Tibolone treatment for perimenopausal depression: Three cases

To the Editor

Perimenopause begins approximately 4 years prior to the cessation of menstrual periods and is characterised by irregular menstrual cycles, vasomotor symptoms and vaginal dryness (BMJ Best Practice, 2016; The Royal Women’s Hospital, 2016). Mood changes are also common, with increased rate of diagnosis of depression (increased rates between 9.5% and 16.7%) (Cohen et al., 2006).

Ms A is a 48-year-old teacher who had no past psychiatric history and has two teenage sons and a supportive husband. Over a period of 6 weeks, she became tearful, had poor interrupted sleep, experienced two panic attacks and described feeling ‘foggy’ about routine tasks. She was physically well and described menstrual cycle changes over the past 6 months, with irregular menses. No other physical symptoms of menopause were elicited.

Ms B is a 51-year-old nurse with a 20-year history of depression that had been well-managed with a selective serotonin reuptake inhibitor (SSRI) until the previous year. She described a significant increase in the severity of depressive symptoms, anxiety, panic, anger, hostility, memory impairment and poor concentration. She had been treated with two different serotonin–norepinephrine reuptake inhibitors (SNRIs) (first venlafaxine and then desvenlafaxine) plus antipsychotic medication (quetiapine XR 600 mg/day). Ms B had gained 20 kg in weight, stopped working and no longer engaged in social activities she had previously enjoyed. She’d had a hysterectomy at age 44 for menorrhagia and has a supportive female partner.

Ms C is a 52-year-old administrative assistant, who described depressed mood, tearfulness, anxiety symptoms and poor sleep for the past 3 years. There was no past psychiatric history, and her current symptoms were fluctuating in severity, without returning to her previously stable mental state. She had been treated with escitalopram, but felt angry and that her thoughts were racing on this. These symptoms settled 2 weeks after stopping medication, but her experience with this SSRI made her refuse further antidepressant treatment.

All three women were diagnosed with either de novo perimenopausal depression or, in the case of Ms B, perimenopausal exacerbation of depression. Tibolone, a newer form of hormone treatment, was prescribed for each patient, and improvement in mood was noted by each woman within 6–8 weeks. In particular, anxiety and panic symptoms improved markedly.

Mood changes occur commonly in perimenopause, but are often unrecognised, to the detriment of the patient. It is essential that clinicians take a thorough menstrual history from patients so that all symptoms of menopause are elicited and appropriately managed.