更年期抑郁的治疗经验ppt课件

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,更年期抑郁的治疗经验,*,Menopause and DepressionExperience in Treatment,George Linn, MD&PhD,Beijing 2012,更年期抑郁的治疗经验,1,Menopause and DepressionExper,Objectives,Menopause associated psychological changes and symptoms,Pathophysiology in Menopause Depression,Alternative Treatment options for bothersome symptoms ( Medications),Medication for the women who is Contraindicated for Hormone,更年期抑郁的治疗经验,2,ObjectivesMenopause associated,Depression in Menopause,Trend of Suicide in a womans Life,Two peak in all life of women,Adolescence and Menopause,Menopause symptom related psychotic disease (Depression),Metabolism,Volume 54, Issue 5, Supplement, May 2005, Pages 4952,更年期抑郁的治疗经验,3,Depression in MenopauseTrend o,更年期抑郁的治疗经验,4,更年期抑郁的治疗经验4,Estrogen with Serotonin,1. Inhibit the Monoamine Oxidase (MAO) function,2. Moderate the serotonin (alpha 1) receptor effect,Darlene Deechera, From menarche to menopause: Exploring the underlying biology of depression in women experiencing hormonal changes,Psychoneuroendocrinology,Volume 33, Issue 1, January 2008, Pages 317,更年期抑郁的治疗经验,5,Estrogen with Serotonin 更年期抑郁的,更年期抑郁的治疗经验,6,更年期抑郁的治疗经验6,Serotonin in Menopause,Serotonin decrease it amount,Serotonin decrease it effect,更年期抑郁的治疗经验,7,Serotonin in MenopauseSerotoni,更年期抑郁的治疗经验,8,更年期抑郁的治疗经验8,更年期抑郁的治疗经验,9,更年期抑郁的治疗经验9,Estrogen and Depression,Premenstrual Dysphoric Disorder (PMDD),Post Partum Depression,Postmenopause Depression,更年期抑郁的治疗经验,10,Estrogen and Depression Premen,更年期抑郁的治疗经验,11,更年期抑郁的治疗经验11,更年期抑郁的治疗经验,12,更年期抑郁的治疗经验12,更年期抑郁的治疗经验,13,更年期抑郁的治疗经验13,Six Women and Their Nightmares,更年期抑郁的治疗经验,14,Six Women and Their,Case #1,35 yo G1 P0 female presents with c/o hot flashes and amenorrhea for 12 months. She doesnt know why this is happening, her sex are worsening. Daily work is bothered. Suicide intention and conflict with her husband occurred. She wants your help.,更年期抑郁的治疗经验,15,Case #135 yo G1 P0 female pres,Case #1 DDx,Premature Menopause,Pituitary Tumors,Ovarian Failure,Cerebellum Atrophy,Iatrogenic Effect,更年期抑郁的治疗经验,16,Case #1 DDxPremature Menopause,Case #1 Test,LH, FSH, E2 and Testosterone,Sono Examination,Brain Computer Tomography,更年期抑郁的治疗经验,17,Case #1 TestLH, FSH, E2 and Te,Case #1 Treatment,Hormone ( E+P) (Angeliq),Hot Flush Persistent,SSRI,(Selective Serotonin Reuptake Inhibitors),Clonidine,更年期抑郁的治疗经验,18,Case #1 TreatmentHormone ( E+P,Case #2,45 yo G2 P2 female presents with c/o hot flashes and irregular menses (q 3-5 mos) for the past 9 months. Body weight gained in recent. Her mood and behavior change.,Family Abuse in recent,21 yo daughter refused to live with her.,DDx,Tests,更年期抑郁的治疗经验,19,Case #245 yo G2 P2 female pres,Case #2 DDx,Schizophrenia,Transitional Menopause,更年期抑郁的治疗经验,20,Case #2 DDxSchizophrenia 更年期抑郁,Case #2 Test,FSH, E2 and Testosterone,Psychological Consultation,更年期抑郁的治疗经验,21,Case #2 TestFSH, E2 and Testos,Case #2 Treatment,SNRI for her schizophrenia,Hormone Replacement,更年期抑郁的治疗经验,22,Case #2 TreatmentSNRI for her,Case #3,65 yo WF presents to start HRT. She heard it would help protect her heart, make her feel younger and help her memory. She went through menopause 10 years ago and has not had any problems except an recurrent depression. She is 54”, 108 lbs. By the way, she had a wrist fx 2 yrs ago takes her evista faithfully.,更年期抑郁的治疗经验,23,Case #365 yo WF presents to st,Case #3 Treatment,Prozac or not ?,Tricyclic antidepresents ?,更年期抑郁的治疗经验,24,Case #3 TreatmentProzac or not,Case #4,49 yo WF presence b/c she cant stand her hot flashes anymore. She cant sleep very well b/c she wakes up 3 times a night drenched with sweat. She is an executive at First National Bank. She has a history of breast cancer 2 years ago. “Please Dr.Linn, I need some hormones or something.”,更年期抑郁的治疗经验,25,Case #449 yo WF presence b/c s,Case #4 Treatment,Benzodiazepine,Barbiturate,Hormone Replacement,Tomoxifen ?,更年期抑郁的治疗经验,26,Case #4 TreatmentBenzodiazepin,Case #5,55 yo BF returns to discuss stopping her HRT. She has been taking it for 5 years now with good relief of her vasomotor and sexs. After discontinuing her HRT, she was involved with slight depression and chronic pain.,更年期抑郁的治疗经验,27,Case #555 yo BF returns to dis,Case #6,53 yo breat cancer woman stage 1 began continuous tomoxifen for 4 years. She is now having some vaginal spotting. After using the aromatase inhibit, severe insomnia and disorder bother her.,更年期抑郁的治疗经验,28,Case #653 yo breat cancer woma,Case #6 Treatment,Hystectomy,Regain Tomoxifen,Stop Aromatase Inhibitor,SSRI or SNRI,更年期抑郁的治疗经验,29,Case #6 TreatmentHystectomy 更年,HRT or SSRI (1),Postmenopausal women with depression respond better to selective serotonin reuptake inhibitors (SSRIs) if they are also taking hormonal therapy (HT), Italian researchers suggest.,E Hall, BN Frey, CN Soares - Drugs, 2011 - ,更年期抑郁的治疗经验,30,HRT or SSRI (1) Postmenopausal,HRT & SSRI (2),Random Control, No response to SSRIs in 170 postmenopausal women with a depressive episode, as defined by the DSM-IV criteria, 47 of whom were on HT.,E Hall, BN Frey, CN Soares - Drugs, 2011 - ,更年期抑郁的治疗经验,31,HRT & SSRI (2)Random Control,HRT & SSRI(3),Among patients who were not also taking HT, the response rate to SSRIs was only 63.2%, compared with 83.7% among patients taking HT. Furthermore, the rates of remission were similar for the two groups, at 52.63% and 79.07%, respectively.,SR Davis, F Jane - Expert Opinion on Pharmacotherapy, 2010,更年期抑郁的治疗经验,32,HRT & SSRI(3)Among patients wh,HRT & SSRI (4),They also found that levels of luteinizing hormone (LH) may provide a means of predicting which women are likely to respond,GB Mahady - NIH/ODS (Ed.), US NIH, 2010 - ods.od.nih.gov,更年期抑郁的治疗经验,33,HRT & SSRI (4)They also found,SSRI & Placebo,SSRI are also superior to Placebo,Clinical improvement at week 8 (decrease of 50 percent or more from baseline in hot flash frequency) was significantly greater in the escitalopram group than in the placebo group (55 percent vs. 36 percent).,Menopause: September/October 2006 - Volume 13 - Issue 5 - pp 780-786,更年期抑郁的治疗经验,34,SSRI & PlaceboSSRI are also su,SNRI,serotonin and norepinephrine reuptake inhibitors,Off-Label Use in Postmenopause Syndrome such as insomnia, anxiety and depression,The case of menopausal symptoms, nerve pain, hot flashes and emotional stress are relieved.,David F. Archer,Volume 200, Issue 3, March 2009, Pages 238.e1238.e10,更年期抑郁的治疗经验,35,SNRIserotonin and norepinephr,Menopause Terminology: STRAW* Staging System,*STRAW = Stages of Reproductive Aging Workshop.,Stages most likely to be characterized by vasomotor symptoms.,Soules MR, et al.,Menopause,. 2001;8:402-7.,Stages:,-2,-1,+1,+2,Terminology:,Duration of Stage:,Menstrual,Cycles:,Menopausal Transition,Postmenopause,Early,Early,Late,Late,Perimenopause,Variable,Variable cycle length (7 daysdifferent from normal),2 skippedcycles and aninterval of amenorrhea(,60 days),4 yrs,Untildemise,None,0,Final Menstrual Period,1 yr,Amen. 12 mos.,a,b,更年期抑郁的治疗经验,36,Menopause Terminology: STRAW*,Vasomotor symptoms:Why dont we treat every women with hormones?,更年期抑郁的治疗经验,37,Vasomotor symptoms:Why dont,Menopausal Complaints: Treatments,Hormones vs non-hormones vs herbals,What kind of herbal drug is effective ?,Efficacy ?,更年期抑郁的治疗经验,38,Menopausal Complaints: Treatm,Clinical Event,Hazard Ratio, 95% confidence interval,HERS E+P,WHI E+P,WHI E alone,CHD Events,0.99 (0.80-1.22),1.29 (,1.02-1.63,),0.91 (0.75-1.12),Stroke,1.23 (0.89-1.70),1.41 (,1.07-1.85,),1.39 (,1.10-1.77,),Pulm. Embolism,2.79 (0.89-8.75),2.13 (,1.39-3.25,),1.34 (0.87-2.06),Breast Cancer,1.30 (0.77-2.19),1.26 (1.00-1.59),0.77 (0.59-1.01),Colon Cancer,0.69 (0.32-1.49),0.63 (,0.43-0.92,),1.08 (0.75-1.55),Hip Fracture,1.10 (0.49-2.50),0.66 (,0.45-0.98,),0.61 (,0.41-0.91,),Death,1.08 (0.84-1.38),0.98 (0.82-1.18),1.04 (0.88-1.22),Global Index,-,1.15 (1.03-1.28),1.01 (0.89-1.70),更年期抑郁的治疗经验,39,Clinical EventHazard Ratio, 95,Hormones Contraindicated,Breast CA,Endometrial CA,Undiagnosed vaginal bleeding,CHD,Venous thrombosis,Stroke,Pregnancy,What is not here, that is a CI on OCPs?,更年期抑郁的治疗经验,40,Hormones ContraindicatedBreast,Specific Geriatric Issues,Other assessments to be made.,更年期抑郁的治疗经验,41,Specific Geriatric IssuesOther,Cognitive Function,Normal decline,Dementia,Alzheimers,Vascular,Others,Depression,Medications,EtOH,MMSE,更年期抑郁的治疗经验,42,Cognitive FunctionNormal decli,Sensory,Visual,Auditory,Balance,更年期抑郁的治疗经验,43,SensoryVisual更年期抑郁的治疗经验43,Polypharmacy,Medication List,Drug-drug interactions,Altered pharmacokinetics, pharmacodynamics,Herbals,OTC,更年期抑郁的治疗经验,44,PolypharmacyMedication List更年期,