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The Assessment And Treatment Of The Psychiatric Aspects Of The Female Reproductive Cycle – Part 2
We would like to start by focusing on menopause. By definition, this phase of reproductive life is a time when the permanent cessation of menstruation occurs due to the cessation of egg production as well as the cessation of estrogen production. The phase leading up to menopause, or peri-menopause, is the period before menopause and lasts until the first year of amenorrhea (no period).
Many women use menopause as a catch-all term to describe a time when there are a myriad of uncomfortable syndromes and symptoms. These can notably include a vasomotor disturbance – better known as ‘hot flushes’. They consist of both profuse sweating and intense heat.
Hot flashes can be sudden and diffuse, gradual and progressive, in a single episode or in rapid succession. They can occur at any time, but tend to be more common at night. These “attacks” are due to the decrease in levels of female gonadal hormones – especially estrogen.
Other commonly experienced symptoms may include vaginal dryness, libidinal decline, uro-genital problems involving bladder dysfunction, difficulty with discomfort during intercourse, varying degrees of increased cardiovascular risk, osteoporosis, and variety of psychiatric and psychological intrusions.
Included are: mood disorders, i.e. major depressive disorder, exacerbation thereof, particularly when there are other comorbid conditions such as: dysthymia, anxiety disorders , i.e. panic disorder, obsessive compulsive disorder, generalized anxiety disorder, hypochondriasis and phobic reactions. .
There may also be an increase in somatic complaints – organic or perceived, a decrease in cognitive abilities and acuity leading to a decrease in attention, concentration and productivity. Sleep disturbances, i.e. insomnia, are common.
Mood disorders, especially depression, are twice as common among women as among men (21% versus 12%). Additionally, according to the World Health Organization’s Global Bureau of Diseases survey, unipolar depression (not bipolar depression) is the leading cause of disease-related disability in women. Ischemic heart disease was the single chronic disease with the greatest impact.
When you consider that the average age of onset of the perimenopausal transition is 47.5 years and the average life expectancy for women is 77 years, that means a possible life phase of 30 years or more with these lingering consequences if left untreated. Each year, 1.3 million women reach menopause. About 20% of them will experience dysfunctional depression.
The Harvard Moods and Cycles Study recruited premenstrual women between the ages of 36 and 44 who all had major depressive episodes. They followed these women for 9 years looking for new episodes of their pre-existing depressive symptoms. Of note, those who entered perimenopause were twice as likely as women who had not yet begun the perimenopausal transition to develop clinically significant major depression.
During periods of perimenopausal transition, estrogen levels fluctuate and decline; follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels increase; melatonin and growth hormone levels decline, as do progesterone levels. These hormonal variations contribute to quite a large amount of many of the aforementioned and other symptoms.
Treatment options include hormone replacement therapy – standard or bio-identical varieties. These can play a useful role, but the risks and benefits should be carefully considered and understood before deciding whether or not to use them. Antidepressants, particularly the SSRI and SNRI classes, have been helpful for many symptoms, but not all.
They are safe and non-addictive tools to treat these needs. Both clonidine and gabapentin have some benefits for reducing hot flashes. Group therapy, individual cognitive behavioral therapies, alternative methods, healthy eating, and routine physical activity can all be positive factors in treating symptoms/disorders. Younger women with surgically induced menopause have a markedly increased likelihood of having major depressive symptoms. Additionally, several related biopsychosocial issues contribute to this outcome.
Attitudes towards midlife, aging, loss, change, and menopause itself are very important considerations that affect the onset and intensity of disorders. In addition to this, questions about purpose in life, interpersonal relationships, body image, social supports, cultural/family influences, “empty nest” issues are all psychological influences on this syndromic disorder. Smoking is also a negative factor.
It is important to understand and examine the physical and psychological reasons for these disorders. When both areas are assessed, we get closer to meeting the true needs of each patient in their context and are more successful in determining how treatment should proceed on an individual basis.
Q. In these difficult economic times, what should new patients or even existing patients do to seek care?
A. Patients who postpone or abandon needed psychiatric care will most likely struggle with more intrusive illnesses that rob them of their potential to lead more healthy and productive lives. The decision to choose treatment when finances are difficult is very difficult. We work with patients on an individual basis to help them overcome these difficult obstacles whenever possible. It is a respectful patient-physician partnership.
Q. “What form of treatment for these problems do you offer?
A. I provide the full psychiatric assessment of these biological and emotional states. Thereafter, any identified need that would benefit from psychopharmacological interventions, multiple psychotherapeutic modalities, appropriate laboratory testing, and collaborative OB-GYN referral and alternative medical care are readily available. Medication needs and psychotherapies are provided solely by me for better continuity of care and greater comfort for the patient.
Q. Are there age limits for the female population you treat?
A. We start our age-appropriate care at 14 and continue it into geriatric care.
Q. How long does it take to see improvement?
A. A patient’s preferences, psychiatric history, depression, anxiety – even psychosis will create the severity that will determine which options to consider and in what order. An individualized plan will be developed. The veracity of the improvement depends on the patient’s problems, priorities and comfort with the recommended treatments.
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