Like the popular Ladies' Home Journal column, "Can This Marriage Be Saved?" this section of the Alexander Newsletter will explore real-life dilemmas and show how women suffering from stress or mood swings can achieve happier and more balanced lives. In the months ahead, we will present compelling case histories designed to appeal not only to women but to the health professionals who care for them. The following is a composite history and reflects the experience of several patients in my practice.
Jane W. is a tall woman with penetrating, intelligent eyes. She came to see me because she was exhausted and increasingly anxious. In her late 40s, Jane was carrying a full load: She had a child with learning disabilities, a demanding job, and a newly unemployed husband. Clearly, she needed a good night's rest to calm her nerves and deal with all these challenges.
Jane's two kids, aged 7 and 9, were happy, but the younger one had difficulty concentrating and was not reading up to his grade level. Jane was an elementary teacher in the public schools and was well equipped to coach her son, but she was already putting in long hours teaching. She was also the chief breadwinner in the family. She had a good and satisfying marriage. However, when her husband's company was downsized, he lost his job and had yet to find new clients as a self-employed computer consultant.
Jane became agitated when her husband lost his job. At this point, her periods started to come more frequently, though she had less bleeding each time. And she suddenly complained of feeling over-heated, especially at night. She used to have cold feet and a cold nose - cuddling with her husband in bed used to warm her up, but when she came to see me, close physical contact only increased her discomfort and made her pull away. Occasionally she woke up to find her nightgown soaked with sweat. She had only an occasional daytime hot flash; her main problem was her raised body heat at night.
Jane's gynecologist knew that night sweats were disrupting her rest but hesitated to treat the problem with estrogen. Jane's sister had had pre-menopausal breast cancer and Jane had voiced a strong concern about her risks of developing this disease. The gynecologist wasn't sure that hormone replacement would increase Jane's chances of getting cancer, but he wisely assumed that any uncertainty about this treatment would make her even more anxious than she already was. At that point, he referred her to me, thinking that a psychiatrist who specialized in menopause might help.
"I've always felt a bit nervous," Jane confessed. "The truth is I come from a family of 'nervous Nellies.' All the women are high strung. I've never had a panic attack. The nervousness is just there, all the time."
I asked whether she had ever felt this anxiety before.
"Well, yes," she said, "When there was some big event - like my sister's illness - or a lot of stress." Jane's biggest problem now was her husband's unemployment, her son's learning disability, the need for special tutors and her fear of going deeper into debt.
"I could deal with this stress a lot better," she said, " if only I could get a good night's sleep! All my life, I could count on waking up rested, and that would help me cope with any challenges. But now, I'm totally at sea."
Jane denied being depressed but said that at times she just felt sad.
"No one in my family was depressed but my mother had 'bad nerves.'" Jane explained. "My mother never got help because she didn't believe in psychiatry.'" This low-level anxiety also afflicted Jane's aunts.
Jane's anxiety worsened just before her period yet she had no other symptoms of PMS.
While a low-level of anxiety ran in Jane's family, everyone seemed to be able to manage it. However, such emotions often break through to the surface during the menopausal transition. Since Jane didn't feel comfortable taking hormones, I suggested an antidepressant.
"We know that stress and untreated anxiety or depression can worsen hot flashes in most women," I explained to her. "So if we deal with your mood problems, it's likely your hot flashes will improve, and you'll be able to get some good, renewing sleep. This approach doesn't work as well as taking estrogen, but I think it will bring you some relief."
Three of the newer antidepressants-Prozac, Paxil and Effexor-have been studied for the treatment of hot flashes. Effexor performed the best so I recommended this to Jane. My other patients have responded well to Celexa, Luvox, Paxil, Prozac and Zoloft. Successfully controlling anxiety with anti-depressants can, in turn, lessen perimenopausal symptoms.
Jane started with a very low dose of Effexor and built up to 75 mg daily. This is less than the standard daily dose for depression, but was enough to manage her level of anxiety and hot flashes. After four to six weeks on the medication Jane felt more relaxed than she had in over 20 years, her hot flashes had largely disappeared, and she was sleeping through the night. After consultation, Jane decided to stay on the Effexor until her menopause was over and then slowly taper off.
I pointed out that while hot flashes may diminish after menopause, Jane's underlying struggle with anxiety and nervousness may not. I also suggested that at some point, Jane might want to try psychotherapy and learn specific techniques for dealing with anxiety. This might allow her to reduce her dependency on medication. Jane said she didn't have the time or finances to do that now but that she would consider psychotherapy in the future.
Keywords
- Hot Flashes
- Perimenopause
- Anxiety
- Sleep Disturbance
- Situational Stress
- Family history: first degree relative with breast cancer
- Treatment: Effexor 75 mg
General References
(2000). "Drug helps breast cancer survivors. Antidepressant reduces severity and frequency of hot flashes." Clin J Oncol Nurs 4(5): 199. Abstract
(2001). "Breast cancer and hot flashes. Options for relief." Mayo Clin Health Lett 19(3): 6. Abstract
(2002). "Treating hot flashes with drugs: an update." Harv Womens Health Watch 9(12): 6. Abstract
Barlow, D. H. (2000). "Venlafaxine for hot flushes." Lancet 356(9247): 2025-6. Abstract
Barton, D., V. B. La, et al. (2002). "Venlafaxine for the control of hot flashes: results of a longitudinal continuation study." Oncol Nurs Forum 29(1): 33-40. Abstract
Bydder, S. A. and N. A. Spry (2002). "Treatment for hot flushes in women receiving tamoxifen." Med J Aust 177(5): 266. Abstract
Dvorak, S. R. (2002). "Beyond estrogen: new alternatives for the management of hot flashes." S D J Med 55(1): 11-2. Abstract
Gottlieb, N. (2000). "Nonhormonal agents show promise against hot flashes." J Natl Cancer Inst 92(14): 1118-20. Abstract
Grady-Weliky, T. A. and D. M. Hartmann (2001). "Flushing in a menopausal woman taking venlafaxine." Am J Psychiatry 158(8): 1330. Abstract
Loprinzi, C. L. and D. Barton (2000). "Estrogen deficiency: In search of symptom control and sexuality [comment] [editorial]." J Natl Cancer Inst 92(13): 1028-9. Abstract
Loprinzi, C. L., J. W. Kugler, et al. (2000). "Venlafaxine in management of hot flashes in survivors of breast cancer: a randomised controlled trial." Lancet 356(9247): 2059-63. Abstract
Loprinzi, C. L., T. M. Pisansky, et al. (1998). "Pilot evaluation of venlafaxine hydrochloride for the therapy of hot flashes in cancer survivors." J Clin Oncol 16(7): 2377-81 Abstract
Loprinzi, C. L., J. A. Sloan, et al. (2002). "Phase III evaluation of fluoxetine for treatment of hot flashes." J Clin Oncol 20(6): 1578-83. Abstract
Pritchard, K. I. (2001). "The role of hormone replacement therapy in women with a previous diagnosis of breast cancer and a review of possible alternatives." Ann Oncol 12(3): 301-10. Abstract
Quella, S. K., C. L. Loprinzi, et al. (1999). "Pilot evaluation of venlafaxine for the treatment of hot flashes in men undergoing androgen ablation therapy for prostate cancer." J Urol 162(1): 98- 102. Abstract
Roth, A. J. and H. I. Scher (1998). "Sertraline relieves hot flashes secondary to medical castration as treatment of advanced prostate cancer." Psychooncology 7(2): 129-32. Abstract
Shanafelt, T. D., D. L. Barton, et al. (2002). "Pathophysiology and treatment of hot flashes." Mayo Clin Proc 77(11): 1207-18. Abstract
Sloan, J. A., C. L. Loprinzi, et al. (2001). "Methodologic lessons learned from hot flash studies." J Clin Oncol 19(23): 4280-90. Abstract
Somerfield, M., A. Jatoi, et al. (2003). "Hazards of Quality-of-Life Data for Clinical Decision Making." J Clin Oncol 21(9 Suppl): 82-3. Abstract
Stearns, V., K. L. Beebe, et al. (2003). "Paroxetine controlled release in the treatment of menopausal hot flashes: a randomized controlled trial." JAMA 289(21): 2827-34. Abstract
Stearns, V., C. Isaacs, et al. (2000). "A pilot trial assessing the efficacy of paroxetine hydrochloride (Paxil) in controlling hot flashes in breast cancer survivors." Ann Oncol 11(1): 17- 22. Abstract
Weitzner, M. A., J. Moncello, et al. (2002). "A pilot trial of paroxetine for the treatment of hot flashes and associated symptoms in women with breast cancer." J Pain Symptom Manage 23(4): 337-45. Abstract
Wymenga, A. N. and D. T. Sleijfer (2002). "Management of hot flushes in breast cancer patients." Acta Oncol 41(3): 269-75. Abstract
This article is for educational purposes only and is not intended as a substitute for medical advice. Please consult with a clinician to review any current symptoms and address your medical concerns.
