**6. Menopause and psychiatric disorders**

One of the most consistent findings in psychiatry and psychology is that from menarche onwards females are at higher risk than males of developing both depressive and anxiety disorders. This sex difference remains robust throughout the lifespan, including old age, in the years beyond the reproductive period. The extensively reported link between puberty, the perinatal period, and menopause and excessive amounts of anxiety and depressive symptoms has directed several researchers to suggest the concept of reproductive-related disorders (RRDs). These psychiatric conditions are said to include a collection of disorders categorized by their connection to reproductive processes and a maladaptive response by patients defined as being "genetically vulnerable" to normal hormonal variations. Other authors have examined not only the validity of such a construct, but also with respect to menopause, whether the marked cross-cultural changes in menopausal symptoms support this hypothesis [62]. While most women do not suffer negative mood consequences during menopausal transition, the risk to develop a major depression disorder (MDD) or depressive symptoms throughout perimenopause is greater than in the premenopausal stage. Nevertheless, estimates from individual studies are diverse and hence the true risk estimate is unknown [63].

Depression (at both the symptom and the disease level) was related with poorer QoL, and that this link appeared to be stable over time. Getting better from MDD after treatment resulted in higher QoL, and the QoL improved even in patients who did not fully recover from the depressive episode. Since MDD affects QoL negatively irrespective of medical health, it is imperative to identify MDD and treat MDD patients. Consequently, it is importantly suggested that the health personnel in specialist and primary healthcare settings have a dual treatment perspective, including both psychological and physical health [64].

MDD is an incapacitating disorder, which frequently directs to substantial personal, societal, and economic costs. It affects 20% of adults in the US, and women are known for being overly more affected than men. The roots of such increased risk (2-fold on average) have been the subject of discussion and research from diverse perspectives—from epidemiology to genetics, from copying strategies to hormone variations. Windows of risk for MDD—also known as reproductiverelated depressive episodes—are probable linked with an augmented sensitivity suffered by several women to variations in the hormonal situation that happen throughout the luteal phase of their cycles, in the course of the postpartum phase, and/or throughout the menopause transition [65]. The odds-on depressive symptoms in perimenopause are doubled when associated to the premenopause and similar when compared to the postmenopause. Furthermore, throughout the perimenopausal phase, women describe a higher level of depressive symptoms severity when compared to the premenopause but not to the postmenopause. Moreover, there are signs for a positive connexion between vasomotor complaints and MDD during the perimenopause [63]. The presence of a menopause-associated depression, though, has been a more discussed issue. While it is irrefutable that variations in sex hormones and metabolism may affect QoL and overall functioning among certain women throughout midlife years, supplementary aspects—not connected to the menopause transition—may also influence MDD at this stage in life, involving comorbid medical illnesses, cardiovascular complications, vasomotor symptoms (VMS), sleep disorders, and stressful life events [65].

It is suggested that declines in estrogen around menopause are associated with declines in cognitive functioning as well as increased risk of depressive symptoms

**95**

episodes [65].

*Quality of Life and Menopause*

*DOI: http://dx.doi.org/10.5772/intechopen.88983*

stages than in premenopause [66].

and depressive disorders. Estrogen promotes neuronal growth and survival and acts on the cholinergic system, which is closely linked to cognitive functioning, particularly memory. Several studies suggest that cognitive function supported by the prefrontal cortex may be particularly sensitive to estrogen. Estrogen also has a role in neurotransmitter systems involved in depression. For instance, estrogen acts as a serotonergic agonist/modulator by increasing receptor binding sites, synthesis, and uptake in animal models and postmenopausal women and numerous longitudinal studies have demonstrated an increased risk of depressed mood in the menopausal transition compared to the premenopausal stage. The peri- and post-menopausal phases are linked with declines in delayed verbal memory compared to premenopause. Moreover, the postmenopausal stage is linked with reductions in phonemic verbal fluency contrasted to perimenopause. Evidences propose that women are at a meaningfully augmented risk of getting MDD, as determined either by symptom inventory or by structured clinical interviews, in the peri- and post-menopausal

The strengthened burden related with depression, at any point in time, is undisputable. Thus far, the existence and perseverance of symptoms of depression over time—symptoms that do not reunite criteria for MDD—may furthermore trigger anyway psychosocial difficulties and negatively impact total health. It is, consequently, significant that physicians maintain a tighter surveillance and regularly re-evaluate the necessity for treatments to resolve depressive symptoms (e.g., low mood, reduced psychological energy and pleasure with habitual activities, and sleep problems), whether by employing pharmacologic options, behavioral/ lifestyle modifications, or supplementary alternatives. An important amount of both cross-sectional and prospective reports have discovered a possible relationship between different menopause staging and the risks for depressive symptoms or MDD (new onset or recurrent). In general, information from cross-sectional trials show that symptoms of depression can be found by up to 70% of patients throughout perimenopause contrasted with almost 30% in premenopausal period. Longitudinal studies can describe the ideal approach for evaluating the link between reproductive staging and MDD, have also proposed an augmented risk (1.5- to 3.0-fold) for symptoms of depression during the menopause transition. This augmented risk was documented even between women with no preceding

Longitudinal trials have acknowledged possibility reasons for the presence of midlife MDD that appear persistent during the lifetime; they establish a continuum of risk for MDD and very likely function as regulating aspects. These aspects can be considered as: (1) demographic or socioeconomic (i.e., unemployment, low education, and being black or Hispanic); (2) health-related (e.g., greater body mass index, being a smoker, reporting poor health, and decreased functioning due to chronic medical diseases); and (3) psychosocial (e.g., reduced social care, record of anxiety, and one or more stressful life events). A prior MDD episode signifies the robust prognosticator for MDD throughout midlife years, while antecedents of mood symptoms with a hormone-related background (i.e., history of premenstrual syndrome/PMDD or postpartum depression) have been discreetly related to MDD

Investigators also explored the causative role of timing-related, context-related influences. Once more, results from cross-sectional and longitudinal investigation were valued foundations and helped to recognize in facilitating or triggering

(1) hormone changes (i.e., the occurrence of wider variations in follicle-stimulating hormone [FSH] and estradiol [E2] levels over time); (2) menopause-related

during the menopause phase and initial postmenopausal years [65].

elements linked to menopause-related MDD. These elements include:

#### *Quality of Life and Menopause DOI: http://dx.doi.org/10.5772/intechopen.88983*

*Quality of Life - Biopsychosocial Perspectives*

unknown [63].

**6. Menopause and psychiatric disorders**

including both psychological and physical health [64].

(VMS), sleep disorders, and stressful life events [65].

One of the most consistent findings in psychiatry and psychology is that from menarche onwards females are at higher risk than males of developing both depressive and anxiety disorders. This sex difference remains robust throughout the lifespan, including old age, in the years beyond the reproductive period. The extensively reported link between puberty, the perinatal period, and menopause and excessive amounts of anxiety and depressive symptoms has directed several researchers to suggest the concept of reproductive-related disorders (RRDs). These psychiatric conditions are said to include a collection of disorders categorized by their connection to reproductive processes and a maladaptive response by patients defined as being "genetically vulnerable" to normal hormonal variations. Other authors have examined not only the validity of such a construct, but also with respect to menopause, whether the marked cross-cultural changes in menopausal symptoms support this hypothesis [62]. While most women do not suffer negative mood consequences during menopausal transition, the risk to develop a major depression disorder (MDD) or depressive symptoms throughout perimenopause is greater than in the premenopausal stage. Nevertheless, estimates from individual studies are diverse and hence the true risk estimate is

Depression (at both the symptom and the disease level) was related with poorer QoL, and that this link appeared to be stable over time. Getting better from MDD after treatment resulted in higher QoL, and the QoL improved even in patients who did not fully recover from the depressive episode. Since MDD affects QoL negatively irrespective of medical health, it is imperative to identify MDD and treat MDD patients. Consequently, it is importantly suggested that the health personnel in specialist and primary healthcare settings have a dual treatment perspective,

MDD is an incapacitating disorder, which frequently directs to substantial personal, societal, and economic costs. It affects 20% of adults in the US, and women are known for being overly more affected than men. The roots of such increased risk (2-fold on average) have been the subject of discussion and research from diverse perspectives—from epidemiology to genetics, from copying strategies to hormone variations. Windows of risk for MDD—also known as reproductiverelated depressive episodes—are probable linked with an augmented sensitivity suffered by several women to variations in the hormonal situation that happen throughout the luteal phase of their cycles, in the course of the postpartum phase, and/or throughout the menopause transition [65]. The odds-on depressive symptoms in perimenopause are doubled when associated to the premenopause and similar when compared to the postmenopause. Furthermore, throughout the perimenopausal phase, women describe a higher level of depressive symptoms severity when compared to the premenopause but not to the postmenopause. Moreover, there are signs for a positive connexion between vasomotor complaints and MDD during the perimenopause [63]. The presence of a menopause-associated depression, though, has been a more discussed issue. While it is irrefutable that variations in sex hormones and metabolism may affect QoL and overall functioning among certain women throughout midlife years, supplementary aspects—not connected to the menopause transition—may also influence MDD at this stage in life, involving comorbid medical illnesses, cardiovascular complications, vasomotor symptoms

It is suggested that declines in estrogen around menopause are associated with declines in cognitive functioning as well as increased risk of depressive symptoms

**94**

and depressive disorders. Estrogen promotes neuronal growth and survival and acts on the cholinergic system, which is closely linked to cognitive functioning, particularly memory. Several studies suggest that cognitive function supported by the prefrontal cortex may be particularly sensitive to estrogen. Estrogen also has a role in neurotransmitter systems involved in depression. For instance, estrogen acts as a serotonergic agonist/modulator by increasing receptor binding sites, synthesis, and uptake in animal models and postmenopausal women and numerous longitudinal studies have demonstrated an increased risk of depressed mood in the menopausal transition compared to the premenopausal stage. The peri- and post-menopausal phases are linked with declines in delayed verbal memory compared to premenopause. Moreover, the postmenopausal stage is linked with reductions in phonemic verbal fluency contrasted to perimenopause. Evidences propose that women are at a meaningfully augmented risk of getting MDD, as determined either by symptom inventory or by structured clinical interviews, in the peri- and post-menopausal stages than in premenopause [66].

The strengthened burden related with depression, at any point in time, is undisputable. Thus far, the existence and perseverance of symptoms of depression over time—symptoms that do not reunite criteria for MDD—may furthermore trigger anyway psychosocial difficulties and negatively impact total health. It is, consequently, significant that physicians maintain a tighter surveillance and regularly re-evaluate the necessity for treatments to resolve depressive symptoms (e.g., low mood, reduced psychological energy and pleasure with habitual activities, and sleep problems), whether by employing pharmacologic options, behavioral/ lifestyle modifications, or supplementary alternatives. An important amount of both cross-sectional and prospective reports have discovered a possible relationship between different menopause staging and the risks for depressive symptoms or MDD (new onset or recurrent). In general, information from cross-sectional trials show that symptoms of depression can be found by up to 70% of patients throughout perimenopause contrasted with almost 30% in premenopausal period. Longitudinal studies can describe the ideal approach for evaluating the link between reproductive staging and MDD, have also proposed an augmented risk (1.5- to 3.0-fold) for symptoms of depression during the menopause transition. This augmented risk was documented even between women with no preceding episodes [65].

Longitudinal trials have acknowledged possibility reasons for the presence of midlife MDD that appear persistent during the lifetime; they establish a continuum of risk for MDD and very likely function as regulating aspects. These aspects can be considered as: (1) demographic or socioeconomic (i.e., unemployment, low education, and being black or Hispanic); (2) health-related (e.g., greater body mass index, being a smoker, reporting poor health, and decreased functioning due to chronic medical diseases); and (3) psychosocial (e.g., reduced social care, record of anxiety, and one or more stressful life events). A prior MDD episode signifies the robust prognosticator for MDD throughout midlife years, while antecedents of mood symptoms with a hormone-related background (i.e., history of premenstrual syndrome/PMDD or postpartum depression) have been discreetly related to MDD during the menopause phase and initial postmenopausal years [65].

Investigators also explored the causative role of timing-related, context-related influences. Once more, results from cross-sectional and longitudinal investigation were valued foundations and helped to recognize in facilitating or triggering elements linked to menopause-related MDD. These elements include: (1) hormone changes (i.e., the occurrence of wider variations in follicle-stimulating hormone [FSH] and estradiol [E2] levels over time); (2) menopause-related

symptoms (e.g., existence and seriousness of VMS and insomnia); and (3) global health (current poor health and low functioning because long-lasting diseases). Psychosocial stressors (including poor social help and stressful life events—the latter not only considered by the severity and number of episodes but also founded on the timing of their manifestation linked to the menopause transition per se) [65].

Nevertheless, symptoms of MDD such as insomnia and low energy in midlife women may be challenging to differentiate from menopausal symptoms and may not often reveal an MDD. They might also be associated to symptoms of the menopause such as VMS. This is reliable with the results of investigations of depressive symptoms, which demonstrate that they are more frequent throughout the menopausal transition in comparison with both pre and postmenopausal stages. It is too reliable with the remark that depressive symptoms could growth around the postmenopausal phase as somatic symptoms progressively become less frequent and/or severe, and that they can improve with the management of central menopausal symptoms such as VMS [67]. Also, psychological aspects as inter-personal relations, role, and sociocultural factors are defined as predictors for MDD during menopause [63].

Antidepressants are the first-line management of MDD around midlife years, mainly for women who had suffered numerous MDD episodes before (not always hormone-related) and women describing serious symptoms, important functional harm, and/or communicating suicidal thoughts. For recurrent episodes, a prior response to a particular antidepressant (agent or class) must lead the main resolution on what to use initially. For women facing MDD for the first time, women who never received treatment before, or women with antecedents of partial/no response to antidepressants before, current evidence confirmed the efficacy and tolerability of numerous SSRIs and SNRIs at typical doses; there are trials on fluoxetine, sertraline, venlafaxine, citalopram, escitalopram, duloxetine, and desvenlafaxine [65]. In a recent published paper, data support further study of vortioxetine for treating menopausal depression and associated symptoms (VMS) and was generally well-tolerated [68].

The association between depression and menopause has been extensively explored, but the study of anxiety remains largely neglected. This is surprising, since symptoms of anxiety in the community are more common than those of depression, and generalized anxiety disorder (GAD) is the second most prevalent psychiatric disorder in the primary care setting [62]. Peri- and post-menopausal phases represent a window of risk for emergence of anxiety symptoms and disorders in the life cycle of adult women. Compared to MDD, anxiety symptoms and disorders remain mainly unknown throughout this period of a woman's life, regardless of major impact on QoL if not identified and treated [69]. 'Anxiety' is a general term that can opaque the important difference between anxiety symptoms and anxiety disorders. Anxiety includes various symptoms such as feeling on edge, worrying, specific fears, and physiological arousal, and these may be distressing to the patient. Anxiety disorders, however, are defined by reference to specific criteria, and have much lower prevalence than anxiety symptoms. Most of the investigations reviewed measured anxiety symptoms, rather than anxiety disorders. There are physical correspondences between anxiety symptoms, particularly panic attacks and VMS. These include increasing sensations of heat through the chest and head, palpitations, and sweating connected with increased metabolic rate and noradrenergic dysregulation. It is not clear, however, whether body sensations of anxiety come first VMS or vice versa. The up-to-date data based on large community-based investigations proposes that psychological

**97**

*Quality of Life and Menopause*

symptoms in this group [70].

*DOI: http://dx.doi.org/10.5772/intechopen.88983*

perceived control over their hot flashes [62].

symptoms during the menopause transition are related with known risk factors for anxiety and MDD, including stressful life events. An additional cognitive aspect that could be significant for comprehending the link between anxiety and VMS is that of catastrophic thinking. It is well-known that catastrophic thinking has a negative effect on perceived symptom seriousness in chronic health diseases. Those who report increased catastrophic thoughts also be likely to register poorer

Investigation has showed that sleep problems are frequent in middle-aged women, among whom the frequency of sleep problems has been observed to elevate in the period between pre- to peri- and post-menopause. While the precise process causing the connexion between elevated sleep troubles and the development of menopause is not completely recognized, it is probably linked to establish relationship between sleep disturbances. It has been found that VMS and depressed mood at this period in a woman's life are closely related, women who suffer from VMS and sleep troubles, 30% of them were severely depressed. The results of one study were that the findings of this study show that difficulty in initiating sleep (DIS) is meaningfully connected with anxiety and non-restorative sleep (NRS) is meaningfully related with MDD in peri- and post-menopausal women in a clinical scenery. Those who describe suffering DIS or NRS may be highly probable to likewise be experiencing anxiety or MDD, correspondingly, signifying that management of these problems might increase the related insomnia

Multiple randomized controlled trials (RCTs) support the efficacy of SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs) as first-line treatments for anxiety disorders. An analysis of 12 RCTs in panic disorder found a mean effect size for SSRIs relative to placebo of 0.55. In the case of GAD, response rates for SSRIs of between 60 and 75% are generally reported in RCTs, compared to response rates between 40 and 60% for placebo. Data suggest that post-traumatic stress disorder (PTSD) may be less amenable to current pharmacotherapy compared to other anxiety disorders. A Cochrane review of pharmacotherapy for PTSD including 35 RCTs and 4597 participants did support the use of SSRIs as first-line medication treatment. The benzodiazepines (BZD) play a significant position in the management of several anxiety disorders; but, these drugs are commonly kept for second-line or accessory utilization because of their tolerability and abuse danger issues. BZD possess the benefit of a fast onset of action, tempting their employment premature in the process of management preceding to the onset of action of a co-administered SSRI/SNRI. Information backing the longer-term efficacy of BZD is more inadequate [71]. BZD inappropriate use (i.e., misuse and overuse) is a global public health concern. Regardless of existing information about augmented sensitivity to adverse effects in the elderly that should guide to additional carefulness. Only 30% of BZD prescriptions in these women are believed correct. The largely prevalent deficient conditions are disproportionate length and/or dosage of a medical prescription or self-medication, particularly in a situation where it would be contraindicated, for example, long-acting BZD in the elderly. Polypharmacy and comorbidities are the main risk factors. Results of benzodiazepines incorrect employment are falls, delirium and other cognitive dysfunction, acute respiratory failure, traffic accidents, abuse, addiction, and withdrawal symptoms. A developing apprehension is a possibly elevated risk of dementia. Opposing many physicians' idea, discontinuation of long time BZD use in elderly patients is achievable, with acceptable psychotherapeutic or pharmacological options, and can direct to long-term abstinence [72]. Anticonvulsants, including gabapentin and pregabalin, have mixed data to support efficacy in

#### *Quality of Life and Menopause DOI: http://dx.doi.org/10.5772/intechopen.88983*

*Quality of Life - Biopsychosocial Perspectives*

per se) [65].

menopause [63].

well-tolerated [68].

symptoms (e.g., existence and seriousness of VMS and insomnia); and (3) global health (current poor health and low functioning because long-lasting diseases). Psychosocial stressors (including poor social help and stressful life events—the latter not only considered by the severity and number of episodes but also founded on the timing of their manifestation linked to the menopause transition

Nevertheless, symptoms of MDD such as insomnia and low energy in midlife women may be challenging to differentiate from menopausal symptoms and may not often reveal an MDD. They might also be associated to symptoms of the menopause such as VMS. This is reliable with the results of investigations of depressive symptoms, which demonstrate that they are more frequent throughout the menopausal transition in comparison with both pre and postmenopausal stages. It is too reliable with the remark that depressive symptoms could growth around the postmenopausal phase as somatic symptoms progressively become less frequent and/or severe, and that they can improve with the management of central menopausal symptoms such as VMS [67]. Also, psychological aspects as inter-personal relations, role, and sociocultural factors are defined as predictors for MDD during

Antidepressants are the first-line management of MDD around midlife years, mainly for women who had suffered numerous MDD episodes before (not always hormone-related) and women describing serious symptoms, important functional harm, and/or communicating suicidal thoughts. For recurrent episodes, a prior response to a particular antidepressant (agent or class) must lead the main resolution on what to use initially. For women facing MDD for the first time, women who never received treatment before, or women with antecedents of partial/no response to antidepressants before, current evidence confirmed the efficacy and tolerability of numerous SSRIs and SNRIs at typical doses; there are trials on fluoxetine, sertraline, venlafaxine, citalopram, escitalopram, duloxetine, and desvenlafaxine [65]. In a recent published paper, data support further study of vortioxetine for treating menopausal depression and associated symptoms (VMS) and was generally

The association between depression and menopause has been extensively explored, but the study of anxiety remains largely neglected. This is surprising, since symptoms of anxiety in the community are more common than those of depression, and generalized anxiety disorder (GAD) is the second most prevalent psychiatric disorder in the primary care setting [62]. Peri- and post-menopausal phases represent a window of risk for emergence of anxiety symptoms and disorders in the life cycle of adult women. Compared to MDD, anxiety symptoms and disorders remain mainly unknown throughout this period of a woman's life, regardless of major impact on QoL if not identified and treated [69]. 'Anxiety' is a general term that can opaque the important difference between anxiety symptoms and anxiety disorders. Anxiety includes various symptoms such as feeling on edge, worrying, specific fears, and physiological arousal, and these may be distressing to the patient. Anxiety disorders, however, are defined by reference to specific criteria, and have much lower prevalence than anxiety symptoms. Most of the investigations reviewed measured anxiety symptoms, rather than anxiety disorders. There are physical correspondences between anxiety symptoms, particularly panic attacks and VMS. These include increasing sensations of heat through the chest and head, palpitations, and sweating connected with increased metabolic rate and noradrenergic dysregulation. It is not clear, however, whether body sensations of anxiety come first VMS or vice versa. The up-to-date data based on large community-based investigations proposes that psychological

**96**

symptoms during the menopause transition are related with known risk factors for anxiety and MDD, including stressful life events. An additional cognitive aspect that could be significant for comprehending the link between anxiety and VMS is that of catastrophic thinking. It is well-known that catastrophic thinking has a negative effect on perceived symptom seriousness in chronic health diseases. Those who report increased catastrophic thoughts also be likely to register poorer perceived control over their hot flashes [62].

Investigation has showed that sleep problems are frequent in middle-aged women, among whom the frequency of sleep problems has been observed to elevate in the period between pre- to peri- and post-menopause. While the precise process causing the connexion between elevated sleep troubles and the development of menopause is not completely recognized, it is probably linked to establish relationship between sleep disturbances. It has been found that VMS and depressed mood at this period in a woman's life are closely related, women who suffer from VMS and sleep troubles, 30% of them were severely depressed. The results of one study were that the findings of this study show that difficulty in initiating sleep (DIS) is meaningfully connected with anxiety and non-restorative sleep (NRS) is meaningfully related with MDD in peri- and post-menopausal women in a clinical scenery. Those who describe suffering DIS or NRS may be highly probable to likewise be experiencing anxiety or MDD, correspondingly, signifying that management of these problems might increase the related insomnia symptoms in this group [70].

Multiple randomized controlled trials (RCTs) support the efficacy of SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs) as first-line treatments for anxiety disorders. An analysis of 12 RCTs in panic disorder found a mean effect size for SSRIs relative to placebo of 0.55. In the case of GAD, response rates for SSRIs of between 60 and 75% are generally reported in RCTs, compared to response rates between 40 and 60% for placebo. Data suggest that post-traumatic stress disorder (PTSD) may be less amenable to current pharmacotherapy compared to other anxiety disorders. A Cochrane review of pharmacotherapy for PTSD including 35 RCTs and 4597 participants did support the use of SSRIs as first-line medication treatment. The benzodiazepines (BZD) play a significant position in the management of several anxiety disorders; but, these drugs are commonly kept for second-line or accessory utilization because of their tolerability and abuse danger issues. BZD possess the benefit of a fast onset of action, tempting their employment premature in the process of management preceding to the onset of action of a co-administered SSRI/SNRI. Information backing the longer-term efficacy of BZD is more inadequate [71]. BZD inappropriate use (i.e., misuse and overuse) is a global public health concern. Regardless of existing information about augmented sensitivity to adverse effects in the elderly that should guide to additional carefulness. Only 30% of BZD prescriptions in these women are believed correct. The largely prevalent deficient conditions are disproportionate length and/or dosage of a medical prescription or self-medication, particularly in a situation where it would be contraindicated, for example, long-acting BZD in the elderly. Polypharmacy and comorbidities are the main risk factors. Results of benzodiazepines incorrect employment are falls, delirium and other cognitive dysfunction, acute respiratory failure, traffic accidents, abuse, addiction, and withdrawal symptoms. A developing apprehension is a possibly elevated risk of dementia. Opposing many physicians' idea, discontinuation of long time BZD use in elderly patients is achievable, with acceptable psychotherapeutic or pharmacological options, and can direct to long-term abstinence [72]. Anticonvulsants, including gabapentin and pregabalin, have mixed data to support efficacy in

certain anxiety disorders. The data for second-generation antipsychotics (SGAs) in anxiety disorders are likewise mixed [71].

### **7. Menopause and sexual disorders**

Female sexual dysfunction (FSD) and QoL are both multidimensional and have a bidirectional relationship across the reproductive life span and beyond. Methodological difficulties exist in assessing the actual prevalence of FSD because it is difficult to define the level of distress related to sexual symptoms. Around 40–50% of women present at least one sexual symptom, and various disorders related with hormonal variations at menopause, such as vulvovaginal atrophy (VVA) and hypoactive sexual desire disorder (HSDD), have an important influence on sexual function and QoL. Sexual troubles reach a highest point at midlife, decay with age, and are importantly partner-associated [73].

Although in human's sexual drive and performance are to some degree untied from sex hormones, menopause is the most studied medical condition in the framework of FSD from a biological perspective since there is a strong state of hormonal deficiency. Both the substantial descent in blood estrogen levels with natural menopause and the androgen reduction with age and, ultimately, with surgical menopause, have been exposed to back, to a distinct degree, to sexual complains such as low desire, reduced excitement, dyspareunia, orgasm difficulties, and diminished sexual gratification. In contrast, menopause impacts psychologic and cognitive characteristics of sexuality throughout the variation in blood sex hormones, but this could be partially related on the particular antecedents of the specific patient. The mainly important factors are age, global and mental health, and attainment of reproductive objectives, education, body image, self-esteem, values and experiences. Even length and quality of relationship, and global and sexual health of the sexual partner, are significant [73].

Sexual health and function are important goals in the management of menopausal women. The majority of these women wants their sexuality to be a significant part of their life and intensely desire to maintain a healthy and satisfactory sexual life. Nevertheless, the risk of having a disease that negatively affects sexual satisfaction and function as well as the risk for using prescription drugs that have an adverse impact in sexual function increases as women age. Although sexual dissatisfaction and dysfunction are highly predominant in peri- and post-menopausal women, few reveal their concerns to the health care provider. Age-related declines in sexual function may meaningfully reduce QoL [74].

Sexual function decays throughout midlife. The Study of Women's Health Across the Nation and other related observed that this drop links with the menopausal period, including in women who experience hysterectomy. Though symptoms such as vaginal dryness rise during the same interval, variations in sexual functioning are unrelated of other symptoms linked to the menopausal period. Decrease in sexual frequency throughout this period of life is multifactorial. One main factor that women do not participate in sexual activity is absence of a sexual partner. Women who are more sexually active previously menopause appear to remain to participate in sexual behaviors during midlife, even with reduced "functional sex." Lifestyle situations, including enough sleep and exercise, contribute to better sexual functioning during midlife [75, 76].

Vulvovaginal atrophy (VVA) is an important factor of genitourinary syndrome of menopause (GSM) and can end in postcoital vaginal bleeding, vaginal burning, irritation, and pain and distress with sexual behavior. Symptomatic GSM is frequently associated by reduced secretions from vulvar sebaceous glands and

**99**

*Quality of Life and Menopause*

*DOI: http://dx.doi.org/10.5772/intechopen.88983*

burning and raise the risk of sexual dysfunctions.

mon with bupropion and mirtazapine [75].

approaches, like mindfulness meditation or exercise.

crucial element of preserving QoL into older adulthood [75].

decreased vaginal lubrication during sexual arousal. Hypo-estrogenic climacteric patients frequently face a change of the vaginal microbiome from lactic acidproducing lactobacilli to gram-negative and -positive bacteria. This change in the vaginal microbiome causes raising of the vaginal pH, local immune changes, and increased cytokine synthesis, which exacerbates symptoms of vaginal dryness and

Pelvic organ prolapses (POP) consist of descent of one or more woman reproductive organs (anterior and/or posterior vaginal wall, the uterus or the apex of the vagina). The occurrence of pelvic floor relaxation rises with elderly and is theorized to appear from a mixture of connective tissue degradation, pelvic denervation, and devascularization, all of which prompt to prolapse. Dyspareunia, chronic pelvic pain, and poor self-image are related with POP. All of these undesirable physical alterations can destroy sexual desire and performance. Many medical problems, like diabetes, hypertension, and breast cancer, and their treatments, have been related with female sexual dysfunction. These conditions become more common as women move through midlife. Other medications have been associated with FSD. Among the most common responsible factors is the use of antidepressants. Although MDD itself is associated with sexual dysfunction, odds of sexual dysfunction are 4–6 times higher for women taking an antidepressant. Sexual side effects are less com-

The presence of MDD and anxiety symptoms during the menopausal period is frequent. Mood disorders and sexual dysfunction are significantly comorbid, with 25–75% of depressed women reporting sexual symptoms even when treating for other problems. It is important for health personnel to screen women with sexual complaints for MDD and anxiety disorders and be aware of that not all women with FSD have a MDD or an anxiety disorder. Common life stressors also have an undesirable influence. Midlife women may be look after for children of their own, may have adult offspring at home, and/or may attend to aging parents. Job-associated stress and economic worries are also frequent. Health personnel must be familiar to the costs of life stressors and convince patients to cultivate stress diminution

Patients who suffered or are victims of violence and abuse are at augmented risk for FSD, with those who suffered sexual abuse, up to 44% of women over their lifetime, at predominantly elevated jeopardy. The link between abuse antecedent and FSD is not totally explicated by psychiatric disorders, such as MDD, anxiety, and post-traumatic stress disorder (PTSD). It is significant to utilize evidence-based, trauma-informed management tools to ask for these experiences when treating patients with FSD. Helping women preserve healthy sexual function with aging is a

#### *Quality of Life and Menopause DOI: http://dx.doi.org/10.5772/intechopen.88983*

*Quality of Life - Biopsychosocial Perspectives*

anxiety disorders are likewise mixed [71].

**7. Menopause and sexual disorders**

sexual partner, are significant [73].

functioning during midlife [75, 76].

with age, and are importantly partner-associated [73].

in sexual function may meaningfully reduce QoL [74].

certain anxiety disorders. The data for second-generation antipsychotics (SGAs) in

Female sexual dysfunction (FSD) and QoL are both multidimensional and have a bidirectional relationship across the reproductive life span and beyond. Methodological difficulties exist in assessing the actual prevalence of FSD because it is difficult to define the level of distress related to sexual symptoms. Around 40–50% of women present at least one sexual symptom, and various disorders related with hormonal variations at menopause, such as vulvovaginal atrophy (VVA) and hypoactive sexual desire disorder (HSDD), have an important influence on sexual function and QoL. Sexual troubles reach a highest point at midlife, decay

Although in human's sexual drive and performance are to some degree untied from sex hormones, menopause is the most studied medical condition in the framework of FSD from a biological perspective since there is a strong state of hormonal deficiency. Both the substantial descent in blood estrogen levels with natural menopause and the androgen reduction with age and, ultimately, with surgical menopause, have been exposed to back, to a distinct degree, to sexual complains such as low desire, reduced excitement, dyspareunia, orgasm difficulties, and diminished sexual gratification. In contrast, menopause impacts psychologic and cognitive characteristics of sexuality throughout the variation in blood sex hormones, but this could be partially related on the particular antecedents of the specific patient. The mainly important factors are age, global and mental health, and attainment of reproductive objectives, education, body image, self-esteem, values and experiences. Even length and quality of relationship, and global and sexual health of the

Sexual health and function are important goals in the management of menopausal women. The majority of these women wants their sexuality to be a significant part of their life and intensely desire to maintain a healthy and satisfactory sexual life. Nevertheless, the risk of having a disease that negatively affects sexual satisfaction and function as well as the risk for using prescription drugs that have an adverse impact in sexual function increases as women age. Although sexual dissatisfaction and dysfunction are highly predominant in peri- and post-menopausal women, few reveal their concerns to the health care provider. Age-related declines

Sexual function decays throughout midlife. The Study of Women's Health Across

Vulvovaginal atrophy (VVA) is an important factor of genitourinary syndrome of menopause (GSM) and can end in postcoital vaginal bleeding, vaginal burning, irritation, and pain and distress with sexual behavior. Symptomatic GSM is frequently associated by reduced secretions from vulvar sebaceous glands and

the Nation and other related observed that this drop links with the menopausal period, including in women who experience hysterectomy. Though symptoms such as vaginal dryness rise during the same interval, variations in sexual functioning are unrelated of other symptoms linked to the menopausal period. Decrease in sexual frequency throughout this period of life is multifactorial. One main factor that women do not participate in sexual activity is absence of a sexual partner. Women who are more sexually active previously menopause appear to remain to participate in sexual behaviors during midlife, even with reduced "functional sex." Lifestyle situations, including enough sleep and exercise, contribute to better sexual

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decreased vaginal lubrication during sexual arousal. Hypo-estrogenic climacteric patients frequently face a change of the vaginal microbiome from lactic acidproducing lactobacilli to gram-negative and -positive bacteria. This change in the vaginal microbiome causes raising of the vaginal pH, local immune changes, and increased cytokine synthesis, which exacerbates symptoms of vaginal dryness and burning and raise the risk of sexual dysfunctions.

Pelvic organ prolapses (POP) consist of descent of one or more woman reproductive organs (anterior and/or posterior vaginal wall, the uterus or the apex of the vagina). The occurrence of pelvic floor relaxation rises with elderly and is theorized to appear from a mixture of connective tissue degradation, pelvic denervation, and devascularization, all of which prompt to prolapse. Dyspareunia, chronic pelvic pain, and poor self-image are related with POP. All of these undesirable physical alterations can destroy sexual desire and performance. Many medical problems, like diabetes, hypertension, and breast cancer, and their treatments, have been related with female sexual dysfunction. These conditions become more common as women move through midlife. Other medications have been associated with FSD. Among the most common responsible factors is the use of antidepressants. Although MDD itself is associated with sexual dysfunction, odds of sexual dysfunction are 4–6 times higher for women taking an antidepressant. Sexual side effects are less common with bupropion and mirtazapine [75].

The presence of MDD and anxiety symptoms during the menopausal period is frequent. Mood disorders and sexual dysfunction are significantly comorbid, with 25–75% of depressed women reporting sexual symptoms even when treating for other problems. It is important for health personnel to screen women with sexual complaints for MDD and anxiety disorders and be aware of that not all women with FSD have a MDD or an anxiety disorder. Common life stressors also have an undesirable influence. Midlife women may be look after for children of their own, may have adult offspring at home, and/or may attend to aging parents. Job-associated stress and economic worries are also frequent. Health personnel must be familiar to the costs of life stressors and convince patients to cultivate stress diminution approaches, like mindfulness meditation or exercise.

Patients who suffered or are victims of violence and abuse are at augmented risk for FSD, with those who suffered sexual abuse, up to 44% of women over their lifetime, at predominantly elevated jeopardy. The link between abuse antecedent and FSD is not totally explicated by psychiatric disorders, such as MDD, anxiety, and post-traumatic stress disorder (PTSD). It is significant to utilize evidence-based, trauma-informed management tools to ask for these experiences when treating patients with FSD. Helping women preserve healthy sexual function with aging is a crucial element of preserving QoL into older adulthood [75].

*Quality of Life - Biopsychosocial Perspectives*
