John Studd, DSc, MD, FRCOG
Consultant Gynaecologist, Chelsea & Westminster Hospital, London
Why is it depression is more common in women than men? Why is it that twice as many women are prescribed antidepressants and tranquillisers than men? Perhaps it is the extra stress of life as a woman coping with family, work, husbands and with the added social problems of divorce, poor job prospects and general frustration of life at home. This is the feminists point of view, but it does not really explain why life should be more stressful or depressing for a woman than it may be for a man. However, there is a belief that at times of anxiety and stress, women complain and men misbehave. That means that women go to their doctors and are prescribed antidepressants and men go out drinking and worse.
All this may be true but there is also a hormonal factor and most women will recognise that "hormones" are part of the problem. This may be the pill, periods, pregnancy or the menopause. These factors affect greatly mood and behavior. It is very likely that a decrease in the hormone oestrogen, or changes of hormones from the ovaries, like oestrogen and progesterone, produce depression. This is why depression in women occurs at times of great hormonal change, such as puberty, after a baby is born as post-natal depression, before a period as pre-menstrual depression and when the periods eventually stop as menopausal depression. They are often linked. It is very common for doctors to see a woman of about 45 with severe depression for years who will say that she was last well when she was last pregnant 10 or so years ago. She then developed post-natal depression three months after the baby was born whichÔ lasted for about nine months, she had anti-depressants and when the periods returned the depression became worse each month with the period and she developed pre-menstrual depression. This becomes worse with age and then she hits depression in her mid forties. People do not realise that the depression around the menopause is at its worst in the two or three years before the periods stop. This means that women will go to their doctor with depression but as they are still having periods, albeit with fairly low oestrogen levels, the hormonal cause of the depression is not recognised. They are then treated with anti-depressants rather than oestrogens.
Although at times pregnancy may be very inconvenient, both socially and financially, depression and suicide is quite rare in the last half of pregnancy, but is increased tenfold after birth because the sudden fall of hormones in part of the cause of post-natal depression. Post-natal depression occurs in at least one in ten women after delivery. Most women believe that depression and exhaustion after pregnancy is normal due to the problems of breatfeeding, lack of sleep and general exhaustion. That may be so but there is also a hormonal element, and it is well proven now that oestrogens will alleviate the depression in most cases of post-natal depression, even when the more usual anti-depressant drugs have failed.
Recently a woman's magazine had a cover which said "Does PMS exist or are you just a grumpy old cow". Premenstrual syndrome is a very real hormonal problem that occurs in both normal women and also women with other causes of depression or personality problems. They will complain that for two or more days, sometimes as many as 14 days each month, they will have irritability, depression, sore breasts, abdominal bloating, tiredness and loss of sex drive. They will often have five or six day periods which may be heavy or painful, thus they may only have about 7 or 10 good days a month. These women are aware that their hormones are causing the trouble and unless they can find treatment which works, they find themselves less successful at work and barely tolerated by the family at home.
There are three sorts of hormone responsive depression which can be succesfully treated with oestrogens. These are postnatal depression, premenstrual depression and menopausal depression.
This work is just about complete in my clinics and many scientific trials show how helpful it is. There is not much evidence that oestrogen tablets work, as all the research has been done with oestrogens applied on or through the skin. The most straightforward way of treating is to use oestrogen patches. A hormone implant of oestradiol, or sometimes with testosterone, for poor sex drive and energy is also effective.
These quite high doses of oestrogen work because they stimulate the brain into making chemicals to help depression. There is also another mechanism in premenstrual depression, in that these doses stop ovulation and stop the cyclical hormonal changes (whatever they are) in the ovaries and thus stop the symptoms of PMS. It is brilliant treatment but unfortunately, although used by most gynaecologists, is hardly used by any psychiatrists. Patches can be worn on the thigh or the abdomen, and absorption of oestrogen from the patches is very efficient. The patches are changed twice a week. This oestrogen treatment works brillantly well for severe PMS, but strangely enough it is much more difficult to treat mil PMS because this may merely be the normal symptoms which precede a period in somebody who has a fairly neurotic and worrying personality.
There is one problem. The women has to have a withdrawal bleed and will take some sort of progestogen such as Norethisterone, or Provera, or Duphaston for the first ten days of every month to produce a regular bleed and prevent overstimulation of the lining of the womb. These tablets often reproduce a few of the premenstrual symptoms. This is called progestogen intolerance and most women with PMS suffer from this so it becomes a problem of treatment. There are a couple of options for this intolerance to progestogen tablets. Firstly the progestogen can be put into the cavity of the uterus in the form of a coil, much like the usual birth control coils, but one which releases progestone into the cavity having a local effect on the lining of the womb. The periods will also stop in about three months. Thus a women will have oestrogens for her premenstrual depression or menopausal depression. They do not have to have the progestogen tablets nor will she have any periods. It seems a good deal and it has certainly transformed the lives of many thousands of women.
The other choice of course is hysterectomy in women whose families have been completed. There is no doubt that monthly premenstrual depression which occurs with heavy, painful periods and often menstrual headaches is a great burden for any woman to bear. These can of course be treated with a hysterectomy and HRT in the form of oestrogen pills, or patches or implants. It does seem to be a fairly crazy notion that hysterectomy can cure depression but it certainly can in circumstances. Every single scientific paper in the last ten years has shown that depression in large groups of women is less common after hysterectomy than before hysterectomy. Many women instantly feel that this is so and that their hormones and periods contribute to their ill health. These are the patients who come to hospital requesting a hysterectomy and are so much better and lucky to find a gynaecologist sympathetic to their views. There are so many women "out there" whose depression and misery is the result of some sort of hormonal imbalance. Their stress is made worse by the fact that they are usually given anti-depressants and no attempt is made to manipulate their hormones. It is for this reason that I started the first clinic in the country at the Chelsea and Westminster Hospital and at the Lister Hospital in London for the treatment of hormone related depression. It is called a psycho-endocrine clinic which is merely a posh name for the recognition that hormones have a profound effect upon the mood, behaviour and well-being of women.