更年期抑郁的治疗经验.ppt

Menopause and DepressionExperience in Treatment,George Linn,MD&PhDBeijing 2012,Objectives,Menopause associated psychological changes and symptoms Pathophysiology in Menopause Depression Alternative Treatment options for bothersome symptoms(Medications)Medication for the women who is Contraindicated for Hormone,Depression in Menopause,Trend of Suicide in a womans LifeTwo peak in all life of womenAdolescence and Menopause Menopause symptom related psychotic disease(Depression)Metabolism,Volume 54,Issue 5,Supplement,May 2005,Pages 4952,Estrogen with Serotonin,1.Inhibit the Monoamine Oxidase(MAO)function2.Moderate the serotonin(alpha 1)receptor effect Darlene Deechera,From menarche to menopause:Exploring the underlying biology of depression in women experiencing hormonal changes,Psychoneuroendocrinology,Volume 33,Issue 1,January 2008,Pages 317,Serotonin in Menopause,Serotonin decrease it amountSerotonin decrease it effect,Estrogen and Depression,Premenstrual Dysphoric Disorder(PMDD)Post Partum DepressionPostmenopause Depression,Six Women and Their Nightmares,Case#1,35 yo G1 P0 female presents with c/o hot flashes and amenorrhea for 12 months.She doesnt know why this is happening,her sex are worsening.Daily work is bothered.Suicide intention and conflict with her husband occurred.She wants your help.,Case#1 DDx,Premature MenopausePituitary TumorsOvarian FailureCerebellum AtrophyIatrogenic Effect,Case#1 Test,LH,FSH,E2 and TestosteroneSono Examination Brain Computer Tomography,Case#1 Treatment,Hormone(E+P)(Angeliq)Hot Flush PersistentSSRI(Selective Serotonin Reuptake Inhibitors)Clonidine,Case#2,45 yo G2 P2 female presents with c/o hot flashes and irregular menses(q 3-5 mos)for the past 9 months.Body weight gained in recent.Her mood and behavior change.Family Abuse in recent21 yo daughter refused to live with her.DDxTests,Case#2 DDx,Schizophrenia Transitional Menopause,Case#2 Test,FSH,E2 and TestosteronePsychological Consultation,Case#2 Treatment,SNRI for her schizophrenia Hormone Replacement,Case#3,65 yo WF presents to start HRT.She heard it would help protect her heart,make her feel younger and help her memory.She went through menopause 10 years ago and has not had any problems except an recurrent depression.She is 54”,108 lbs.By the way,she had a wrist fx 2 yrs ago takes her evista faithfully.,Case#3 Treatment,Prozac or not?Tricyclic antidepresents?,Case#4,49 yo WF presence b/c she cant stand her hot flashes anymore.She cant sleep very well b/c she wakes up 3 times a night drenched with sweat.She is an executive at First National Bank.She has a history of breast cancer 2 years ago.“Please Dr.Linn,I need some hormones or something.”,Case#4 Treatment,Benzodiazepine BarbiturateHormone ReplacementTomoxifen?,Case#5,55 yo BF returns to discuss stopping her HRT.She has been taking it for 5 years now with good relief of her vasomotor and sexs.After discontinuing her HRT,she was involved with slight depression and chronic pain.,Case#6,53 yo breat cancer woman stage 1 began continuous tomoxifen for 4 years.She is now having some vaginal spotting.After using the aromatase inhibit,severe insomnia and disorder bother her.,Case#6 Treatment,Hystectomy Regain TomoxifenStop Aromatase InhibitorSSRI or SNRI,HRT or SSRI(1),Postmenopausal women with depression respond better to selective serotonin reuptake inhibitors(SSRIs)if they are also taking hormonal therapy(HT),Italian researchers suggest.E Hall,BN Frey,CN Soares-Drugs,2011-,HRT&SSRI(2),Random Control,No response to SSRIs in 170 postmenopausal women with a depressive episode,as defined by the DSM-IV criteria,47 of whom were on HT.E Hall,BN Frey,CN Soares-Drugs,2011-,HRT&SSRI(3),Among patients who were not also taking HT,the response rate to SSRIs was only 63.2%,compared with 83.7%among patients taking HT.Furthermore,the rates of remission were similar for the two groups,at 52.63%and 79.07%,respectively.SR Davis,F Jane-Expert Opinion on Pharmacotherapy,2010,HRT&SSRI(4),They also found that levels of luteinizing hormone(LH)may provide a means of predicting which women are likely to respond,SSRI&Placebo,SSRI are also superior to Placebo Clinical improvement at week 8(decrease of 50 percent or more from baseline in hot flash frequency)was significantly greater in the escitalopram group than in the placebo group(55 percent vs.36 percent).Menopause:September/October 2006-Volume 13-Issue 5-pp 780-786,SNRIserotonin and norepinephrine reuptake inhibitors,Off-Label Use in Postmenopause Syndrome such as insomnia,anxiety and depression The case of menopausal symptoms,nerve pain,hot flashes and emotional stress are relieved.David F.Archer,Volume 200,Issue 3,March 2009,Pages 238.e1238.e10,Menopause Terminology:STRAW*Staging System,*STRAW=Stages of Reproductive Aging Workshop.Stages most likely to be characterized by vasomotor symptoms.Soules MR,et al.Menopause.2001;8:402-7.,Stages:,-2,-1,+1,+2,Terminology:,Duration of Stage:,Menstrual Cycles:,Menopausal Transition,Postmenopause,Early,Early,Late,Late,Perimenopause,Variable,Variable cycle length(7 daysdifferent from normal),2 skippedcycles and aninterval of amenorrhea(60 days),4 yrs,Untildemise,None,0,Final Menstrual Period,1 yr,Amen.12 mos.,a,b,Vasomotor symptoms:Why dont we treat every women with hormones?,Menopausal Complaints:Treatments,Hormones vs non-hormones vs herbalsWhat kind of herbal drug is effective?Efficacy?,Hormones Contraindicated,Breast CAEndometrial CAUndiagnosed vaginal bleedingCHDVenous thrombosisStrokePregnancyWhat is not here,that is a CI on OCPs?,Specific Geriatric Issues,Other assessments to be made.,Cognitive Function,Normal declineDementiaAlzheimersVascularOthersDepressionMedicationsEtOHMMSE,Sensory,VisualAuditoryBalance,Polypharmacy,Medication ListDrug-drug interactionsAltered pharmacokinetics,pharmacodynamicsHerbalsOTC,