Menopause: the symptom? Or, the disease?
A few years ago, I ran across the following story on the BBC:
“Woman’s Death Blamed on Menopause.”
“A woman who refused to take hormone replacement therapy died while suffering a menopausal episode, an inquest had heard. Margaret Drew…was killed when she walked out of her family home on to a nearby railway line and was hit by a train…There is no trigger to this at all, except hormones making her do things that she normally wouldn’t do, Dr. Carlyon [Cornwall Coroner) concluded…”
Menopause. The silent killer. Oh really? Drew’s husband claims that his wife was “delightful, lovely and friendly” 99% of the time; the other 1% she’d become “totally irrational.” Yet, she refused to try HRT, he says. On the day of her suicide, he said that his wife was “clearly angry about something.”
Something.
Obviously, the conclusion is that that the “something” is hormones. This reminds me of vintage advertising copy that conveys the simple message that a pill a day can cure all that ails, wipe away the tears, mood swings and instability so that women can “transition without tears” (or better yet, without killing themselves).
Notably, a search in the National Library of Medicine’s PubMed database turned up only one recent study specifically dealing with suicide ideation across reproductive stages. In it, researchers compared data in 8,794 women, and found an increased risk of thinking about suicide among women during perimenopause, not before or after entering menopause. These findings remained after controlling for risk factors such as anxiety and mood disorders. HOWEVER, the researchers noted that the study design did not allow them to form any definitive conclusions about the specific reasons for thinking about suicide.
Another search yielded information that the risk for a major depression increases during perimenopause, primarily as the direct result of vasomotor symptoms. The same does not hold true for women before menopause begins or once they enter menopause. Note that while major depression is a risk factor for suicide, not everyone who is depressed will actually kill themselves.
So, are hormonal fluctuations the sole cause of such deep unhappiness that women want to kill themselves?
Interestingly, just a week after the menopause/train suicide story hit the interwebz, a rather controversial set of data also emerged: since 1972, women’s overall level of happiness has dropped. These findings held true regardless of child status, marital status and age. Researcher Marcus Buckingham, writing in the Huffington Post, said that women are not more unhappy than men because of gender stereotyping and related attitudes, due to working longer hours or because of the inequality of housework/responsibilities at home, but rather, the hormonal fluctuations of menopause may be to blame. What’s more, he leaves us hanging so we’ll tune in for part two of the piece to learn the true cause of our declining happiness or better yet, read his book (which evidently guides women through the process of finding the true role that they were meant to play in life).
Importantly, reactions to this study (and various pundits’ assessment of it) have been mixed. One of the most poignant comments I’ve read asks the question “how is happiness measured? What does it mean?”
I have no idea what caused Mrs. Drew to walk into a train and kill herself. Perhaps she was depressed. Clearly she was suicidal.
I have no idea why research shows that women are less happier than they were three decades ago.
However, is menopause the cause? Aren’t these conclusions an example of how the Menopause Industrial Complex perpetuates societal myths that menopause is a disease that requires treatment? That as women, our attitudes, belief systems and actions are hormonally-based and driven? That we are hysterical beings who need guidance on how to find our way and fulfill our dreams, realize our paths, but only if we calm down?
Feeling angry? Blame it on menopause. Unhappy? Blame it on menopause. Not realizing your dreams? Blame it on menopause. Overworked, overstressed, undervalued? Blame it on menopause.
Blame it on menopause.
I don’t know about you but I’m tired, tired of hearing that menopause is not the symptom but the disease. Isn’t it time we start fighting back?
Read MoreWednesday Bubble: Depression and midlife – “overmedicalizing” the menopause
What’s the lowdown on depression, midlife and women? And how does the menopause come into play?
I written previously that depression may affect as many as 20% to 40% of women during menopause. However, gender differences in depression evidently begin well before the menopause and women are 1.5 to 3 times likelier than men to report a lifetime history of depression. Moreover, these distinctions start as early as the teen years and continue until the mid 50s, which researchers say, corresponds to female reproductive. Hence, experts have connected waning and altered hormone levels to high rates of mood and anxiety disorders in women.
Is this hypothesis valid? And, where did it originate?
According to a review in the early online edition of the Journal of Affective Disorders, some research has suggested that premenstrual, post partum and menopausal mood disorders are linked and that women are especially vulnerable during certain time periods. This has led to a proposal that reproductive-related depression have its own classification, and that during midlife in particular, all women should be routinely screened for symptoms. Interestingly enough, however, it has also led some researchers to question if we are “overpathologizing the menopause?” Hallelujah! (If you want to read more on medicalizing the menopause, check out one of my favourite Flashfree posts.)
The key finding?
Although studies demonstrate that significant numbers of women in midlife report depressive symptoms, menopause is only one of a range of factors purported to lead to depression during this timeframe. Others include stress, family life, general health issues and a lack of exercise, as well as a history of some sort of anxiety disorder. What’s more is that how women perceived the effect of menopause on their physical health almost doubled the risk that they would first develop depression at the onset of menopause.
The researchers say that although women might score high on self-reported mood scores, these scales or instruments tend to exaggerate the rate of depression in women in midlife and menopause. They also note that if a score is only taken at one time point that is might indicate temporary distress rather than a long-term problem. They add that during menopause, certain symptoms, such as sleep disturbance and fatigue, may be easily confused with depression even though they have nothing to do with a mood disorder and everything to do with hormones.
The bottom line is that symptom overlap and environmental factors can confuse a diagnosis, and that depression is not necessarily more prevalent during menopause than during other periods in a woman’s life. Consequently, like many things, the studies that are out leave more questions than provide definitive answers. Hence, the call for all women to be screened for depression during menopause may be an example of extreme assumption and not based in true necessity.
Is it possible that depression is just the tipping point in the medicalization of menopause?
What do you think?
Read MoreWorking through the menopausal transition..the first step is the deepest
Back in July of last year, I wrote a post entitled ‘Working through the transition? Or is the transition working you?’ In it, I discussed some research being conducted in the UK that is looking at the effect of menopause and its accompanying symptoms on the work environment and preesenteism, i.e. impact on productivity while at work. Not surprisingly, an overwhelming majority of women surveyed reported that their symptoms, namely fatigue and insomnia, were impacting workplace functioning and relationships with managers and co-workers. Less clear, however, were the roles of other factors, like perceptions and stress.
This raises one of the most common and yet inconsistently addressed issues during menopause: quality of life.
Quality of life is a subjective construct and one that is significantly influenced by a multitude of factors that intersect at any given time, factors such as how well we function, what we think about our lives, how we deal with stress, the type of social and economic support we have and overall wellbeing. And when you throw a bunch of symptoms like hot flashes, depression, anxiety, insomnia, backache, joint pain or forgetfulness on top of any of these, well, all hell can and does break loose!
When researchers looked at 184 women in both early and late transition to menopause who were part of the larger, Seattle Women’s Health study, they learned just how intricate the interrelationship between all these factors truly is. Indeed, among women in their mid to late 40s who were juggling work, families and relationships, the degree to which symptoms interfered with work most relied on how they perceived their health, their life stress and how depressed they were or were not. The findings:
- Symptoms like hot flashes, mood issues, sleep issues, pain, or concentration had a significant impact on work productivity.
- However, when researchers started to tease out and analyze the symptoms over time, they found that how symptoms influenced how women felt about their health was most important. If women felt that their health was excellent or very good, symptoms tended affect their work productivity to a lesser extent than if they perceived their health to be poor or only moderate.
- Perceived stress levels reportedly influenced both work productivity and social/intimate relationships.
- Depression and difficulty concentrating were the final straws in the work/relationship back, affecting performance and the ability or interest in socializing or engaging in intimate or family relationships.
The one thing that these reports and the UK reports had in common were nighttime awakening.
So, let’s take a look at this. How we feel about our wellbeing affects work productivity, as does stress. If we are depressed or have difficulty concentrating, the ability to focus and be productive, either at work or in our worlds in general, starts to fall apart. Frequent awakening during the nighttime hours as a result of both aging and hormones can cause fatigue, depressed mood and concentration issues. In turn, this can influence how well we function at work and at home and the quality of our relationship, to ourselves, our children and our partners.
The conclusion is that we need to step back, take stock and think about how we feel and how that is affecting our wellbeing and our lives.
The solution isn’t simple. Part of it lies in learning how to best address symptoms like sleep disturbances, depression or focus. The other lies in openly communicating to our work colleagues, our managers, our partners and our friends how productivity and our relationships may be suffering and actively involve them in finding solutions to improve wellbeing.
It’s hard work, no doubt. But the more insight we have, the better we are able to deal. And while it starts within, without it, the menopausal tendrils can extend far and widely into our lives.
The first step? Step back deep within yourself, and take stock. It may ultimately be the insight that you need to turn those symptoms on their side where they belong.
Read MoreDepression and menopause: can acupuncture help?
Depression and menopause. It keeps coming up as a topic and so I’m going to continue to write about it until researchers find an effective way to battle depression during menopause, effective meaning that it is an acceptable strategy for women who prefer alternatives to pharmaceutical agents, effective in that it addresses the underlying causes of depression in menopausal women, including fluctuating estrogen levels, sleep disturbances, night sweats, hot flashes and life factors, and effective in that it is affordable. It’s a tall order, isn’t it?
As I’ve noted time and again, depression is an important issue for many but not all menopausal women, affecting approximately 20% to 40% in a some way or another. Just this week, I wrote about use of the SSRI antidepressants as an alternative to HRT for hot flashes and depression, and possibly as a stop-gap measure until practitioners more widely embrace alternative strategies. On the heels of this study comes another in the Online Edition of Menopause journal, examining data from one of my favourite studies, ACUFLASH. If you don’t feel like clicking on the link and updates about this study, briefly, in ACUFLASH, researchers randomized 399 postmenopausal women (1 year since last menstrual period) regularly experiencing at least 7 hot flashes daily to acupuncture or no treatment. Moxibustion was used at the practitioner’s discretion and sessions could also be extended by two weeks (from 12 weeks), if needed. Although the practitioners met beforehand to discuss possible diagnoses and recommended treatment points, all treatment was individualized. Both groups of patients also received self care recommendations, which consisted of a one-page information leaflet on care of menopausal symptoms (e.g. soy, herbs, physical activity and relaxation techniques) which they were free to add at their own discretion.
Overall, the mean frequency of hot flashes declined by 48% in women receiving acupuncture compared with 28% of women using self-care methods only. This means that 50% of women receiving acupuncture experienced a 50% or greater reduction in how often their hot flashes occurred, compared to 16% of women using self-care. Significant reductions were also seen in hot flash intensity. Additionally, the acupuncture group reported significant improvements in vasomotor, sleep, and somatic symptoms over the course of the study.
So, what about acupuncture and depression?
In the current study, researchers examined a sample of 72 women who had participated in ACUFLASH and had either received self-care only or self-care plus acupuncture. At the start, almost 31% of these women reported depressive symptoms and of these, about 17% were determined to suffer from moderate to severe depression (based on a scientific method that measures the severity of depressive symptoms). Although these figures are higher than what is normally seen in the general population, severe depression is often seen among women experiencing very frequent hot flashes (7 or more in a 24 hour period for at least 1 week). And while both groups reported significant declines in depressive symptoms during the 12 week study period by as much as 16%, the declines were similar in both groups, indicating the acupuncture,while helpful for lessening the severity of hot flashes, did not have a specific effect on depression.
If acupuncture doesn’t help depression, why did the results indicate such a high level of improvement that under normal circumstances, an individual could forgo drugs for needles?
A key finding of the original and follow up ACUFLASH studies was the feeling of control over symptoms that was imparted by being educated about self-care. However, here’s the rub: even though acupuncture was shown to significantly benefit both the intensity and frequency of hot flashes, it didn’t provide an edge over depressive symptoms compared to self care alone. The researchers say that this leads them to believe that although a domino effect is at-play (i.e. hot flashes lead to sleep issues lead to symptoms of depression) there is something else that also influences the depression part of the equation.
In the interim, it’s frustrating, right? You can deal with your hot flashes but you still feel blue, low, out of sorts. There is clearly a link between the hot flashes and sleep and depression. It simply needs to be teased out a wee bit further. Keep the faith. We’ll get there!
Read MoreWednesday Bubble: hot flashes and antidepressants
Researchers have been studying antidepressant therapy (namely selective serotonin reuptake inhibitors – SSRIs, and serotonin/norepinephrine reuptake inhibitors –SNRIs) for some time now in hopes of discovering an effective treatment for hot flashes and an alternative to hormone replacement therapy (HRT). However, antidepressants’ ability to ameliorate hot flashes have yielded mixed results in the study arena. One potential advantage of using an antidepressant in this regard is the ability to also effectively address mood swings and depression that occur as hormone levels wane and decline throughout menopause. Hence, I was intrigued by a new study, published this week in the Journal of the American Medical Association, that not only evaluated the benefit of using the SSRI Lexapro for hot flashes but also, whether or not factors such as race and coexisting depressed mood and/or anxiety would affect the results. Notably, African-American women are reportedly more likely than report having particularly bothersome hot flashes.
In this particular trial, 205 menopausal or postmenopausal women reporting at least 28 hot flashes or night sweats per week over a three week period that were bothersome or severe the majority of time were asked to take 10 mg escitalopram (Lexapro) or placebo tablet daily for 8 weeks. This dosage was increased midway through the trial if hot flash frequency didn’t decrease by at least 50% and if severity did not change.
The findings:
- More than half of women reported that the frequency of their hot flashes declined by at least 50% from the study starts (compared to slightly more than a third of women taking placebo)
- Women taking Lexapro reported that the severity of their hot flashes decreased by 24% compared to the study’s start (and a 14% decline in severity among the placebo group)
- The response to Lexapro was rapid and improvements started to be seen within one week
- Reported side effects between the two groups were fairly equal, and mostly related to feeling tired, stomach issues and dry mouth
- Race did not appear to play a role in either group
- Hot flashes returned after Lexapro was stopped
Although the researchers caution that the group of women in the study were highly motivated and not necessarily reflective of women in the general population, I would argue that a woman with severe and frequent hot flashes is motivated, period. I’m not a huge fan of using pharmaceutical medications to address menopausal symptoms for two reasons: 1) menopause is not a disease and, 2) as evidenced by the archives, there is an evolving body of literature that supports the use of alternative strategies for managing menopause. Nevertheless, as someone who has had lifelong bouts of depression that are exacerbated by hormones, I welcome an effective alternative to HRT that might be more broadly embraced by the medical community. Until a greater proportion of healthcare practitioners begins to accept the distinctions between between eastern and western medical philosophies and the potential advantages of complementary strategies, the learning (and begging) curve will continue to be steep.
Perhaps antidepressants are an initial stop-gap while the body of evidence supporting alternatives like acupuncture or isoflavones for hot flashes and depression grows. I’m optimistic we’ll get there. And I will always be happy to see women provided with an alternative to HRT.
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