I thought I would post this newsletter from Prof Studd as he said to pass it on to all interested parties. I thought it may be useful and interesting for people on here.
The really good news over the last few months is that NICE at last
have published their first report on HRT. It has been recommended
that HRT is prescribed more frequently by GPs because the benefits
clearly outweigh the risks. They stress the importance of
transdermal oestrogens over oral. I have not used oral therapy for
about twenty years because transdermal therapy by gels, patches or
implants do not induce coagulation factors in the liver and there is
no increased risk of deep-vein thrombosis, heart attacks or strokes.
In fact the incidence of heart attacks is almost certainly lower with
oestrogen therapy in general and particularly by the transdermal
route.
It is recommended that general practitioners prescribe HRT more often
for hot flushes and night sweats and also consider HRT ‘to ease low
mood that arises as a result of the menopause'. At last! NICE
also states that oestrogen only HRT has little or no increase in the
risk of breast cancer (in fact it is a lower risk) while HRT with
continuous progestogen can be associated with an increased risk of
breast cancer. But any increased risk disappears after stopping HRT.
This will explain why I am so keen on transdermal hormones and even
in women with a uterus I prescribe the minimum duration of natural
progesterone rather than continuous or 12 day addition of synthetic
progestogen for endometrial protection.
I am still having trouble persuading psychiatrists that the first
line treatment for depression in perimenopausal women is oestrogens
but I have taken part in a debate with psychiatrists that will soon
be published in the British Journal of Obstetrics and Gynaecology. I
am enclosing my summary which stresses my support for this treatment
and also my anger at arrogant and bone headed psychiatrists for
deliberately ignoring thirty years of literature demonstrating that
oestrogens help menopausal depression, postnatal depression and
premenstrual depression. It is easier for them to prescribe their
familiar antidepressants. The problem is that they don't work !
The battle continues.
DEBATE
ESTROGENS ARE FIRST LINE TREATMENT FOR DEPRESSION IN PERIMENOPAUSAL
WOMEN
Perimenopausal women with depression (PMD) suffer the many symptoms
of the menopausal transition before the cessation of periods together
with anxiety, poor concentration and loss of libido. These women
often have a continuum of depression from an early age with a history
of hormone related depression of premenstrual depression (PMS) and a
history of post-natal depression (PND). The PND then becomes
cyclical with the return of periods, becoming worse with age until
the mid-forties. They are then denied hormone therapy because they
are not post-menopausal. This pattern of depression in women is best
called Reproductive Depression (RD) and cannot be diagnosed or
excluded by blood tests because the hormone levels will usually be in
the premenopausal range Studd J Nappi R Gynec Endocrinol 2012 28
42-45.
Transdermal oestrogens are safer than oral oestrogens in that they do
not carry any extra risk of thrombosis and also have been reported as
more effective in the treatment of depression. This should be by
patches or gels giving a reasonably high dose using oestrogen patches
of 100ug twice weekly. Soares CN et al 2001 Arch Gen Psychiatry 58
529-34 A similar dose of gels should be used. There is often a loss
of libido and loss of energy at the same time and these women will
benefit from transdermal testosterone although it is unlicensed in
women it can be achieved by testosterone gel, Testim or Testogel
using approximately on tenth of the licensed male dose. Studd J 2011
Climacteric 14 637-642. Those women with a uterus have to have
cyclical progestogen but as these women are progesterone intolerant
it is justifiable to use a shortened course of Norethisterone,
Provera or Utrogestan for seven to ten days each month.
Not all women will have the depression removed by hormone therapy and
there will be a case for the use of antidepressants in a few women
but I believe this is second line treatment for these patients who do
not respond to the more logical transdermal oestrogens. I have tried
to arrange a lecture for years at the RCPsych but I am informed that
there is no interest in this treatment among senior psychiatrists. Is
it a territorial issue? Possibly. Is it a safety objection? This is
unlikely as transdermal oestradiol is safer than long term
antidepressants. Smoller et al 2009 Arch Int Med 2009 169 2128 -39.
Essentially the problem is the failure to recognise the hormonal
component of perimenopausal depression. This failure leads to an
interesting catalogue of explanations. 1 Treatment resistant
depression (wrong treatment) 2 Borderline personality disorder (a
familiar DSM V diagnosis) 3 Bipolar Disorder (It is cyclical! After
all) 4 Premorbid history of depression (depression also occurred
before the current PMD. It was PMS or PND - usually both.)
Most psychiatrists are not effective when treating depression in
women. I hope the few interested psychiatrists will be able to
instruct them .I have failed.
Please pass on the newsletter to your pals and your friendly
psychiatrist
With best wishes and happy new year
John STUDD, DSc, MD, FRCOG
Professor of Gynaecology
______________________________________________________________________
