更年期抑郁的治疗经验

1、Menopause and DepressionExperience in Treatment Objectives Menopause associated psychological changes and symptoms Pathophysiology in Menopause Depression Alternative Treatment options for bothersome symptoms ( Medications) Medication for the women who is Contraindicated for Hormone Depression in Me

2、nopause Trend of Suicide in a womans Life Two peak in all life of women Adolescence and Menopause Menopause symptom related psychotic disease (Depression) Metabolism, Volume 54, Issue 5, Supplement, May 2005, Pages 4952Estrogen with Serotonin 1. Inhibit the Monoamine Oxidase (MAO) function2. Moderat

3、e the serotonin (alpha 1) receptor effect Darlene Deechera, From menarche to menopause: Exploring the underlying biology of depression in women experiencing hormonal changes, Psychoneuroendocrinology, Volume 33, Issue 1, January 2008, Pages 317 Serotonin in Menopause Serotonin decrease it amount Ser

4、otonin decrease it effectEstrogen and Depression Premenstrual Dysphoric Disorder (PMDD) Post Partum Depression Postmenopause Depression Six Women and Their NightmaresCase #1 35 yo G1 P0 female presents with c/o hot flashes and amenorrhea for 12 months. She doesnt know why this is happening, her sex

5、are worsening. Daily work is bothered. Suicide intention and conflict with her husband occurred. She wants your help.Case #1 DDx Premature Menopause Pituitary Tumors Ovarian Failure Cerebellum Atrophy Iatrogenic Effect Case #1 Test LH, FSH, E2 and Testosterone Sono Examination Brain Computer Tomogra

6、phyCase #1 Treatment Hormone ( E+P) (Angeliq) Hot Flush Persistent SSRI (Selective Serotonin Reuptake Inhibitors) ClonidineCase #2 45 yo G2 P2 female presents with c/o hot flashes and irregular menses (q 3-5 mos) for the past 9 months. Body weight gained in recent. Her mood and behavior change. Fami

7、ly Abuse in recent 21 yo daughter refused to live with her. DDx TestsCase #2 DDx Schizophrenia Transitional Menopause Case #2 Test FSH, E2 and Testosterone Psychological ConsultationCase #2 Treatment SNRI for her schizophrenia Hormone ReplacementCase #3 65 yo WF presents to start HRT. She heard it w

8、ould help protect her heart, make her feel younger and help her memory. She went through menopause 10 years ago and has not had any problems except an recurrent depression. She is 54”, 108 lbs. By the way, she had a wrist fx 2 yrs ago takes her evista faithfully.Case #3 Treatment Prozac or not ? Tri

9、cyclic antidepresents ?Case #4 49 yo WF presence b/c she cant stand her hot flashes anymore. She cant sleep very well b/c she wakes up 3 times a night drenched with sweat. She is an executive at First National Bank. She has a history of breast cancer 2 years ago. “Please Dr.Linn, I need some hormone

10、s or something.”Case #4 Treatment Benzodiazepine Barbiturate Hormone Replacement Tomoxifen ?Case #5 55 yo BF returns to discuss stopping her HRT. She has been taking it for 5 years now with good relief of her vasomotor and sexs. After discontinuing her HRT, she was involved with slight depression an

11、d chronic pain. Case #6 53 yo breat cancer woman stage 1 began continuous tomoxifen for 4 years. She is now having some vaginal spotting. After using the aromatase inhibit, severe insomnia and disorder bother her. Case #6 Treatment Hystectomy Regain Tomoxifen Stop Aromatase Inhibitor SSRI or SNRI HR

12、T or SSRI (1) Postmenopausal women with depression respond better to selective serotonin reuptake inhibitors (SSRIs) if they are also taking hormonal therapy (HT), Italian researchers suggest. E Hall, BN Frey, CN Soares - Drugs, 2011 - HRT & SSRI (2) Random Control, No response to SSRIs in 170 p

13、ostmenopausal women with a depressive episode, as defined by the DSM-IV criteria, 47 of whom were on HT. E Hall, BN Frey, CN Soares - Drugs, 2011 - HRT & SSRI(3) Among patients who were not also taking HT, the response rate to SSRIs was only 63.2%, compared with 83.7% among patients taking HT. F

14、urthermore, the rates of remission were similar for the two groups, at 52.63% and 79.07%, respectively. SR Davis, F Jane - Expert Opinion on Pharmacotherapy, 2010 HRT & SSRI (4) They also found that levels of luteinizing hormone (LH) may provide a means of predicting which women are likely to re

15、spond GB Mahady - NIH/ODS (Ed.), US NIH, 2010 - SSRI & Placebo SSRI are also superior to Placebo Clinical improvement at week 8 (decrease of 50 percent or more from baseline in hot flash frequency) was significantly greater in the escitalopram group than in the placebo group (55 pe

16、rcent vs. 36 percent). Menopause: September/October 2006 - Volume 13 - Issue 5 - pp 780-786SNRIserotonin and norepinephrine reuptake inhibitors Off-Label Use in Postmenopause Syndrome such as insomnia, anxiety and depression The case of menopausal symptoms, nerve pain, hot flashes and emotional stre

17、ss are relieved. David F. Archer, Volume 200, Issue 3, March 2009, Pages 238.e1238.e10Menopause Terminology: STRAW* Staging System*STRAW = Stages of Reproductive Aging Workshop.Stages most likely to be characterized by vasomotor symptoms.Soules MR, et al. Menopause. 2001;8:402-7.Terminology:Duration

18、 of Stage:Menstrual Cycles:Final Menstrual PeriodVasomotor symptoms:Why dont we treat every women with hormones?Menopausal Complaints: Treatments Hormones vs non-hormones vs herbals What kind of herbal drug is effective ? Efficacy ?Clinical EventHazard Ratio, 95% confidence intervalHERS E+PWHI E+PWH

19、I E aloneCHD Events0.99 (0.80-1.22)1.29 (1.02-1.63)0.91 (0.75-1.12)Stroke1.23 (0.89-1.70)1.41 (1.07-1.85)1.39 (1.10-1.77)Pulm. Embolism2.79 (0.89-8.75)2.13 (1.39-3.25)1.34 (0.87-2.06)Breast Cancer1.30 (0.77-2.19)1.26 (1.00-1.59)0.77 (0.59-1.01)Colon Cancer0.69 (0.32-1.49)0.63 (0.43-0.92)1.08 (0.75-1

20、.55)Hip Fracture1.10 (0.49-2.50)0.66 (0.45-0.98)0.61 (0.41-0.91)Death1.08 (0.84-1.38)0.98 (0.82-1.18)1.04 (0.88-1.22)Global Index-1.15 (1.03-1.28)1.01 (0.89-1.70)Hormones Contraindicated Breast CA Endometrial CA Undiagnosed vaginal bleeding CHD Venous thrombosis Stroke Pregnancy What is not here, th

21、at is a CI on OCPs?Specific Geriatric IssuesOther assessments to be made.Cognitive Function Normal decline Dementia Alzheimers Vascular Others Depression Medications EtOH MMSESensory Visual Auditory BalancePolypharmacy Medication List Drug-drug interactions Altered pharmacokinetics, pharmacodynamics

22、 Herbals OTCSerotonin in Menopause Serotonin decrease it amount Serotonin decrease it effectEstrogen and Depression Premenstrual Dysphoric Disorder (PMDD) Post Partum Depression Postmenopause DepressionCase #6 53 yo breat cancer woman stage 1 began continuous tomoxifen for 4 years. She is now having

23、 some vaginal spotting. After using the aromatase inhibit, severe insomnia and disorder bother her. HRT or SSRI (1) Postmenopausal women with depression respond better to selective serotonin reuptake inhibitors (SSRIs) if they are also taking hormonal therapy (HT), Italian researchers suggest. E Hall, BN Frey, CN Soares - Drugs, 2011 - HRT & SSRI (2) Random Control, No response to SSRIs in 170 postmenopausal women with a depressive episode, as defined by the DSM-IV criteria, 47 of whom were on HT. E Hall, BN Frey, CN Soares - Drugs, 2011 - Menopause Terminology: STRA