Depression and Libido
Depression is more common in women than men with the excess beginning
at puberty and being no longer apparent five years after the
menopause. There remains controversy whether this excess is due to
environmental factors or hormonal factors but it is significant that
depression occurs at times of hormonal flux such as adolescence, the
post-natal period, the pre-menstrual days and the years around the
time of the menopause. This climacteric depression is usually at its
worst in the two or three years before the periods stop and is also
affected by the cyclical depression of severe PMS.
This combination of post-natal depression, PMS and climacteric depression is
known as the triad of hormone related mood disorders (HRMD) and often occur in
the same vulnerable women. There is good evidence from randomised
placebo-controlled trials that this depression is improved using moderately high
dose oestrogens transdermally either by patches or hormone implant. This
improvement occurs even in women who are not responsive to anti-depressants and
in my view should be first-line therapy.
These patients respond well to oestrogens but are often progestogen-intolerant
responding badly to the necessary cyclical oral progestogens needed if they
still have a uterus. Such patients benefit from the insertion of a progestogen
releasing (Mirena) intra-uterine system. Thus long-term therapy may be
continuous oestradiol patches plus a Mirena coil producing the mental tonic
effect of moderately high dose oestrogens without the bleeding or the cyclical
changes that occur with progestogen tablets.
Loss of libido is a common, under-reported but complex issue in middle aged
women. Hypoactive Sexual Desire Disorder (HSDD) or Female Sexual Arousal
Disorder (FSAD) or Female Orgasmic Dysfunction (FOD) are the modern diagnostic
distinctions. Marital or psycho sexual counselling are frequently employed with
variable success. HRT helps with estrogens being less effective than
Implantation is the only route licensed for women in the UK but it is possible
to prescribe low dose gel or patches off license with the appropriate
Studd, JWW. Panay, N (2004) Estrogens and depression. Climacteric
Gregoire, AJP, Henderson, AF, Kumar, R, Everitt B, Studd JW (1996).
Transdermal oestrogen for treatment of severe postnatal depression.
Lancet 347, 930 -33
Watson, NR, Studd, JWW, Savvas M, Garnett T, Baber RJ, (1989 Treatment of
severe pre-menstrual syndrome with oestradiol patches and cyclical oral
Norethisterone. Lancet ii, 730-34
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