Panel issues guidelines for perimenopausal depression

September 11, 2018

The first-ever guidelines for perimenopausal depression have been developed by The North American Menopause Society and the National Network on Depression Centers Women and Mood Disorders Task Group. PLUS: Are female sterilization rates and cognitive disability linked? ALSO: How does delivery mode in twin pregnancies impact maternal morbidity rates?

The first-ever guidelines for perimenopausal depression have been developed by The North American Menopause Society and the National Network on Depression Centers Women and Mood Disorders Task Group. Co-published in The Journal of Women’s Health and Menopause: The Journal of the North American Menopause Society, the document represents the work of an 11-member expert panel of clinicians and scientists.

The conclusions in the document are based on a systematic review of literature published in English between 1980 and 2015. The guidelines address five topics relevant to symptoms of depression and depressive disorders in perimenopause: 1. epidemiology; 2. clinical presentation; 3. therapeutic effects of antidepressants; 4. effects of hormone therapy (HT); and 5. efficacy of other treatments such as psychotherapy, exercise, and natural health products.

According to the panel’s report, a review of the literature on the relationship between perimenopause stage and depressive symptoms showed that in cross-sectional studies, “45% to 68% of perimenopausal women report elevated depressive symptoms compared with 28% to 31% of premenopausal women.” Six of 11 longitudinal studies reviewed suggested an increased risk of depressive symptoms during the transition. Regarding major depressive episodes, the panel noted that they tend to occur in midlife women with a history of depression.

Risk factors for depressive symptoms in menopause cited in the guidelines include prior major depressive disorder, sociodemographic and psychosocial factors, menopause and anxiety symptoms, and reproductive-related disturbance. The panel found that hot flashes, night sweats, sleep and sexual disturbances, weight/energy changes, and cognitive changes overlap with depression in perimenopause. “Empty nest” and “revolving door” syndromes, they said, have “little enduring effect” on mood.

To evaluate mood disorders in perimenopausal women, the guidelines recommend that clinicians use a validated screening measure such as the PHQ-9, the Menopause Rating Scale, the Menopause-Specific Quality-of-Life Scale, the Greene Climacteric Scale or the Utian Quality-of-Life Scale. 

Antidepressants, cognitive-behavioral therapy and other psychotherapies are recommended as first-line options. Regarding antidepressants, the panel noted that “only desvenlafaxine has been studied and proven efficacious in large randomized placebo-controlled trials of well-defined peri- and postmenopausal depressed women.” Hormonal contraceptives, the guidelines said, have shown some benefits for mood regulation and while estrogen-based therapies may augment clinical response to antidepressants, “their use should be considered with caution.” Looking at HT, the panel characterized the data in depression as “sparse and inconclusive.”   

Are female sterilization rates and cognitive disability linked?

Female sterilization is one of the most common forms of contraception but wide variation exists in the demographics of women undergoing such procedures. In a study in Obstetrics & Gynecologyresearchers looked at whether having cognitive disabilities affected the likelihood of female sterilization.

Using data from the 2011-2015 National Survey of Family Growth, the authors identified 9,971 women aged 15 to 44. The primary independent measure was self-reported disability, which was measured through a series of six questions developed by the US Census Bureau for the American Community Survey about difficulties participants have, including problems with hearing, sight, processing information, mobility, and dexterity. Based on the participants’ answers, the authors divided the participants into three mutually exclusive groups: no disability, cognitive disability, and noncognitive disabilities. The authors then looked at three outcomes of interest: sterilization status, age at sterilization, and whether the woman had a hysterectomy. 

The authors found that the three groups of women varied significantly in several characteristics. Age at sterilization differed greatly: Women with cognitive disabilities were the youngest (regression adjusted age = 27.3 years, 95% CI 27.0-27.6) followed by women with noncognitive disabilities (28.3 years, 95% CI 27.9-28.8), and women without any disability (29.8 years, 95% CI 29.5-30.0). Women with disabilities also had higher sterilization rates than women without any disability (24.7% among women with noncognitive disabilities, 22.1% cognitive disabilities, 14.8% no disability, P< .05). 

After adjusting for all model covariates, odds of sterilization were approximately 1.5 times higher among females with cognitive disabilities compared with those without disabilities (adjusted OR 1.54, 95% CI 1.19-1.98, < .01). The women with cognitive disabilities also had 2.6 times higher odds of hysterectomy than did women without disabilities (adjusted OR 2.64, 95% CI 1.43-4.56, < .001).

The authors noted a few limitations of their study. Participants self-reported any disabilities and the data did not include institutionalized individuals who may have more severe disabilities and different rates of sterilization. The National Survey of Family Growth data do not include the reasons why females underwent sterilization or hysterectomy. 

The researchers believe that their results indicate that nonmedical, non-sociodemographic links between sterilization and cognitive disability may exist. They intimated that historic remnants of systematic oppression to control and limit the reductive autonomy of marginalized individuals, including the disabled, may be one possible tie. The authors urged more research on the topic to explore what is driving the disability-related differences in female sterilization. 

How does delivery mode in twin pregnancies impact maternal morbidity rates?

As twin pregnancies have become increasingly frequent, the issues of patient safety and planned delivery mode have become more important. In a study in Obstetrics & Gynecology, researchers looked at the association between planned mode of delivery and severe acute maternal morbidity in women with twin pregnancies.

The secondary analysis used data from the JUmeaux MODe d’Accouchement, the French national, prospective-population study of twin deliveries that took place between February 10, 2014 and March 1, 2015. From this study, the authors excluded women whose planned mode of delivery was unknown, those who delivered before 24 weeks’ gestation, women who were recommended a specific mode of delivery by their obstetrician, or who developed complications during pregnancy. The final cohort for the analysis included 8,124 women with twin pregnancies at 24 weeks’ gestation or greater with two live fetuses. Participants were stratified by maternal age at delivery (younger than 30, 30-34 years, and 35 years or older). The primary outcome of the analysis was a composite of intrapartum or postpartum severe acute maternal morbidity. 

Of the women, 3,062 (37.7%) had planned cesarean deliveries and 5,062 (62.3%) had planned vaginal deliveries; among the latter group, 4,015 (79.3%) delivered both twins vaginally. The authors found no significant overall association between the planned mode of delivery and severe acute maternal morbidity (6.1% in the planned cesarean delivery group and 5.4% in the planned vaginal delivery group; adjusted relative risk [ARR] 1.00, 95% CI 0.81-1.24). However, the authors found a significantly higher risk of maternal morbidity in the women aged 35 year who had planned cesarean rather than vaginal deliveries (7.8% vs 4.6%; ARR 1.44, 95% CI 1.02-2.06). 

A few limitations of the study were identified. These were primarily based on the observational design, because presence of possible unmeasured confounding cannot be ruled out. The JUmeaux MODe d’Accouchement study also did not include pregnancies in hospitals that performed fewer than 15000 annual deliveries, which limits the generalizability to smaller hospitals. However, the authors believe their findings should promote conversations between ob/gyns and their older patients with twin pregnancies about delivery plans, given the higher risk of severe maternal morbidity in cesarean deliveries in this group.