Menarche Perimenopause Menopause Premenopause Postmenopause Ages 4257 Depressed, anxious, disturbed sleep, decreased concentration Fully assess/especi

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1 KISEP Review Article J Korean Neuropsychiatr Assoc Vol 42, No 1 생식정신의학 : 폐경주변기및폐경기 전진숙 Reproductive Psychiatry:Perimenopause and Menopause Jin-Sook Cheon, MD Department of Neuropsychiatry, Kosin University, School of Medicine, Busan, Korea The most troublesome symptoms of perimenopause and menopause are hot flushes, insomnia, depression, sexual dysfunction and cognitive decline. The suggested mechanism is the hormonal changes of estrogen, progesterone and androgen as well as neuromodulating effect of estrogen, which enhances activity of 5-HT and norepinephrine, inhibiting monoamine oxidase and dopamine. Though testosterone deficiency is not analogous to female menopause, male climacteric has become a clinical issue in current psychiatry. KEY WORDS:Menopause Hot flushes Depression Estrogen Neuromodulation Male climacteric. 서 론 - 폐경기증상 46

2 Menarche Perimenopause Menopause Premenopause Postmenopause Ages 4257 Depressed, anxious, disturbed sleep, decreased concentration Fully assess/especially note 1. Somatic symptoms, menstrual pattern 2. Past psychiatric history, including reprodution-related history 3. Current psychosocial issues 4. TSH Age years Fig. 1. Reproductive life cycle. 2) FSH & LH IU/L Mean circulating hormone levels Estradiol Estrone Pg/mL Estradiol Estrone Fig. 2. The perimenopausal transition. 4) FSH Age years Menopause LH No Yes FSH E2 1. Consider psychiatric d/o 2. Consider repeat FSH, E2 in 3 months 3. Consider standard psychiatric treatment Yes Yes Symptoms remit No further psychiatric treatment needed Vasomotor symptoms 1. Perimenopause does not rule out psychiatric comorbidity 2. Educate re menopause, HRT 3. Refer to gyencologist 4. Offer psychotherapy group, individual HRT Begin psychiatric treatment Symptoms remit No FSH E2 Yes Yes No NoNo 1. Consider psychiatric d/o 2. Consider standard psychiatric treatment No Yes No further psychiatric treatment needed Fig. 3. Psychiatric evaluation of the middle-aged depressed womanspecial considerations. 15) TSHthyroid-stimulating hormone, FSHfollicle-stimulating hormone, d/odisorder, E2estradiol, HRThormone replacement therapy

3 기전 Cholesterol HO CH3 C=O CH3 C=O HO CH2OH H O=C C=O O O HO Pregnenolone Progesterone 11-Deoxycorticosterone Corticosterone 18-Hydroxycorticosterone Aldosterone CH3 CH3 C=O C=O OH OH HO CH2OH C=O OH O HO 17-Hydroxypregnenolone 17-Hydroxyprogesterone 11-Deoxycortisol Cortisol OH HO O O O O Dehydroepiandrosterone Androstenedione Testosterone O OH Estrone Estradiol HO O H Dihydrotestosterone OH Fig. 4. Synthetic pathways for steroid hormones. 25) Circled numbers identify synthetic enzymes 1 cytochrome P450 CYP 11A cholesterol desmolase, 23-hydroxysteroid dehydrogenase, 3CYP hydroxylase, 4CYP11B2 11hydroxylase, 18-hydroxylase, 18- oxidase, 5CYP17 17-hydroxylase, 17, 20-lyase, 617hydroxysteroid dehydrogenase or oxidoreductase, 7aromatase, 85-reductase, 9 CYP11B1 11-hydroxylase. 48

4 - - GABA VIP, NE, EP Aspartate FSH Estrogens Fig. 5. Ovarian axis. 26) Intrinsic circadian rhythm Hypothalamus CRH + Anterior pituitary ACTHLPH/-end + Adrenal cortex cortisol Stress Stress sensory stimuli Hypothalamus GnRH Pituitary Ovary Dopamine, serotonin, CRH, OT LH Progesterone Ovary estrogen/ progesterone Fig. 6. Overview of hypothalamic-pituitary-adrenal HPA axis function. 27) ACTHadrenocorticopropic hormone, -LPH/end-lipotropin and -endorphin, CRHcorticotropin-releasing hormone. - - 치료 - 49

5 남성갱년기 Table 1. Alternative treatments for hot flushes 45) Clonidine, Bromocriptine, Naloxone, Bellergal, Veralipride, Methyldopa, Venlafaxine, Vitamin E, Megestrol acetate, Medroxyprogesterone acetate Tibolonea steroid related to 19-nortestosterone Natural therapiesginseng, Agnus castus, Red sage, Black cohosh, Beth root, Phytoestrogens legumes, soybeans Dehydroepiandrosterone DHEA 50

6 결 T E2 LH GnRH Leydig cell + Testicle T Sperm Fig. 7. Hypothalamic-pituitary-testicular axis. 54) GnRHgonadotropin-releaing hormone, LHluteinizing hormone, FSHfolliclestimulating hormone, Ttestosterone, DHTdihydrotestosterone, ABPandrogen-binding protein, E2estradiol, +positive influence, negative influence. 론 Hypothalamus Pituitary ABP Seminiferous tubule FSH Inhibin T DHT E2 Sertoli cell 51

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Treatment and Role of Hormaonal Replaement Therapy

Treatment and Role of Hormaonal Replaement Therapy Treatment and Role of Hormone Replacement Therapy Chung-Ang University Hospital Chee Jeong Kim 7.2 5.3 6.4 5.6 7.3 5.5 1 1 2 3 4 10 11 7 34 49 122 123 1.0 - - 10. 2001 1998 1998 Improvement of postmenopausal