WHEN a menopausal woman presents to a GP with signs of depression, hormone replacement therapy should be on the treatment list alongside antidepressants, an Australian expert says.
Professor Jayashri Kulkarni, director of Monash University’s Australian HER Centre, told InSight+ that menopausal depression was under-diagnosed, under-funded and under-researched, but was an important factor in women’s mental health in menopausal age.
“Hormone replacement therapy should definitely be considered as an option,” he said.
Writing in Nature last week, Professor Kulkarni said “depression caused by menopause may be more severe than that experienced by pre- and post-menopausal women (or men of any age)”.
“Not coincidentally, suicide rates for women are also highest in the 45-64 age group,” he wrote, citing US research by Curtin and colleagues.
Professor Kulkarni wrote that there were several reasons why menopausal depression had not received enough attention, including the fact that it is not recognized as a specific condition in any of the standard diagnostic manuals.
“As with many aspects of women’s mental health, menopausal depression is at the bottom of the barrel when it comes to research funding and clinical trials,” she told InSight+.
“Patients in this group are caught between two hard rocks.
“On the one hand, there is the misogynistic extreme right that has no interest in women’s health in general. On the other hand, there are the far-left feminists who don’t want to talk about hormones, because they don’t want women in leadership positions to be seen as the whim of their hormones,” said Professor Kulkarni.
Where does this leave GPs with patients presenting with menopausal depression?
“GPs are the cornerstone in terms of managing these patients,” he told InSight+. “They know the patient better and are in a perfect position to diagnose and treat menopausal depression.”
One barrier that doctors must overcome, however, is reluctance to prescribe hormone replacement therapy.
“The good news is that hormone treatments such as estrogen therapy can be an effective way to treat the condition, either as an adjunct to antidepressants or as first-line individual treatment. [here and here],” Professor Kulkarni wrote in Nature.
“However, there is considerable reluctance to use them; in many cases, a diagnosis of any form of depression still leads to an automatic prescription of an antidepressant.”
This reluctance stems from the 2002 trial by Rossouw and colleagues of the Women’s Health Initiative (WHI) that received media attention. The study was stopped early because “the test statistic for invasive breast cancer exceeded the stopping limit for this adverse effect and the global index statistic supported risks exceeding benefits”. The authors reported an increased risk of breast cancer, heart disease, stroke and blood clots.
“The WHI study has since been refuted, but once things like this hit the media headlines, it’s very difficult to change things,” Professor Kulkarni told InSight+.
“Hormone replacement therapy has also advanced, including the development of selective synthetic estrogen receptor modulators, which should improve safety.”
Professor Kulkarni urged GPs, psychiatrists and other mental health professionals treating women in their 40s and 50s to ask about menopause at the start of treatment and to be prepared to prescribe hormone treatments.
In the meantime, efforts are underway to have menopausal depression considered as a specific condition as part of clinical guidelines.
“We need more funding for research, especially direct clinical trials,” Professor Kulkarni told InSight+.
Associate Professor Vinay Lakra, President of the Royal Australian and New Zealand College of Psychiatrists told InSight+ that:
“The College supports raising awareness of menopause as a time of vulnerability to depression, both new onset and relapse for women who have previously had depression.
“Access to expert multidisciplinary care where hormonal and mental health treatment options can be safely accessed and considered individually in terms of likely risks and benefits can be very beneficial.”
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