychiatric history, administration of a GnRH agonist did not uniformly precipitate depressive symptoms. Analysis of Menopause and its Effects Essay. In another related study involving withdrawal of estradiol treatment in women with and without a history of perimenopausal depression, those with history of this type of depression were more likely to experience depressive symptoms as a result of withdrawal of estradiol therapy (Box 2).
A major depressive episode is defined by the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) (1994) as 5 or more of the following symptoms, present most of the day nearly every day for a minimum of 2 consecutive weeks. At least 1 symptom is either depressed mood or loss of interest or pleasure.
The DSM-IV criteria for depressive disorders, as for other mental disorders, require that the depressive episode cause significant distress or dysfunction. A depressive episode can be classified as mild, moderate, or severe, with or without psychotic symptoms. Psychotic symptoms can include hallucinations (usually auditory perceptual disturbances) and delusions (false beliefs). A depressive disorder may be recurrent if a patient has had an episode in the past. A person whose depressive symptoms do not meet criteria for a major depressive episode may be classified as having minor depression or/and adjustment disorder with depressed mood if a significant recent stressor is present. Chronic symptoms of depression not meeting criteria for a major depressive episode may represent a dysthymic disorder. Analysis of Menopause and its Effects Essay.
A depressive episode can also occur in the setting of bipolar disorder, a mood disorder that also involves at least 1 previous manic episode. Before treatment of depression, a bipolar-type disorder should be ruled out because of different effective treatment regimens. As anxiety disorders are very common in women with depression, assessment for panic symptoms, generalized worry, as well as obsessive thoughts and compulsive behaviors should be included. In addition, evaluation for substance abuse and dependence, which can significantly affect mood, should be included. Medical workup for illnesses that can present with depressive symptoms, such as hypothyroidism and anemia, is also appropriate.
A complete interview for depressive symptoms in every perimenopausal patient is not necessary or time efficient. Screening tools can be used to determine who will need further evaluation. Referral of patients to a mental health specialist depends on the primary care provider’s level of expertise in assessment and treatment of depression, the availability of mental health resources, and patient/family preference. Even if a provider initiates treatment, there may be reason for referral at a later point (Table 4).
Table 4
Major Depression | Indications for Further Psychiatric Evaluation |
---|---|
At least one of these must be present: | Evidence of suicidal ideation, inability to care for self or dependent others, or aggressivity/homicidal ideation |
Depressed mood | |
Loss of interest or pleasure in most or all activities |
|
|
|
Four or more of the following must be present: |
Failure to respond to or is intolerant of initial treatment trial |
Insomnia or hypersomnia | Patient or clinician interested in modalities requiring specialty expertise (psychotherapy or electroconvulsive therapy, transcranial magnetic stimulation) |
Change in appetite or weight | |
Psychomotor retardation or agitation | |
Low energy | |
Poor concentration | |
Thoughts of worthlessness or guilt | Psychotic symptoms present |
Recurrent thoughts about death or suicide | History of bipolar disorder or psychotic disorder |
Significant psychiatric comorbidity (anxiety disorders, substance use, cognitive disorder) |
|
Unclear diagnosis of depression |
First-line treatment of a major depressive episode may involve psychotherapy, antidepressants, or a combination thereof. Treatment is often tailored to patient preference and severity of depression. Certainly, a more severe episode would require combined psychotherapy and pharmacotherapy. A mild to moderate episode may respond to either psychotherapy or an antidepressant alone, and if a patient is interested in a trial of medication, it may benefit significantly if this is started soon after the diagnosis is made. Primary care practitioners frequently make the initial diagnosis of depression and are in a position to begin this treatment in a timely manner when possible.
Selective serotonin reuptake inhibitors (SSRIs) are the first-line medications used in the treatment of depression. These SSRIs include fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro), sertraline (Zoloft), and paroxetine (Paxil). Each of these medications is equally likely to be effective and share similar side effect profiles. Patients often describe gastrointestinal upset, jitteriness, or headache, but these symptoms usually abate in the first few weeks of therapy. Once initiated, it may take 6 to 8 weeks for a patient to respond; however, often, patients notice a difference within the first month of treatment. Dosage can be titrated to achieve improved effectiveness, with increases approximately every month as tolerated. Of particular concern in this population is the risk for sexual side effects (decreased libido and difficulty with arousal and achieving orgasm). Analysis of Menopause and its Effects Essay. As depression can also affect a woman’s sexual function, however, the risks of discontinuation of medication may outweigh the burden of these side effects. A switch to a different SSRI or another antidepressant class or the addition of bupropion (Wellbutrin), which acts on the dopaminergic system, may be helpful. As stated previously, estrogen can be helpful in treating perimenopausal depression and changes in sexual function as well. Conversely, several different SSRI antidepressants have been shown to be effective in treating perimenopausal vasomotor symptoms (Box 3).38
Serotonin and norepinephrine reuptake inhibitors, such as venlafaxine (Effexor) or duloxetine (Cymbalta) can be particularly helpful in patients with comorbid anxiety. Bupropion can be helpful when patients have low energy, but it can exacerbate anxiety and insomnia. Psychostimulants such as modafinil (Provigil) or methylphenidate (Ritalin) can sometimes be useful in these cases but have less evidence for efficacy. Tricyclic antidepressants and monoamine oxidase inhibitors are useful in treatment-resistant depression but often have more significant side effects, particularly in older patients. Electroconvulsive therapy is often very well tolerated, safe, and effective in these older patients who fail to respond to or do not tolerate medications. There is also growing evidence for the utility of transcranial magnetic stimulation in this group (Box 4). Analysis of Menopause and its Effects Essay.
Several forms of psychotherapy may be beneficial for patients with depression, including cognitive behavioral therapy, interpersonal therapy, and psychodynamic psychotherapy. A range of providers with psychotherapy training are available (social workers, psychologists, nurse practitioners, psychiatrists), but resources may be limited because of the patient’s insurance, location, and financial situation.
In double-blind placebo-controlled trials, perimenopausal women receiving short-term 17β-estradiol transdermally had remission rates as high as 80%.37,39 In other randomized controlled trials, when estrogen was given to postmenopausal women with depression, there were no significant improvements in symptoms40 or the treatment was not superior to an SSRI agent.36 So it seems that the low estrogen levels involved in the menopause transition is an important factor in the development of depression in some women but does fully explain the increased risk for depression in this population. Moreover, these data indicate a window of opportunity for estradiol’s antidepressant effects, with women with perimenopausal but not postmenopausal depression responding to estrogen therapy (Box 5).
Menopause and cognition
Many women complain of changes in their cognitive function during the menopause transition, with the majority reporting worsening of memory. Verbal memory (word list learning and recall), which women generally excel at when compared with men, is often the type of complaint noted. Women may notice difficulty remembering names and other verbally told information. In addition, they may report other cognitive challenges, with more trouble organizing and planning or possibly with concentration. In one study of 205 menopausal women, 72% reported some subjective memory impairment.41Symptoms were more likely to be associated with perceived stress or depressive symptoms than perimenopausal stage, but overall, cognitive symptoms were more prevalent early in the menopause transition. Analysis of Menopause and its Effects Essay.Aside from being bothersome, these symptoms raise women’s concerns regarding their risk for dementia; however, it remains unclear whether these symptoms correspond to an increased risk for more serious chronic issues.
The first cross-sectional study to measure cognitive change in association with menopause showed that women in early menopause, late menopause, and postmenopause did not vary in memory performance according to stage and did not have abnormalities in memory testing.42 Overall, women who had initiated any form of hormone replacement therapy before their last period performed better on memory testing than those who started it after menopause. Longitudinal study of menopausal status and measured cognitive performance8 showed no impairments in overall cognitive function, but women entering menopause failed to improve as much on repeated tests compared with premenopausal women (they would be expected to improve over time with practice on the same test) (Box 6).
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An important question is whether women who have cognitive difficulties during the menopause transition are at greater risk for cognitive impairment later in life. Patients and their clinicians can be reassured, however, that for most women cognitive function is not likely to worsen in the postmenopause in any pattern other than that expected with normal aging. Although it is not likely that cognitive function returns to a woman’s premenopausal baseline in postmenopause, she may adapt to and compensate for the symptoms with time. Analysis of Menopause and its Effects Essay.
A gradual decline in some cognitive functions is expected to occur with normal aging, beginning in midlife, around the age of 50 years. Decreases in processing speed are often present, and sometimes mild changes in memory for newly learned information and executive function can also occur. However, some types of cognitive changes, collectively called mild cognitive impairment (MCI), are thought to be a manifestation of very early dementia. MCI and dementia are highly unlikely in people younger than 50 years, but risk increases significantly with age, with greater than 10% of the population older than 65 years at risk for developing dementia. (Those diagnosed with MCI have an increased risk of conversion to dementia like that in Alzheimer disease [AD], with approximately 10% developing dementia each year).43 AD is by far the most common type of dementia, but other types of dementia can occur with varying presentations, including vascular dementia, Lewy body dementia, and frontotemporal dementia. AD often presents with impaired memory first, but other types of dementia can present with impaired language, behavioral changes, or motor abnormalities (Box 7). Analysis of Menopause and its Effects Essay.