Menopause Matters Forum
Menopause Discussion => All things menopause => Topic started by: GypsyRoseLee on May 15, 2016, 09:39:31 AM
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I know that NICE now don't advocate prescribing ADs as first line treatment for peri menopause symptoms.
But, does anyone know if this is still the case, even if a woman doesn't exhibit hardly ANY physical symptoms of peri menopause?
What I mean is, if you are in your 40s and suddenly start suffering with anxiety and depression (like me) but still have very regular periods, no hot flushes, no VA etc does NICE still advocate HRT rather than ADs?
I just think that if you do start to suffer with anxiety and depression in your 40s, then why can't it just be treated the 'regular' way with ADs?
Or is (probably) hormonal anxiety/depression somehow different to regular anxiety/depression and won't respond to regular ADs?
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My GP is of the mind that depression and anxiety need to be treated with ADs regardless of whether hormones are causing it. He says trying to treat it with HRT is too vague and random because of my own hormonal rises and falls.
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Hi GRL,
I was wondering how you've been getting on.
I'm not sure what the guidelines are but from personal experience with my GP, consultants both NHS & private all tried to put me on SSRI meds.
I suffer with panic disorder as a result of PTSD so have had a whole host of anti depressants in the past and not one helped with my anxiety. All the SSRI/SNRI meds gave me intolerable gastric side effects, the worse was venlafaxine which made me so ill I went down to 6 1/2 stone. I had mirtazipine which made me fat! The only one I liked was Trazodone as it gave me a good nights sleep but unfortunately did nothing for my anxiety. The only thing that stops my panic is diazepam but that brings addiction and tolerance issues.
Are you having a problem getting anti depressants prescribed and are they steering you in the direction of HRT?
The way I see it is if it's peri causing anxiety then it's down to hormone imbalance so I think it's the hormone imbalance that should be addressed. I think root causes should be treated not symptoms.
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My GP is of the mind that depression and anxiety need to be treated with ADs regardless of whether hormones are causing it. He says trying to treat it with HRT is too vague and random because of my own hormonal rises and falls.
Sorry our posts crossed!
I don't agree with your GP. Treat the cause first is my opinion.
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I personally think that hrt is miraculous with sorting out the physical issues i.e. hot flushes,aches etc but not very good at sorting out the mood swings ,anxiety,palps,etc especially in peri. But that's what I have experienced.
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I personally think that hrt is miraculous with sorting out the physical issues i.e. hot flushes,aches etc but not very good at sorting out the mood swings ,anxiety,palps,etc especially in peri. But that's what I have experienced.
The oestrogen part helped me a great deal with the panic attacks as my physical symptoms such as hyperventilating improved significantly but I just couldn't tolerate the progesterone and this caused the anxiety to worsen.
I wish they would invent a drug that works like diazepam that isn't addictive and cause tolerance.
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I started suffering with anxiety, panic attacks, low mood, bouts of crying over trivial things when in my 40s & was prescribed AD (Citalopram) and found the symptoms went away completely. My doctor said that even if the symptoms were due to menopause then the treatment with ADs should sort them out & she was right in my case.
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The things is that AD's are given for a long or short a time as the women and her doctor think right. This might only be for a few months.
HRT, on the other hand is long term, usually years. That does not appeal to me at all.
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Stella, your GP sounds like mine. He doesn't think it matters what is chemically causing anxiety or depression. You just treat it the same as any other sort and use ADs.
He pointed out that PND is very successfully treated with ADs, and that's definitely hormonal.
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GRL, I was wondering how you have been getting on. I am sorry to say that I have no personal experience of ADs but from various things I have heard over the years and also my partner's mother's experience, it would appear that hormones and depression/anxiety are very closely linked and very often women need both ADs and HRT.
I've tried to pump my partner for as much information about his mother as I can but being a bloke, he's not that switched on to this kind of thing. She had PMS, PND and depression/anxiety all her life but it much got much worse once peri menopausal. We are not sure but we think she tried to take her own life on at least one occasion. She was on HRT and Prozac (after telling the doctor she was suicidal) and then she finally had the mother of all breakdowns when she was 50. She was admitted to A&E and ended up in a psych ward and they really didn't know what to do with her. She had the most horrendous, enormous ovarian cysts and they thought she had encephalitis at one point and in my opinion, she should have had a full hysterectomy at that point. To cut a very long story short, she struggled on for many years with what is now a very outdated form of HRT and ADs and spent most of her time in bed.
She finally had a full hysterectomy 10 years ago following a prolapse and yet more ovarian cysts and what a difference. She is still on HRT (oestrogen only I believe) and apparently wishes she had had the hysterectomy years ago. I only get this second hand because she is not comfortable discussing it with me.
My personal view is that you need to get a proper diagnosis with extensive blood tests, get on the right AD and then start to filter in the hormones as and when your own levels drop. You will need both if you suffer from PMS and anxiety because (sorry to be doom and gloom) women with PMS rarely do well with the menopause and need hormones. This has to be worth a try.
If all else fails (sorry, but I am going to be very blunt here) and if it was me, I really would be considering a full hysterectomy (the whole lot including ovaries) to spare myself the rollercoaster of hormone spikes and to get an even keel. Once you rid yourself of your own hormones (the progesterone being the worst offender and a hormone you need to rid yourself of) you can then pump in the ones you need and avoid the spikes that are causing all these problems. You may well need ADs too but how can you be any worse off?
I know that Professor Studd thinks that a hysterectomy should not be viewed negatively and only as a last resort and I agree with him.
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Hello
Not sure of the answer but I started with anxiety and depression in my 40's with few physical symptoms and irregular periods and I was treated with AD's.
How are you getting on?
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I was wondering how you were as well :)
This isn't NICE related, but was produced by NAPS/Nick Panay - there's reference to anti depressants towards the end. This is with regard to PMS, rather than peri-menopause, but I think it's still very relevant (especially given your lack of physical symptoms):
http://www.pms.org.uk/assets/files/guidelinesfinal60210.pdf
Selective serotonin reuptake inhibitors (SSRIs)
There is increasing evidence that serotonin may be important in the causality of PMS. A number of SSRIs
have been used to treat severe PMS/PMDD. There are also data suggesting improvement of physical symptoms
with SSRIs though this is probably due to the improved perception rather than genuine reduction in
symptom severity. A meta-analysis of all available randomised controlled trials involving SSRIs used in
premenstrual syndrome confirmed superior efficacy compared with placebo.
The Commission on Human Medicines endorses the view that SSRIs are effective medicines in the treatment
of depression and anxiety conditions and that the balance of risks and benefits in adults remains positive
in their licensed indications. Prescribing should be restricted to those health professionals who have a
particular expertise in this area. Randomised studies have now shown that half-cycle SSRI treatment is as
efficacious as continuous administration. The results of a recent trial showed that the total premenstrual
scores were lower in the luteal-phase dosing group in each of the three treatment months but the differences
were not statistically significant from full-cycle dosing group. Further analysis of each of the symptoms
showed significant differences (P < 0.05) in favour of luteal-phase dosing for mood swings, nervous tension,
feeling out of control and confusion.
The importance of this is that PMS sufferers are less likely to develop dependence on this regimen, benefit
is immediate and women are more likely to accept the treatment as it can be regarded as being different
from the regimens used for psychiatric disorders. In the author‟s opinion, the optimum regimens for PMS
are half-cycle citalopram or escitalopram, 20mg per day from day 15 to day 28 of the cycle. This regimen
appears to be effective even in women whose previous SSRI treatment has failed. Severe PMS also improves
significantly with either luteal-phase or symptom-onset dosing of escitalopram with good tolerability.
Recommendation A:
In view of their proven efficacy and safety in adults, SSRIs should be considered one of the first line
pharmaceutical management options in severe PMS.
I can see the logic that, regardless of the cause, you need to treat the symptoms to get some relief (especially short term) in which case ADs - if you can find the right one to suit your needs - can really help. This was certainly the case for me (tried a few until I got the right one). However, in your case, it does seem that the cause is still hormonal, despite your lack of physical symptoms, and that ultimately, it's your hormones that need to be tamed.
Rememberer how well you originally responded to the pill: "But just to say, still feeling really good on the BCP. This has been one of the best weekends I have spent in years. I am going for hours and hours now actually forgetting that I have been so ill with my hormones these last 2 years. There was a time where it was all I could really think about because it loomed over everything and anything. My skin is really good too, so soft and smooth. No libido though. But I am hoping this might come back a bit in time?
I took my last tablet last night and have decided to give myself just a 4 day break. Hopefully enough to give me a bleed and enough to stop a build up of too much progesterone? But not long enough to give me too much of a withdrawal dip from the oestrogen either? It's going to be a bit of trial and error. I have decided not to update my diary every day from now on. I hope what I have posted has been useful.".
- If it was solely a psychological problem, you wouldn't have responded so positively to the pill at first, surely?
The reason I am saying this is maybe you need to consider a two pronged approach. Treat the psychological symptoms with ADs, then where you're feeling ready, try a hormonal route as well as the AD. I needed the AD to give me the confidence to stick with a hormonal treatment longer term, if that makes sense? I would never have persevered with different pills if I hadnt had the initial boost from ADs.
Reading this through, I am not sure I am making much sense .... but hope it just may be helpful!
B xx
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That's really interesting Briony. I can't imagine stopping and starting SSRI's like that as they can give unpleasant start up effects that can take 4-6 weeks to settle down and you're supposed to taper the withdrawal over several months.
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Lisa, I didnt explain very clearly - sorry. I didnt start and stop just like that. I was put on them originally for pain relief, Amitriptyline and then Cymbalta with a few months between. Coming off Cymbalta (due to realising my pain was caused by hormones, not nerve damage) was hideous and took a while. Part of the process involved using Prozac as a bridging drug (something to do with half-lives). Prozac seemed to really help with PMS. It wasnt until later that I realised it can be prescribed for PMS/PMDD so I stuck on it for much longer at a very low dose.
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Lisa, I didnt explain very clearly - sorry. I didnt start and stop just like that. I was put on them originally for pain relief, Amitriptyline and then Cymbalta with a few months between. Coming off Cymbalta (due to realising my pain was caused by hormones, not nerve damage) was hideous and took a while. Part of the process involved using Prozac as a bridging drug (something to do with half-lives). Prozac seemed to really help with PMS. It wasnt until later that I realised it can be prescribed for PMS/PMDD so I stuck on it for much longer at a very low dose.
Oh poor you I've had duloxetine/cymbalta before & it's terrible to get off. I felt like I was getting electric shocks into my brain. Well done for getting off it though as its very unpleasant X
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It's hideous isnt it? I am afraid I now get a bit preachy if anyone I know is thinking of taking it - but only because I dont want them to become a member of the "head zapps club"! :o
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It's hideous isnt it? I am afraid I now get a bit preachy if anyone I know is thinking of taking it - but only because I dont want them to become a member of the "head zapps club"! :o
Lol!! 'Head Zapps club' so you know exactly what I meant. Isn't it horrendous? I was worse coming off venlafaxine than the cymbalta.
It scares me when I read people saying that they've been prescribed them, I think should I warn them as I don't want to scare them. The doctors definitely need to explain how hard it is to come of these drugs before prescribing them. I don't think they fully appreciate just how hard it is. Psychiatrists might have a better understanding but I've found GPs to be clueless.
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If you think about serotonin, it's also a hormone like thyroxine, epinephrine (adrenaline) and cortisol. Hormones interact with each other, switching them on and off.
Oestrogen volatility will, hence, have a knock on effect with these hormones and can cause anxiety and depression.
I get the GPs point that as the sex hormones are so up and down during peri that it's hard to control them, so controlling the hormone that chucks out the symptom could be a simpler way.
As Briony says about your symptoms improving briefly with the pill, the cause is likely to be oestrogen surges but if you are struggling to control this with HRT/the pill, then ADs alone might be the way forward until you reach menopause when HRT will hopefully work better - if you choose it.
Don't get too attached to NICE guidelines as, although in the HRT ones published recently it's good for us, they tend to have their own financial agenda.
I could surmise that ADs are more expensive than HRT, but I won't as that would be very cynical of me. ;)
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I know that NICE now don't advocate prescribing ADs as first line treatment for peri menopause symptoms.
But, does anyone know if this is still the case, even if a woman doesn't exhibit hardly ANY physical symptoms of peri menopause?
What I mean is, if you are in your 40s and suddenly start suffering with anxiety and depression (like me) but still have very regular periods, no hot flushes, no VA etc does NICE still advocate HRT rather than ADs?
I just think that if you do start to suffer with anxiety and depression in your 40s, then why can't it just be treated the 'regular' way with ADs?
Or is (probably) hormonal anxiety/depression somehow different to regular anxiety/depression and won't respond to regular ADs?
You have rasied a complex issue GypsyRoseLee! The point is (from memory) NICE defines peri-menopause according to the STRAW criteria based on (for the majority) on changes in cycle length combined with age and physical symptoms of the menopause. They do not refer to the time before peri-menopause ( which many refer to loosely as peri-menopause) - which is mostly the late reproductive stage/phase but when hormonal changes begin but ovulation still occurs and cycles are still regular or shortening. This is the stage when pms becomes much worse for many women due to extremes in hormonal fluctuations which seem to occur (highs and lows of oestrogen, not sure whether progesterone peaks too?) - and this is more difficult to treat from what I gather - and Panay and Studd seem to understand this phase more than many docs.
Standard HRT is most successful for women in the true peri stage when cycles have become lengthened and oestrogen levels have fallen - as I understand. I think the BCP may well work better (for many women) in this earlier phase because it controls the cycle?
Hurdity x
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GypsyRoseLee, I just wanted to say that I've read back on your previous posts over time here as I suspected what you're going through is very much the same as my experience of peri menopause, and it is! I went through almost a carbon copy of what you're experiencing right now. I didn't try HRT though, as I had serious allergies to multiple medications and my GP and Consultant Gynae. didn't want to risk it at the time.
I actually had a TAH when I was 36, and it didn't really affect me much. But just a year ago aged 46 after suffering all of what you describe for 3 years, I had to have surgery of bilateral oopherectomy which then put me into surgical menopause. My symptoms DID change after the surgery - my anxiety was much, much less but now I am faced with a new set of challenges such as depressed mood, hot flushes, severe joint pain, weight gain etc. I have HAD to start HRT as I could hardly walk! This surgery is drastic and I wouldn't advise losing your ovaries unless it is for disease.
I also tried 3 different anti depressants during peri, and for me SSRI'S made the anxiety much worse on start up so that I couldn't continue. If you are able to tolerate beta blockers and/or diazepam, your GP can supplement those to get you through the first few weeks (I was unable to take either - drug allergy and the beta blockers interfering with the action of my epi pen if needed to use it).
You've had a really rough time of it with experimenting with the HRT, haven't you? My personal theory is that for some of us who swing wildly hormonally in peri, HRT can aggravate the times when our estrogen levels spike, causing the anxiety to go completely bonkers. I think if you can coast on anti depressants until you enter menopause proper, you may settle down enough to try HRT again then if you would like to.
It can be trial and error with the SSRI's too. Don't be afraid to tell your GP if one is not suiting you and if you'd like to try another.
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Hi Briony & Lisa789!
I'm a Duloxetine girl! Dreading coming off them but I got myself off Venlafaxine in the past so if I can do that, can do anything.....fingers crossed.
Yesterday I tried a 30mg Duloxetine currently on 20mg and I had totally forgotten how flat and down they make you feel. Yes my mind quitened down a bit but couldn't think of anything and made me tired. The problem with that med is that it isn't slow release. Not sure whether to consider a very slow bead counting method once my HRT is sorted.
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Hi Mis71Mum,
Don't be worrying about coming off them while you still need them. As you said you got off venlafaxine so you'll get off duloxetine if you need to. I found the venlafaxine withdrawal harder than duloxetine.
Sometimes I don't know what the pharmaceutical companies are thinking of. All anti depressants should have the slow release option so you don't get that crash feeling. I found duloxetine was the worse and had to make sure I took it the exact time as my body let me know if I was late taking it.
Good luck and I hope things settle down for you soon xx
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Thank you for all your replies, everyone is so helpful and supportive as always.
If you can remember everything suddenly went really bad for me toward the end of February. I was trying Femoston 2/10, and while fine on the oestrogen only tabs, only 3 days into the combi tabs and my anxiety and low mood was intolerable. So I stopped them and applied a 50mg Estradot patch until I saw Dr Annie 2 weeks later.
But the patch did nothing, and I quickly got worse and worse and my anxiety was through the roof + very dark suicidal thoughts (somehow I knew I would never act on them, but it was still so distressing to have them). I had always assumed I had been at my lowest when I had PND, but this was worse.
Dr Annie's HRT regime did nothing. So after a few weeks I started taking Trazadone. But I felt so desperate I also went to see Prof. Studd. His regime didn't seem to be helping either, and my anxiety seemed worse.
I have now been Trazadone for the last 8 weeks, and it's only these last 10 days that I have started to notice improvements. I also stopped HRT just over a week ago.
I stopped, because looking back over last year when I was on various HRT I still always got lots of days per month when I felt dreadfully low and anxious. And these bad days weren't tied into my withdrawal bleed or taking Utro. I now think it was my own hormonal surges that I was responding to, and that the HRT sometimes helped but also really hindered too.
Like Hurdity points out, because my own periods are still very regular (though lighter and slightly shorter cycle) and I don't have any other physical symptoms, then I may not even yet be truly peri menopausal! In which case taking HRT just might not be appropriate yet, and might actually kill more than cure.
For the time being I am just going to stick with my AD (now that it finally seems to be kicking in) and just keep an eye on how my periods are over the next few months. Early menopause runs very strongly in the women of my family so I am hoping that it shouldn't be too far away for me?
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That's interesting about the trazodone gypsyroselee I'm on my second week of it but not feeling the benefit yet but looks from your experience it could take s few weeks more
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Every night B4 my bleed began I would cry. Buckets. Once the period began that crying would stop. Depression set in at a later date. It became a problem in 1988 and was treated intermittently with ADs until a Psychiatrist who visited at home because my GP was concerned, could see a cycle - and advised taking ADs for Life. Took some accepting, I can tell you!
Peony - what don't you like the idea of: ADs or HRT ………. :-\. I now accept that if a medication is likely to work for me the I'll give it a go ::) - after all, that bus might be along 2-morrow!
I believe that symptoms should be treated. If a lady presents in Surgery crying then depression and any associated anxiety should be treated for 4-6 months, enabling her to see the wood for the trees. By keeping a diary: food, mood, hormones: she can then chart any changes that make her feel worse. That might be meno related.
It really can be Trial and Error which is tiring :-[
:bighug: GRL!
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Oh that's great news GRL, really hope that you continue to see the light at the end of the tunnel.
Very pleased to hear that you are improving and keep posting.
All the best xxx
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Have to be very careful of what I say here for fear of outing myself, but by pure coincidence, I came across something interesting today: a teenaged girl who has crippling anxiety which has got worse over the past few years. Now at a severely worrying (and potentially dangerous) point. She has seen all sorts of counsellors, tried a low dose AD and even been sent to a paediatric psychologist. No one has questioned anything but her mental health. However, recently, following a string of blood tests, it was revealed she actually has a severe hormonal imbalance and that her acute depression and anxiety are caused by this. I had assumed the pill would have been prescribed, but instead the consultant has placed her on an incredibly high dose of AD as he said it will achieve a better result. When I heard about it today, I immediately thought of this thread.
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That's really interesting, Briony! And just goes to show that there is NO understanding out there about how hormone's can cause severe mental health problems. Professor Stuff is about the only one out there who acknowledges this. Yes, I also got tarred with the 'you have an anxiety disorder' thing when I was in peri. Except I didn't, as for the most part my anxiety cleared up after I had my BSO. It was almost instant! I was rather on top of the world for about 3 months after my surgery with no HRT, and then the depression started. No estrogen, don't you know!
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All that work that Dr Kath did in the 1990s for nowt then! :-\
Are you able to send a note to the Consultant concerned?
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I definitely think hormones are the driving force behind my anxiety.
Over the years I've had diagnosises of PTSD, depression, social anxiety and the current one is panic disorder with agoraphobia. I definitely think it's hormones driving my anxiety and causing me to have panic the whole time wondering when the next panic attack is going to strike.
For the short time i was on Evorel patches for the first time in years the anxiety felt numbed. I couldn't tolerate the progesterone tablets I was given so couldn't stay on oestrogen alone. I've since been moved onto continuous BCP so I'm hoping that improves my anxiety.
What us women have to put up with!
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It is so tiring :'(
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For me though, it makes more sense to treat the cause than the symptoms. Then surely you are getting to the root of the problem. But I suppose at that age, the young girl will experience fluctuations.
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Chicken and egg? At her age PMT should have been investigated.
4 me the problems were never discussed, so I was unable to get to the bottom of my panic attacks because no one asked me what was causing them :-[.
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I felt quite shocked/guilty when I found out as I tend to always think 'is it hormones?' (perhaps too much so) when someone has those sorts of issues. I think with her, the anxiety was so extreme that, combined with the lack of obvious physical symptoms (no period pain, no acne etc), I - like my colleagues - only considered a psychiatric cause. It was interesting to hear the person who told me (I wasnt involved directly) say it has now been classified as a 'physical illness' as opposed to psychiatric.
I ummed and ahhed about posting this, but do genuinely think it's an important issue and hope others could be helped. I have kept it as anonymised as possible.
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For me though, it makes more sense to treat the cause than the symptoms. Then surely you are getting to the root of the problem. But I suppose at that age, the young girl will experience fluctuations.
I wholeheartedly agree with this. I was pushed from pillow to post, tried countless anti depressants all which caused gastric symptoms and was prescribed more meds to treat the side effects. At one point I was on 5 different types of mediation for anxiety I believe was caused by hormone imbalance. Medication to supposedly help the anxiety and the other 4 to deal with the side effects of the anti depressants. It's ridiculous.
It seems like the medical world hasn't progressed much when it comes to diagnosing hormone issues and mental health. The only thing they're doing different is not putting us in asylums. The answer still seems to be anti depressants and in extreme cases anti psychotics. This route masks the symptoms and doesn't address the underlying issue.
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Unfortunately as we all know from hearing all the different experiences on here no one hrt/ad fits allsizes ! Its not like finding the exact strain of infection then prescribing the correct anti biotic is it ? :-\
These hormones are far too complex to be treated that simply. I have come to the conclusion that maybe it would be better to see an endocrinologist who specializes in female hormones than seeing a gynecologist.