Primary care physicians and gynecologists treating women with menstrual disorders should follow a multidisciplinary approach including a depression screening. The burden of menstrual abnormalities caused by MDD should not be underestimated. The plausible reasons for this are unhealthy lifestyles in depressed patients like smoking, alcohol, drug use, physical inactivity, sleep disturbances, non-compliance with medical regimens in addition to varied sensory perception and dysregulation of autonomic, inflammatory, and immune systems . Other than menstruation disorders, MDD is a risk factor for several other disorders as well, such as cardiovascular disease, diabetes, dizziness, and chronic pain. This can be due to higher variability in hormonal levels or because of over-awareness and higher reporting of distressing symptoms . The more symptoms that a woman presents with heavy bleeding, gushing, passage of clots, the stronger the association with a history of MDD. A study in 2012 concluded that there is an increased incidence of heavy menstrual bleeding by 1.89 times in women with a past medical history of MDD. One of such under-recognized yet very pertinent symptoms is menstrual cycle abnormalities, including dysmenorrhea, menorrhagia, menstrual irregularities, and premenstrual symptoms . Women diagnosed with MDD are more likely to experience severe disease with somatic symptoms and a higher degree of functional impairment . The prevalence of depression in prepuberty and after the age of 55 years is almost equal between males and females . This increased susceptibility is seen only during reproductive years, especially during premenstrual, pregnancy, and perimenopausal phase. Structural differences between the brains of men and women, altered sensitivity to various neurotransmitters and hormones like serotonin, gamma-aminobutyric acid (GABA), allopregnanolone, estrogen, and corticosteroids along with genetic predisposition and cultural factors, such as lower health-seeking behaviors, social isolation, high incidence of abuse, and marital and child-rearing stressors, contribute to the development of depression in women . Interaction between various factors namely neurobiological, hormonal, genetic, social, environmental has been implicated to explain these differences . Moreover, depressive disorders such as premenopausal dysphoric disorder and postpartum depression are gender-specific. The lifetime prevalence of MDD is 26.1% among women whereas it is 14.7% among men in the United States . Women are afflicted with depression twice more likely than men, and it is the second leading cause of disease burden for women in the United States . Major depressive disorder (MDD) is associated with significant gender disparity. The increasing prevalence of depression, women’s health, multiple female-specific subtypes, and the preexisting burden of menstrual disorders necessitates more detailed studies on the effects of depression on the menstrual cycle. Furthermore, the treatment of depression can be the etiology of various menstrual abnormalities, while menstrual disorders themselves could be the cause of depression. Co-existing or history of depression can either be the cause of or interfere in the treatment of these disorders. Menstrual disorders contribute to a significant number of outpatient gynecological visits per year in the United States. On the other hand, amenorrhea has also been reported as a side effect of sertraline and electroconvulsive therapy. Even the treatment of underlying depression has been shown to cause menorrhagia. Patients with dysmenorrhea and coexisting depression had enhanced pain perception along with a poor response to pain relief measures. The association between dysmenorrhea and depression was found to be bidirectional and congruent in most studies. In addition, it is seen that menopausal changes predisposed females to an increased risk of depression. The resulting changes in luteinizing hormone (LH) amplitude, follicle-stimulating hormone (FSH) levels, and LH pulse frequency were noted in patients with depression.īesides depression, earlier surgical menopause is associated with cognitive decline. Excessive corticotropin-releasing hormone (CRH) levels in depression lead to inhibition of the hypothalamic-pituitary-gonadal (HPG) axis and increased cortisol levels which further inhibits the action of gonadotropin-releasing hormone (GnRH) neurons, gonadotrophs, and gonads. The association was found to be the greatest in women with natural menopause at the age less than 40 years. A strong association is noted between depression and early perimenopause as well as menopause.
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