Understanding Mood Disorders During Menopause: Insights from Dr. Gabriel André

PARIS — As women approach menopause, many face a wide array of physical and emotional challenges. Among these, mood disorders can significantly impact quality of life, often exacerbated by hormonal fluctuations. Dr. Gabriel André, a gynecologist-obstetrician based in Strasbourg, France, discussed the implications of these disorders at the Santé Paris Femmes 2024 congress, shedding light on the complexities surrounding mood, hormones, and treatment options for women in this crucial transitional period.

Hormonal Fluctuation and Vulnerability

Perimenopause, the transitional phase leading to menopause, typically occurs between the ages of 40 and 50. This time is often marked by a host of symptoms, including irregular menstrual cycles, breast tenderness, hot flashes, and notably, mood disorders. Dr. André highlighted that women with a history of mood disorders, such as those who have experienced depression while on birth control or those sensitive to premenstrual syndrome and postpartum depression, are particularly vulnerable during this time. “If a continuous state of sadness persists for more than 15 days, it warrants professional intervention from a psychiatrist or psychotherapist,” he emphasized.

The gynecologist’s role is essential as the symptoms of menopause can be confused with those of depression. "The challenge is that menopausal symptoms overlap with those of depression," he noted, demonstrating the need for careful diagnosis and treatment.

Research indicates that during perimenopause, many women experience notable mood fluctuations, which often settle over time. An 8-week study involving women averaging 48 years old found a clear association between the severity of depressive symptoms and fluctuating estradiol levels. Dr. André pointed out that the absence of progesterone and anovulation could further exacerbate these depressive scores.

Hormone Therapy and Antidepressants

When it comes to treating mood disorders during menopause, there are numerous avenues to explore. Dr. André explained that the brain possesses estrogen and progesterone receptors, influencing changes in mood through two primary pathways: the serotonergic pathway, where estrogens enhance serotonin levels, and the GABA (gamma-aminobutyric acid) pathway, which is gaining recognition for its role in mental well-being.

Menopausal hormone therapy (MHT) has been shown to potentially alleviate depressive symptoms. Dr. André discussed a Canadian study that involved about 170 women experiencing perimenopause or early menopause who were treated with a combination of antidepressants and hormone therapy. “The intriguing finding was that combining the two resulted in significant interactions and improvements,” he stated, acknowledging that while combining treatments is not common practice in France, it is more accepted in Canada.

The Role of Progestogens

Dr. André cautioned against the use of androgenic progestogens during treatment for mood disorders, highlighting research that shows that combining dienogest and estradiol continuously yields better results for brain health. "Increasing estrogen doses to combat deficiencies can actually worsen depressive symptoms during certain cycles," he warned. "Choosing the correct level of estrogen is critical; the highest amount is not necessarily the most effective."

He advocated for transdermal administration of MHT coupled with a continuous combined protocol to minimize fluctuations in hormone levels, which can adversely affect mood. Importantly, if a patient does not respond positively to treatment, rather than increasing the estradiol dose, it may be more beneficial to consider lowering it, which contrasts typical approaches to hormone therapy.

Natural progesterone also shows promising effects on the brain, notably helping with anxiety and depressive symptoms.

Understanding GABA and Mental Well-being

Dr. André explained the role of GABA in mental wellness, emphasizing that it might take precedence over serotonin in certain cases. As the primary inhibitory neurotransmitter of the central nervous system, sufficient levels of GABA can foster feelings of calm and well-being, while insufficiency can lead to anxiety and agitation. He noted that the effects of GABA can vary, especially when it comes to certain hormonal treatments and fluctuations experienced during menopause.

Finding the right balance of GABA and other hormones, such as estradiol and progesterone, is crucial. "Determining the optimal dose requires precision, as excessive or insufficient amounts could lead to paradoxical effects," he warned.

For women who are clearly beyond menopause, treatment focus should shift towards other symptoms like sleep issues and libido that can significantly impact mood. Dr. André pointed out that mood disorders should be factored into the risk-benefit assessment when contemplating stopping hormonal treatment, reiterating the importance of comprehensive care.

Non-Hormonal Emerging Therapies

Advancements in non-hormonal therapies demonstrate promising potential in addressing menopause-related symptoms, including mood disorders. Medications like fezolinetant and elinzanetant, which affect the hypothalamus and its regulation of temperature, have undergone phase 3 trials and have shown effectiveness in reducing the frequency and severity of vasomotor symptoms like hot flashes. Since such symptoms can influence mood, this emerging line of treatment could positively impact overall emotional health.

Dr. André concluded with practical advice beyond pharmaceutical options, emphasizing the importance of lifestyle factors. "Ketogenic diets, physical activity, and maintaining a robust social life are also essential components of wellness during menopause," he suggested.

As women navigate the complexities of menopause, understanding the intricate relationship between hormonal changes and mood disorders can empower them to seek appropriate care and alleviate the burdens that accompany this natural transition.