8 December 2014
A recent review written by three Finnish psychiatrists supports the use of estrogens, perhaps together with antidepressants, for depression and anxiety in perimenopausal women . Depressive symptoms are experienced by 15–50% of women during the menopausal transition and up to 30% of perimenopausal depression is severe enough to be regarded as a depressive disorder. This problem, described as 'reproductive depression'  occurs with fluctuations of gonadal hormones in the form of premenstrual depression, postnatal depression and climacteric depression. In the menopausal age group, the depression, anxiety and loss of self-confidence are at their worst in the 2–3 years of the transition period before the cessation of periods. Toffol and colleagues, in their review of the literature, have come to the conclusion that hormone therapy may contribute to the alleviation of menopause-related depressive symptoms. They claim that the administration can be followed across time and should be specifically individualized. In cases of more severe depressive disorders, a combination of antidepressants and hormone therapy should be considered. This view has also been proposed by others [3,4].
The perimenopause is usually accompanied by more-or-less-impairing climacteric symptoms of hot flushes, palpitations and tachycardia as well as some degree of psychological symptoms of sleep impairment, anxiety, panic attacks and depressive symptoms. The proportion of perimenopausal women suffering depressive symptoms ranges between 15% and 50%. It is possible that the fluctuations in estrogen levels and their eventual fall increase the risk in women who are vulnerable. These are particularly women who have had a premorbid history of psychiatric problems, particularly anxiety and depression related to reproductive events such as menstruation, post pregnancy and the contraceptive pill.
The cause of this hormone-responsive depression is unclear but, in our present state of knowledge, it is certain that gonadal hormones produce many effects on the central nervous system. In the adult brain, estrogen and progestogen receptors are widely expressed in different regions. Estrogen receptors are present not only in the hypothalamus but also in the hippocampus, amygdala, cerebellum, pituitary, cerebral cortex and glial cells. The mechanism is even more complex in that there are different types of estrogen receptors which are expressed in different brain regions and in different cells within the same brain region and even in the same cell in the same region. Therefore, the final effects induced by estrogens change depending on the type of receptor to which they bind. Target genes include those responsible for neurotransmitters, serotonin and GABA. The role of progesterone is even more complicated as it is involved in the control of opioidergic, sertoninergic and cholinergic systems with anxiolytic effects.