Depressed Mood Through Women’s Reproductive Cycle: Correlation to Mood at Menopause

By Becker, D; Orr, A; Weizman, A; Kotler, M; Pines, A

Key words: MENOPAUSE, PREMENSTRUAL SYNDROME, POSTPARTUM, PREGNANCY, DEPRESSION, MOOD

ABSTRACT

Objectives Depressive symptoms are frequent through the different stages of a woman’s reproductive cycle. The aim of this study was to evaluate a possible correlation of depressive mood before menstruation, during pregnancy, after delivery and around the menopause.

Methods The sample consisted of 110 women (mean age 52 years, standard deviation 4 years) who rated their mood at present and retrospectively at different stages of the reproductive cycle. Mood was rated using a visual analogue scale.

Results A significant statistical association was found between the present mood and mood at the premenstrual period, but not with mood at pregnancy or after delivery. These findings were independent of age, menopausal status or use of hormone replacement therapy.

Conclusions The statistical association between depressed mood around menopause and before menstruation supports the assumption that there is a common etiology, which could be attributed to hormonal or psychological factors, or both.

INTRODUCTION

Women are prone to anxious/depressive symptoms during the different phases of the reproductive cycle: the days preceding menstruation, the postpartum period, and the years leading up to menopause (perimenopause). Given the similarity of the symptomatic manifestations, it seems reasonahle to assume that these phenomena share epidemiological and etiological features as well, and may also respond similarly to treatment.

As early as 1951, Donovan’ observed that 95% of the women who suffered from emotional problems during menopause had previously approached him at different periods in their life with similar complaints. Subsequent research conducted on community and clinical samples pointed to a possible correlation between perimenopausal depression and a history of premenstrual dysphoric disorder (PDD) or premenstrual syndrome (PMS).

Recent studies, most investigating depressive symptoms rather than a full-blown depressive syndrome, have confirmed this link. Harlow and colleagues2, for example, found a significant correlation between high scores among menopausal women on the Center for Epidemiological Studies Depression Scale (CES-D) and previous experience of PMS. Similarly, using the 20-Selfreporting Questionnaire (SRQ), Novaes and colleagues3 found an association between a high rate of depression in the perimenopausal period and a history of PMS. Furthermore, Freeman and co-workers4 reported that PMS may predict depressed mood, sleep disorders and decreased libido during perimenopause. A similar conclusion was reached by Guthrie and colleagues5 who found a higher prevalence of past PMS among women suffering hot flushes around menopause. Other studies also indicated that depressive symptoms in perimenopause may be associated with a history of postpartum depression (PPD)6, and that PMS may predict PPD (Bloch, personal communication).

The above-mentioned findings suggest that these phenomena may share a common biological etiology, perhaps linked to a decrease or fluctuation in the levels of estrogen and progesterone. In other words, the symptoms of distress may be related either to the absolute changes or to the rate of changes in hormone levels, or to their indirect effect on the neuroendocrine and circadian systems.

Support for this etiological hypothesis can be found in studies such as that of Bjorn and colleagues7 who examined the reaction of postmenopausal women exposed to medroxyprogesterone; those who had previously suffered from PMS reacted with a more significant mood improvement than those who had not. Bloch and colleagues8 similarly demonstrated a difference in the hormonal reaction of euthymic women to steroid manipulation: those who had PPD showed more signs of depression than those who did not.

Findings of this sort led to the Hypoestrogenism continuum theory9 which posits a connection between different phenomena in the woman’s reproductive cycle: anxious/depressive symptoms in the premenstrual, postpartum, and perimenopausal periods, and relative well-being during pregnancy (due to higher levels of estrogens). More recently, Studd and Panay”‘ have published a critical review about what they call ‘the triad of hormone-responsive mood disorders’.

Depressive symptoms during menopause and PMS or PPD may be connected to more than only hormonal fluctuations, however. In a previous study11, the current authors identified specific personality characteristics that were shared by women attending menopause clinics who were scoring high on a menopause symptom scale, regardless of their actual menopausal status (pre-, peri- or postmenopausal). This raises the possibility that a psychological vulnerability, such as difficulty in coping with transitional periods and changes, may act on a biologically vulnerable personality structure in a form of ‘kindling’. The present study therefore relates to a spectrum of hormonal transitions in the woman’s reproductive cycle in an attempt to discover whether there is indeed an association not only between PMS and depressive feelings at menopause, but also between these symptoms and PPD, a sense of well-being during pregnancy, and menstrual migraine.

METHODS

Sampling and procedures

The sample consisted of 113 women who had been assessed periodically at a menopause clinic. Questionnaires were completed by women admitted consecutively from February to May 2004. Only three (3%) did not consent to participate and fill the questionnaire. Instructions were given by the treating physician, who also indicated the woman’s menopausal status according to her medical history and hormonal profile, and whether or not she was taking hormone replacement therapy (HRT).

The average age of the participants was 52 years (standard deviation (SD) +4 years). Fiftyseven were currently taking HRT, and 15 reported a history of antidepressant treatment. In terms of menopausal status, 76 (69%) were postmenopausal (no bleeds for at least 12 months, estradiol level < 100 pmol/1, follicle stimulating hormone (FSH) level >40 lU/ml), and 34 (31%) were premenopausal, with 14 women in this group being defined as perimenopausal in view of a history of irregular menstruation and a rise in FSH level.

Instruments

The questionnaire consisted of five questions, with responses marked on the visual analogue scale. The questions related to the woman’s mood during the month prior to testing and at three points in the reproductive cycle: the premenstrual period, pregnancy, and the months following delivery. The fifth question asked about her general health status in the preceding month. The participants were also asked about headaches during menstruation and the use of antidepressant medications.

The visual analogue scale (VAS) is a measure instrument for rating subjective perception that is believed to range across a continuum of values and cannot be directly measured. It consists of a horizontal line (100 mm in length), anchored by words descriptors at each end (O = not at all, 10 = maximum). The VAS score is determined by measuring the length in millimeters from the left hand of the line to the point that the patient marks12.

Statistics

The statistical analysis was conducted by a SPSS 11 Software. t Tests were performed on the nonparametric data, the averages of the VAS scores were subjected to one-way ANOVA tests, and correlations were calculated using the Pearson correlation test.

RESULTS

One-way ANOVA yielded no statistically significant difference among post-, peri- and premenopausal women in respect to mood parameters. However, a significant correlation was found between mood in the premenstrual period and mood 1 month prior to testing (R = 0.364, p < 0.001), and between mood in the premenstrual period and mood during pregnancy (R =0.340, p<0.001) and after delivery (R = 0.340, p < 0.001 ).

Table 1 Mood score during the last month and at three time periods pertinent to the reproductive cycle

t Tests yielded a significant difference between women who had taken antidepressants and those who had not in respect to mood in the premenstrual period (p < 0.028) and during pregnancy (p < 0.027), but not in the postpartum or menopausal periods (Table 1).

Significant differences were also found between women taking HRT and those not receiving such treatment on current mood (p < 0.023) and subjective health (p < 0.008) (Table 1). In addition, a significant association was found between headaches during menstruation (reported by 41% of the women) and mood during the premenstrual period (p < 0.001). No correlation was found between age and mood (Table 1).

In an effort to obtain further confirmation of the results, the sample was divided into two groups according to VAS score for the preceding month: high (above 60; n = 48) and low (below 40; n = 49). A significant statistical difference was found between the groups for the premenstrual period mood (p < 0.001), but not for mood during pregnancy or in the postpartum period (Table 2).

DISCUSSION

The major findings of this research point at a significant correlation between depressed mood around menopause and depressed mood during the premenstrual period. No support was found for the concept of the Hypoes\trogenism continuum9 which assumes that depressed menopausal women also suffered previously from PMS and emotional difficulties in the postpartum period, but enjoyed mental well-being during pregnancy. The lack of association between depression during menopause and emotional difficulties after childbirth, along with a correlation between menopausal depression and PMS, might be attributed to the fact that menopausal depression and PMS are both part of one continuum, while postpartum depression probably belongs to a different continuum, that of affective diseases13. This statement applies primarily to the symptomatic aspects, yet not excluding a common etiology also for postnatal depression, as suggested by Studd and Panay10.

Table 2 Group I (‘high’ (>60)) vs. Group II (‘low’ (<40)) current mood scores in relation to mood in the premenstrual period, during pregnancy and after delivery

The lack of correlation between mood reported around menopause, on the one hand, and age, menopausal status, or use of HRT on the other hand, suggests that there is a phenotype of women who have emotional difficulties or are more biologically vulnerable at transition periods in the reproductive cycle. This notion focuses on the characteristics of the menopausal woman, rather than on the cessation of menstruation and its physiological consequences.

Certain limitations of the study should be considered. First, we preferred not to use an accepted psychiatric instrument to diagnose and measure emotional distress during hormonal changes in women, even if it may downgrade the validity of our conclusions. We believe that standard tools do not measure the full range of distress, and tend to detect only clinical syndromes associated with affective disorders. Furthermore, standard tools overlook the possibility of a wide variety of depressive distress afflicting women during different phases of the reproductive cycle14. Consequently, they may impede, or even ignore, any possible connection between these entities. This may be analogous to the high prevalence of PMS (diagnosed by less strict criteria) found in the female population, while at the same time the prevalence of PDD (relying on criteria used for affective disorders) in the same population is less than 10%15.

For the purposes of this preliminary research, we therefore chose to employ VAS to detect distress in general before trying to define it in conventional psychiatric terms.

As discussed above, there still remains a need to develop specific tools for assessing psychological symptoms in the aforementioned nosological groups (mood disorders in menopause or in the premenstrual period).

Another methodological question relates to the reliability of rating mental distress as reported retrospectively. It might be argued that a woman who feels depressed and pessimistic about her life in the present may relate to her past in the same manner, so that current mood will distort reports of mood in other periods. However, several longitudinal studies on the reliability of PMS reports3,16,17 have compared the validity of recall after a few weeks and a few years, and found retrospective PMS reporting to be consistent and reliable. Studd and colleagues, however, found that current mood affects the perception of retrospective data in respect to PMS10, which may have a potential impact on the recall of the severity of the previous depression. In our study, although a correlation between the report on the current period and retrospective reporting of all other periods was expected, women were shown to discriminate between the different periods. Those currently depressed did not necessarily report depression in the postpartum period, but did report premenstrual period depression, while women who did not report current depression mentioned symptoms of depression during the postpartum and premenstrual periods. Similarly, the reported association found in the present study between menstrual migraine and mood during the premenstrual period, although not with any other periods in the reproductive cycle, is further indication of the validity of retrospective report. In our opinion, it is important that these methodological considerations be taken into account in future explorations of a possible correlation between psychological distress around menopause and other psychological phenomena in the various phases of the woman’s reproductive cycle.

This study demonstrates the importance of a more thorough comparison of women scoring high and low on mood, both in the premenstrual period and around menopause. In view of our findings, an attempt should be made to focus on differences in personality features and coping mechanisms as well as on hormonal and other biological parameters.

Conflict of interest Nil.

Source of funding Nil.

References

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D. Becker, A. Orr, A. Weizman*, M. Kotler and A. Pines[dagger]

Ness Ziona-Beer Ya’acov Mental Health Center, * Research Unit, “Geha” Mental Health Center,

[dagger] Internal Medicine Department T, Ichilov Medical Center, Sackler School of Medicine,

Tel Aviv University, Israel

Correspondence: Dr D. Becken 39b Burlae Street, Tel Aviv 69364, Israel

ORIGINAL ARTICLE

2007 International Menopause Society

DOI: 10.1080/13697130601174374

Received 04-06-06

Revised 22-10-06

Accepted 24-10-06

Copyright Taylor & Francis Ltd. Feb 2007

(c) 2007 Climacteric. Provided by ProQuest Information and Learning. All rights Reserved.