Indian Write-Ups

Psychological symptoms associated with the menopause

In the past it was assumed that the incidence of mental disorders especially depression increased during the menopause. Epidemiological evidence however casts some doubts on this assumption. There is no increase in the number of women suffering from mental disorders during this period, but there is a precipitation or increase in symptoms in constitutionally prone women.

Symptoms are more severe after abrupt cessation of menstruation when the ovaries are surgically removed.

Women who are likely to develop psychological symptoms are rigid, oversensitive, hardworking and having a high sense of duty, those who have invested heavily in child bearing and child rearing activities, having a limited range of interests and poor adult sexual adjustment.

Presentation

The picture is that of a Depression without Retardation, dominated with feelings of anxiety and unreality. The onset is insidious over a period of several months. The women are aware of their deteriorating mental condition and approach for help themselves.

Orientation is preserved and memory intact. There are complaints of easy fatigability and inadequacy “I do not feel like doing anything” – “I will not be able to do it” – being the constant refrain.

Feelings of guilt are prominent; they feel anxious that they are neglecting their house and family. They also tend to blame themselves for misfortunes falling on others. One of my patients felt very guilty and blamed herself for the death of her husband’s friend because she had cursed him seventeen years earlier.

Hypochondrial delusions manifest as preoccupation with associated physical difficulties, e.g. cervical spondylosis, dyspepsia, chest pain, and headaches. They feel they are suffering from some incurable Mental Disease, and fail to be satisfied inspite of constant reassurance.

Paranoid delusions are also present– husbands fidelity being suspect.

In some women suicidal thoughts are present – untreated cases may culminate in attempted or completed suicide.

Some psychosocial conditions prevalent during the inovulational period may aggravate the depressive symptoms.

Preoccupation which might have beens, missed opportunities, and unfulfilled ambitions, disappointments, especially with children. Increased financial pressures. Lack of purpose – children growing up and flying away - Empty Nest Syndrome. Pre-occupation with diminished physical attractiveness and fear of being ineffective sexually.

Interestingly these factors form the content of the patient’s talk – but their removal does not necessarily lead to amelioration of symptoms.

Management

Management of menopausal disorders especially depression requires a holistic approach.

General measures like exercise diet and symptomatic treatment help to relieve the physical discomfort. A one-hour brisk walk every day is advocated with advice to minimize the consumption of tea, coffee and hot spicy food and avoid smoking and alcohol consumption.

Long term Hormone Replacement Therapy HRT, is very helpful in relieving physical symptoms – hot flashes are reduced, osteoporosis can be prevented, and significant reduction of complications due to arteriosclerosis. Conjugated oestrogens are given in combination with progesterone orally or as a combi pack.

HRT does not in any way help to ameliorate the psychological symptoms. Psychological symptoms have to be evaluated and treated according to their severity.

For milder cases psychotherapeutic and sociotherapeutic measures suffice. The patient is reassured, and encouraged to accept the menopause as a natural life event. The other family members must also be included in the treatment programme, creating an atmosphere of understanding. The women should be encouraged to develop new activities, interests and gratifications.

For many patients however the institution of drug therapy is a must.

The mainstays of the treatment are antidepressants. The choice of antidepressants depends upon the physician and which drug the woman accepts. There is an increasing range of antidepressants available in the market today, there is however little to choose between – tricyclics and SSRI’s. Since the patients are suffering from an agitated depression and have high level of anxiety the anti-depressants very often have to be augmented with mood stabilizers i.e. lithium or carbamazepine, therefore the fact that a combination of lithium and SSRI’s may produce neurotoxic symptoms must be kept in mind.

For women who have psychotic symptoms, anti-psychotics may have to be prescribed along with the above treatment. In suicidal patients who are very agitated and difficult to manage electro-convulsive therapy may facilitate early resolution of symptoms.

To conclude one must keep in mind that of the women seeking help for emotional symptoms and depression a disproportionately large number are in the menopausal period. The symptoms are very distressing, requiring active intervention and a holistic approach to treatment.