Updated 15 July 2014

Worse psychological, mental health in women on HRT

Women who use hormone replacement therapy may have worse psychological well-being and mental health than similar women not using hormone therapy.


Women who use hormone replacement therapy may have worse psychological well-being and mental health than similar women not using hormone therapy (HT), researchers from Finland suggest.

"At first we were surprised," said Dr Elena Toffol from National Institute for Health and Welfare, Helsinki, Finland. "In fact, the results are opposite to the majority of the findings reported in the literature so far, and to the general knowledge that administration of HT might be of help for perimenopausal women."

"However, as stated in our article, this was a cross-sectional study, and our findings do not mean that taking HT increases the risk of depression, anxiety or worse psychological well-being," Dr Toffol said. "When we looked at the results more in detail, we thought that they might rather be expression of the high prevalence of depression/depressiveness in connection with the menopause, and this is not surprising."

Dr Toffol and colleagues used data from two national cross-sectional surveys, Health 2000 and The National FINRISK Survey, to look for associations between current use of HT and mental health and psychological well-being among nearly 6 000 perimenopausal and postmenopausal women.

How the research was done

In the 1 433-woman Health 2000 group, 15.1% met full diagnostic criteria for at least one psychiatric diagnosis within the 12 months before the interview. In the 5 354-person FINRISK cohort, 15.7% reported use of psychotropic drugs or diagnosis with a psychiatric disorder in the previous year.

Just over a quarter of the women in both groups (28.4% in Health 2 000, 28.3% in FINRISK) reported using HT in the month before the survey, the authors reported.

Current hormone use was significantly associated with current psychiatric diagnoses, self-reported low mood in the previous year, a recent diagnosis of depression, and current diagnoses of major depressive disorder and anxiety disorder.

In various statistical models, current hormone use was significantly associated with the presence of a psychiatric diagnosis or use of psychotropic drugs in the past 12 months, self-reported diagnosis of depression, and formal diagnosis of major depressive disorder and anxiety, as well as severity of nervousness, frightening thoughts, nightmares, feelings of depression, and headache.

'We need to further research'

The results were consistent across different preparations of HT (oestrogen-only vs combined preparations; oral vs parenteral oestrogens; and combined cyclic vs combined continuous preparations).

"Transition to menopause is a sensitive phase in a woman's life, and a high proportion of women do suffer from impaired psychological well-being, depressive and anxiety symptoms and disorders," Dr Toffol said. "It is important for physicians to assess this dimension when seeing women of menopausal age. It is important to keep in mind that these symptoms and disorders might not be just as a 'normal correlate' of menopause."

"Administration of HT during menopause is known to help reduce climacteric (vasomotor and other) symptoms, and this may also contribute to ameliorating the woman's mood and well-being," Dr Toffol said. "We cannot rule out that HT themselves has an antidepressant effect in some women. However, some other women, perhaps those with more severe depression/anxiety or certain personality traits, do certainly need a psychiatric consultation and a more specific psychiatric/psychotherapeutic help in this phase of their lives."

"Once more, we need to further research the possible beneficial and side effects of hormone therapy, in particular in respect to its different composition and routes of administration," Dr Toffol concluded.

Dr Mary F Morrison, professor of Psychiatry and Internal Medicine at Temple University, Philadelphia, Pennsylvania, has also studied the impact of estradiol on depression. She told Reuters Health by email, "Hormones and mood in women and ageing is a complicated area. There are many hormonal changes happening as women age and oestrogen deficiency and withdrawal with ageing and then repletion does not make a simple story in a large population (with lots of comorbidities and genetic variations)."

Dr Claudio N Soares from McMaster University, Hamilton, Ontario, Canada, who has done similar research, said, the potential association needs to be taken with extreme caution as the limitations of this retrospective study are many: (It was) not a randomised, prospective study. Those who chose to use HT were more likely to be symptomatic (physical, psychological), so there is a reverse causal order here. The studies that have shown improvement of mood or depression in midlife women were done with higher doses, mostly delivered transdermally, in perimenopausal women - not the same population studied here."

Dr Soares suggested, "A proper screening for psychological symptoms (depression, anxiety) in women seeking HT could help clarify the patient's and doctors' expectations of hormone use - what are the symptoms that are more bothersome and what can be done to improve them (in addition to or instead of HT)."

Dr Marie-Laure Ancelin, who specialises in neuropsychiatric epidemiological and clinical research at Hopital La Colombiere, Montpellier, France. Dr Ancelin said, "Short-term HRT use is nevertheless still the best treatment for menopausal symptoms such as hot flashes and night sweats. It remains the treatment of choice for the more than 25 million women worldwide who pass through the menopause each year, of which approximately 80% experience menopausal symptoms for years."

"The findings should not be interpreted to mean that women should not take HT in the first place," Dr Ancelin concluded. "A large number of international top obstetrics-gynaecology and menopause societies support the use of HT in symptomatic women. Practitioners may need to monitor women who decide to initiate and also those who discontinue HT more closely, and offer alternatives to treat depression if it emerges."

(Reuters Health, January 2013)

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