PAPER ON THE TREATMENT OF DEPRESSION IN WOMEN BY OESTROGENS
John Studd, DSc,MD,FRCOG
8 November 2010
There is a clear link between oestrogens and depression in women. Not only is depression twice as common in women than men but it occurs at times of hormonal fluctuation relating to normal physiological life events. Examples are premenstrual depression, postnatal depression and depression in the menopausal transition.
These have all been shown to be effectively treated with transdermal oestrogens in the dose of approximately oestradiol patches 200 mcgs twice weekly or oestrogen gel 2 grams daily. I believe that this treatment is at least as effective as antidepressants but unfortunately no head to head study of these two modalities have ever been undertaken or published. It is possible also to add transdermal testosterone for improvement in mood, energy and libido. The other hormone progestogen is necessary for seven to ten days per month in women who have a uterus in order to prevent endometrial hyperplasia.
In general terms women have an improvement in mood with oestradiol and testosterone and a decrease in mood in progestogen. The trick is to balance these three hormones depending upon the patient’s symptoms and needs. If the woman is progestogen intolerant the insertion of a progestogen releasing Mirena IUS is extremely useful. It is regrettable that patients with premenstrual depression – a clearly endocrine condition requiring suppression of ovulation with oestrogens are given antidepressants. Similarly patients with postnatal depression are given antidepressants without any consideration of oestrogens. Many women in their forties with perimenopausal or transitional depression will claim that they last felt well during their last pregnancy many years ago and then developed postnatal depression which has not really improved. Thus the occurrence of postnatal depression is the clue to the existence of a hormone responsive depression and it is at this time that many women start their ten to twenty year dependence on psychoactive or even mood stabilising drugs. The occurrence of postnatal depression is frequently the turning point in a woman’s mental and emotional health. With this condition there is treatment with various antidepressants over the years with little improvement but much deterioration of personality and self confidence.
The misdiagnosis of premenstrual syndrome by psychiatrists as bipolar disease with treatment by mood stabilising drugs is becoming more obvious. It is not a rare event. Hormone responsive depression cannot be diagnosed by blood tests because all the patients discussed are premenopausal and will have premenopausal levels of FSH and oestradiol. But these may not be optimal for the individual woman. However the way to diagnose premenstrual depression from bipolar disease is in the history. Those women with severe PMS will nearly always have:
- a history of mild or severe PMS as a teenager
- relief of depressive symptoms during pregnancy
- depression that started or recurred postpartum as postnatal depression
- premenstrual depression which returns when menstruation returned months after delivery
- premenstrual depression becoming worse with age blending into the menopausal transition and becoming less cyclical
- cyclical somatic symptoms such as menstrual migraine, bloating or mastalgia
- runs of seven to ten good days per month
- recurrent episodes of depression related to periods but rarely have episodes of mania
In this way a tragic misdiagnosis of bipolar disorder and the use of inappropriate powerful mood stabilising and antidepressant drugs can be avoided.