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Guideline No. 422c: Menopause: Mood, Sleep, and Cognition

Published:November 03, 2021DOI:https://doi.org/10.1016/j.jogc.2021.08.009

      ABSTRACT

      Objective

      Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence.

      Target Population

      Perimenopausal and postmenopausal women.

      Benefits, Harms, and Costs

      Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment.

      Evidence

      Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters.

      Validation Methods

      The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

      Intended Audience

      physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population.

      SUMMARY STATEMENTS

      • 1
        The perimenopausal period is a window of vulnerability for the development of depressive symptoms and major depressive episodes, even in women with no history of depression (high).
      • 2
        Factors related and unrelated to menopause contribute to the occurrence and severity of mood symptoms in mid-life. Factors related to menopause are those that are context-related or timing-related, such as vasomotor symptoms, sleep disturbances, and health problems, whereas those unrelated to menopause represent a continuum of risk that precedes menopause, or longitudinal risk factors, such as unemployment, smoking, and lifetime history of anxiety (high).
      • 3
        Recent large-scale studies show an elevated risk of depression in women following hysterectomy, with or without oophorectomy. A history of primary ovarian insufficiency, which occurs in 1% of women, is also associated with an increased risk of depression (high).
      • 4
        Poor sleep quality, as measured both subjectively and objectively, is common among women in the perimenopausal and postmenopausal periods (high).
      • 5
        Cognitive symptoms, such as worsening memory and slower cognitive speed, are often reported among newly menopausal women, and these symptoms have been demonstrated in prospective, longitudinal studies (moderate).

      RECOMMENDATIONS

      • 1
        Proven therapeutic options for depression at any life stage (i.e., antidepressants, cognitive behavioural therapy, and other behaviour-based psychotherapies) should remain the first-line treatment options for depressive symptoms and episodes during the menopausal transition and postmenopausal years (strong, high).
      • 2
        For women experiencing recurrent episodes of depression during the perimenopausal period, selection of antidepressants should consider the patient's response to and toleration of previous trials of antidepressants (strong, moderate).
      • 3
        For women experiencing new-onset depression, both adverse effects (e.g., sexual dysfunction, weight changes) and drug–drug interactions (e.g., between specific selective serotonin reuptake inhibitors and tamoxifen) specific to this population should be considered (strong, moderate).
      • 4
        There is some evidence that hormone therapy has antidepressant effects similar in magnitude to those observed with classic antidepressant agents in perimenopausal women with depression, with or without concomitant vasomotor symptoms (strong, high). However, hormone therapy is ineffective in treating depressive disorders in postmenopausal women, suggesting a possible window of opportunity for the antidepressant benefits of hormone therapy in perimenopause (strong, moderate).
      • 5
        The approach to poor sleep during the menopausal transition should initially include education about sleep hygiene, and primary sleep disorders should be ruled out (strong, high).
      • 6
        Vasomotor symptoms are a significant contributor to sleep disruption and should be addressed; hormone therapy may improve sleep when vasomotor symptoms are present (strong, high).
      • 7
        Several other therapies for sleep have shown benefit, including cognitive behavioural therapy–insomnia (strong, high), aerobic exercise, eszopiclone, venlafaxine, black cohosh, and valerian root (strong, moderate).
      • 8
        For women with cognitive complaints, lifestyle modifications are recommended to decrease the risk of cognitive decline. These include increasing aerobic exercise and including vegetables in the diet more often, as well as limiting the potential influence of hypertension, diabetes, and atherosclerotic disease (strong, high).
      • 9
        Menopausal hormone therapy has not been shown to significantly improve measures of cognitive function over several years of use (strong, moderate).

      Keywords

      ABBREVIATIONS:

      CBT (cognitive behavioural therapy), CBT-I (cognitive behavioural therapy for insomnia), HT (hormone therapy), MDD (major depressive disorder), PSQI (Pittsburgh Sleep Quality Index), SSRI (selective serotonin reuptake inhibitor), SNRI (serotonin-norepinephrine reuptake inhibitor), VMS (vasomotor symptoms)
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      REFERENCES

        • Steiner M.
        Female-specific mood disorders.
        Clin Obstet Gynecol. 1992; 35: 599-611
        • Soares CN
        • Zitek B.
        Reproductive hormone sensitivity and risk for depression across the female life cycle: A continuum of vulnerability?.
        J Psychiatry Neurosci. 2008; 33: 331-343
        • Schiller CE
        • Johnson SL
        • Abate AC
        • et al.
        Reproductive steroid regulation of mood and behavior.
        Compr Physiol. 2016; 6: 1135-1160
        • Soares CN.
        Mood disorders in midlife women: Understanding the critical window and its clinical implications.
        Menopause. 2014; 21: 198-206
        • Pietrzak RH
        • Kinley J
        • Afifi TO
        • et al.
        Subsyndromal depression in the united states: Prevalence, course, and risk for incident psychiatric outcomes.
        Psychol Med. 2013; 43: 1401-1414
        • Bromberger JT
        • Matthews KA
        • Schott LL
        • et al.
        Depressive symptoms during the menopausal transition: The study of women's health across the nation (swan).
        J Affect Disord. 2007; 103: 267-272
        • de Kruif M
        • Spijker AT
        • Molendijk ML.
        Depression during the perimenopause: A meta-analysis.
        J Affect Disord. 2016; 206: 174-180
        • Cohen LS
        • Soares CN
        • Vitonis AF
        • et al.
        Risk for new onset of depression during the menopausal transition: The harvard study of moods and cycles.
        Arch Gen Psychiatry. 2006; 63: 385-390
        • Bromberger JT
        • Schott L
        • Kravitz HM
        • et al.
        Risk factors for major depression during midlife among a community sample of women with and without prior major depression: Are they the same or different?.
        Psychol Med. 2015; 45: 1653-1664
        • Epperson CN
        • Sammel MD
        • Bale TL
        • et al.
        Adverse childhood experiences and risk for first-episode major depression during the menopause transition.
        J Clin Psychiatry. 2017; 78: e298-e307
        • Gordon JL
        • Rubinow DR
        • Eisenlohr-Moul TA
        • et al.
        Estradiol variability, stressful life events, and the emergence of depressive symptomatology during the menopausal transition.
        Menopause. 2016; 23: 257-266
        • Soares CN.
        Anxiety and the menopausal transition: Managing your expectations.
        Menopause. 2013; 20: 481-482
        • Bromberger JT
        • Kravitz HM
        • Chang Y
        • et al.
        Does risk for anxiety increase during the menopausal transition? Study of women's health across the nation.
        Menopause. 2013; 20: 488-495
        • MacQueen GM
        • Frey BN
        • Ismail Z
        • et al.
        Canadian network for mood and anxiety treatments (canmat) 2016 clinical guidelines for the management of adults with major depressive disorder: Section 6. Special populations: Youth, women, and the elderly.
        Can J Psychiatry. 2016; 61: 588-603
        • Maki PM
        • Kornstein SG
        • Joffe H
        • et al.
        Guidelines for the evaluation and treatment of perimenopausal depression: Summary and recommendations.
        Menopause. 2018; 25: 1069-1085
        • Soares CN.
        Depression and menopause: An update on current knowledge and clinical management for this critical window.
        Med Clin North Am. 2019; 103: 651-667
        • Kelly CM
        • Juurlink DN
        • Gomes T
        • et al.
        Selective serotonin reuptake inhibitors and breast cancer mortality in women receiving tamoxifen: A population based cohort study.
        Bmj. 2010; 340: c693
        • Perez-Lopez FR
        • Martinez-Dominguez SJ
        • Lajusticia H
        • et al.
        Effects of programmed exercise on depressive symptoms in midlife and older women: A meta-analysis of randomized controlled trials.
        Maturitas. 2017; 106: 38-47
        • Green SM
        • Key BL
        • McCabe RE.
        Cognitive-behavioral, behavioral, and mindfulness-based therapies for menopausal depression: A review.
        Maturitas. 2015; 80: 37-47
        • McCurry SM
        • Guthrie KA
        • Morin CM
        • et al.
        Telephone-based cognitive behavioral therapy for insomnia in perimenopausal and postmenopausal women with vasomotor symptoms: A msflash randomized clinical trial.
        JAMA Intern Med. 2016; 176: 913-920
        • Soares CN
        • Almeida OP
        • Joffe H
        • et al.
        Efficacy of estradiol for the treatment of depressive disorders in perimenopausal women: A double-blind, randomized, placebo-controlled trial.
        Arch Gen Psychiatry. 2001; 58: 529-534
        • Maki PM
        • Kornstein SG
        • Joffe H
        • et al.
        Guidelines for the evaluation and treatment of perimenopausal depression: Summary and recommendations.
        Menopause. 2018; 25: 1069-1085
        • Gordon JL
        • Rubinow DR
        • Eisenlohr-Moul TA
        • et al.
        Efficacy of transdermal estradiol and micronized progesterone in the prevention of depressive symptoms in the menopause transition: A randomized clinical trial.
        JAMA Psychiatry. 2018; 75: 149-157
        • Schmidt PJ
        • Nieman L
        • Danaceau MA
        • et al.
        Estrogen replacement in perimenopause-related depression: A preliminary report.
        Am J Obstet Gynecol. 2000; 183: 414-420
        • Kravitz HM
        • Zheng H
        • Bromberger JT
        • et al.
        An actigraphy study of sleep and pain in midlife women: The study of women's health across the nation sleep study.
        Menopause. 2015; 22: 710-718
        • Freeman EW
        • Sammel MD
        • Gross SA
        • et al.
        Poor sleep in relation to natural menopause: A population-based 14-year follow-up of midlife women.
        Menopause. 2015; 22: 719-726
        • Naufel MF
        • Frange C
        • Andersen ML
        • et al.
        Association between obesity and sleep disorders in postmenopausal women.
        Menopause. 2018; 25: 139-144
        • Duman M
        • Timur Tashan S.
        The effect of sleep hygiene education and relaxation exercises on insomnia among postmenopausal women: A randomized clinical trial.
        Int J Nurs Pract. 2018; 24: e12650
        • Tahkamo L
        • Partonen T
        • Pesonen AK.
        Systematic review of light exposure impact on human circadian rhythm.
        Chronobiol Int. 2019; 36: 151-170
        • Heinzer R
        • Marti-Soler H
        • Marques-Vidal P
        • et al.
        Impact of sex and menopausal status on the prevalence, clinical presentation, and comorbidities of sleep-disordered breathing.
        Sleep Med. 2018; 51: 29-36
        • Cintron D
        • Lahr BD
        • Bailey KR
        • et al.
        Effects of oral versus transdermal menopausal hormone treatments on self-reported sleep domains and their association with vasomotor symptoms in recently menopausal women enrolled in the kronos early estrogen prevention study (keeps).
        Menopause. 2018; 25: 145-153
        • Geiger PJ
        • Eisenlohr-Moul T
        • Gordon JL
        • et al.
        Effects of perimenopausal transdermal estradiol on self-reported sleep, independent of its effect on vasomotor symptom bother and depressive symptoms.
        Menopause. 2019;
        • Ensrud KE
        • Guthrie KA
        • Hohensee C
        • et al.
        Effects of estradiol and venlafaxine on insomnia symptoms and sleep quality in women with hot flashes.
        Sleep. 2015; 38: 97-108
        • Caufriez A
        • Leproult R
        • L'Hermite-Baleriaux M
        • et al.
        Progesterone prevents sleep disturbances and modulates gh, tsh, and melatonin secretion in postmenopausal women.
        J Clin Endocrinol Metab. 2011; 96: E614-E623
        • Guthrie KA
        • Larson JC
        • Ensrud KE
        • et al.
        Effects of pharmacologic and nonpharmacologic interventions on insomnia symptoms and self-reported sleep quality in women with hot flashes: A pooled analysis of individual participant data from four msflash trials.
        Sleep. 2018; : 41
        • Soares CN
        • Joffe H
        • Rubens R
        • et al.
        Eszopiclone in patients with insomnia during perimenopause and early postmenopause: A randomized controlled trial.
        Obstet Gynecol. 2006; 108: 1402-1410
        • Taibi DM
        • Vitiello MV
        • Barsness S
        • et al.
        A randomized clinical trial of valerian fails to improve self-reported, polysomnographic, and actigraphic sleep in older women with insomnia.
        Sleep Med. 2009; 10: 319-328
        • Taavoni S
        • Ekbatani N
        • Kashaniyan M
        • et al.
        Effect of valerian on sleep quality in postmenopausal women: A randomized placebo-controlled clinical trial.
        Menopause. 2011; 18: 951-955
        • Jiang K
        • Jin Y
        • Huang L
        • et al.
        Black cohosh improves objective sleep in postmenopausal women with sleep disturbance.
        Climacteric. 2015; 18: 559-567
        • Weber MT
        • Rubin LH
        • Maki PM.
        Cognition in perimenopause: The effect of transition stage.
        Menopause. 2013; 20: 511-517
        • Epperson CN
        • Sammel MD
        • Freeman EW.
        Menopause effects on verbal memory: Findings from a longitudinal community cohort.
        J Clin Endocrinol Metab. 2013; 98: 3829-3838
        • Karlamangla AS
        • Lachman ME
        • Han W
        • et al.
        Evidence for cognitive aging in midlife women: Study of women's health across the nation.
        PLoS One. 2017; 12e0169008
        • Maki PM
        • Wu M
        • Rubin LH
        • et al.
        Hot flashes are associated with altered brain function during a memory task.
        Menopause. 2020;
        • Alexander JL
        • Sommer BR
        • Dennerstein L
        • et al.
        Role of psychiatric comorbidity on cognitive function during and after the menopausal transition.
        Expert Rev Neurother. 2007; 7: S157-S180
        • Wu S
        • Ding Y
        • Wu F
        • et al.
        Omega-3 fatty acids intake and risks of dementia and alzheimer's disease: A meta-analysis.
        Neurosci Biobehav Rev. 2015; 48: 1-9
        • Xu H
        • Wang Y
        • Yuan Y
        • et al.
        Gender differences in the protective effects of green tea against amnestic mild cognitive impairment in the elderly han population.
        Neuropsychiatr Dis Treat. 2018; 14: 1795-1801
        • Kang JH
        • Cook N
        • Manson J
        • et al.
        A randomized trial of vitamin e supplementation and cognitive function in women.
        Arch Intern Med. 2006; 166: 2462-2468
        • Devore EE
        • Kang JH
        • Stampfer MJ
        • et al.
        The association of antioxidants and cognition in the nurses' health study.
        Am J Epidemiol. 2013; 177: 33-41
        • Jiang X
        • Huang J
        • Song D
        • et al.
        Increased consumption of fruit and vegetables is related to a reduced risk of cognitive impairment and dementia: Meta-analysis.
        Front Aging Neurosci. 2017; 9: 18
        • Weng PH
        • Chen JH
        • Chiou JM
        • et al.
        The effect of lifestyle on late-life cognitive change under different socioeconomic status.
        PLoS One. 2018; 13e0197676
        • Aichberger MC
        • Busch MA
        • Reischies FM
        • et al.
        Effect of physical inactivity on cognitive performance after 2.5 years of follow-up: Longitudinal results from the survey of health, ageing, and retirement (share).
        GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry. 2010; 23: 7-15
        • Northey JM
        • Cherbuin N
        • Pumpa KL
        • et al.
        Exercise interventions for cognitive function in adults older than 50: A systematic review with meta-analysis.
        Br J Sports Med. 2018; 52: 154-160
        • Gleason CE
        • Dowling NM
        • Wharton W
        • et al.
        Effects of hormone therapy on cognition and mood in recently postmenopausal women: Findings from the randomized, controlled keeps-cognitive and affective study.
        PLoS Med. 2015; 12 (discussion e)e1001833
        • Espeland MA
        • Shumaker SA
        • Leng I
        • et al.
        Long-term effects on cognitive function of postmenopausal hormone therapy prescribed to women aged 50 to 55 years.
        JAMA Intern Med. 2013; 173: 1429-1436
        • Albert K
        • Hiscox J
        • Boyd B
        • et al.
        Estrogen enhances hippocampal gray-matter volume in young and older postmenopausal women: A prospective dose-response study.
        Neurobiol Aging. 2017; 56: 1-6
        • Epperson CN
        • Shanmugan S
        • Kim DR
        • et al.
        New onset executive function difficulties at menopause: A possible role for lisdexamfetamine.
        Psychopharmacology (Berl). 2015; 232: 3091-3100