Managed Care - March 2008 - (Page M10) Mood, Depression, and the Menopausal Transition JEANNE L. ALEXANDER, MD, FABPN, FRCPC, FAPA, FACPSYCH Director, Psychiatry Women’s Health Program, Kaiser Permanente–Northern California; President and Founder, Alexander Foundation for Women’s Health he prevalence of mood, anxiety, musculoskeletal, The epidemiology for this burgeoning midlife popuand sleep complaints, along with a perception of lation is compelling for those who manage the health of a decline in memory and attention, are common populations. In 2000, there were 32 million women age presenting complaints in the symptomatic peri45 to 65, and there will be approximately 42 million (26 menopausal population. It is not uncommon for these percent of the female population) by 2010 and 47 milwomen also to have psychiatric comorbidities that may lion (22 percent) by 2050 (Figure). One of the most disexacerbate their perimenopausal symptressing somatic symptoms of menopause toms. Thus, symptomatic perimenopausal is severe hot flashes, which 10 to 20 perpatients presenting with symptoms of a cent of perimenopausal women experidepressive or an anxiety disorder, or a ence. It is estimated that approximately 27 combination of both, add to the commillion to 37 million women will experiplexity of the treatment of depression in ence hot flash symptoms between now primary care. and 2050, with about 7 million experiencIn the years ahead, identifying symptoing severe hot flashes (Ratka 2006). matic perimenopausal women with psyVasomotor symptoms. Vasomotor chiatric comorbidities will be important symptoms are the most prevalent comto MCOs on the basis of large numbers plaint during the menopausal transition. alone, due to the aging of the baby boom The risk factors for vasomotor symptoms cohort (Ratka 2006). Reproductive aging include, but are not limited to, older age in women has been divided into four (50 to 54 years) or onset of menopause JEANNE L. stages by the Staging of Reproductive prior to age 53; hysterectomy or oophoALEXANDER, MD Aging Workshop (STRAW) staging sysrectomy in women aged 40 to 60 years tem (Soules 2001) and later modified by the ReSTAGE without hormone replacement therapy; endocrine facCollaboration at the University of Michigan (Harlow tors, such as lower levels of estrogen and inhibin B, or 2008): late reproductive, in which there is no change in higher levels of FSH; psychiatric factors, such as depresmenstrual cyclicity; the early menopausal transition, in sion and anxiety; higher levels of perceived stress; a hiswhich a change in menstrual frequency begins; the late tory of childhood abuse; African-American or Hispanic menopausal transition, defined as more than two skipped descent; a higher-than-average body mass index; and cycles and 3 to 11 months of amenorrhea; and posthaving certain polymorphisms in genes governing estromenopause, defined as 12 months or more of amenorrhea gen receptors and the synthesis and metabolism of estro(Burger 2007, Soules 2001). Progression through these gen (Alexander 2007a). Interestingly, climate has been stages is characterized by increases in serum follicle stimimplicated as a factor affecting the observed frequency of ulating hormone (FSH), luteinizing hormone (LH), and hot flashes in different cultures. Sievert (2005) found an estradiol and a decrease in luteal progesterone (Hale association between hot flash frequency and the differ2007). Women experience both ovulatory and anovulaence in temperatures between the coldest and hottest tory cycles during the transition. The late menopausal months for a particular geographic location. transition is characterized by 60 or more days of amenSeveral authors have observed an association between orrhea along with FSH levels of 40 IU/l or more, and is vasomotor symptoms and a higher prevalence of dein contrast to the definition of the early menopausal tranpressed mood regardless of prior depression (Avis 1994, sition, in which women experience changes of more than Freeman 2007). Joffe (2002) found that approximately 60 7 days in menstrual-cycle length (Randolph 2006). percent of women age 40 to 60 with depression experi- T 10 MANAGED CARE / SUPPLEMENT
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