Nasrudin

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Is anyone here using sex hormone replacement therapy for depression. Thyroid axis problems seems more matter of fact, you test the axis on every admission, if you see a problem, you consult and treat.

But from my literature searches it seems that there is a growing data base that appear to support sex hormone replacement in certain populations of depressed patients.

I'm just curious why I don't hear anything about in my practice circles. Doesn't seem like anybody looks for gonadal axis dysfunction in their depressed patients. Maybe they shouldn't. It just seems like a plausible explanation for many of the subjective and even physical symptoms we look for in depressive disorders.
 

wolfvgang22

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I see primary care in the VA test for low testosterone all the time and treat it. The patients say it helps a lot with low energy. Primary care in my institution asks that we leave the hormone testing and treatment to them, if I want them or endocrinology to treat low hormones, so I do.
I have one patient with low FSH (has only one ovary) I've referred to endocrinology.
 

splik

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given that psychiatrists aren't typically doing physical examinations on their patients and that it is not typically appropriate for psychiatrists to be doing genital examinations on patients, it is not appropriate for psychiatrists to be prescribing hormones. psychiatrists don't treat hypothyroidism either - we use T3 augmentation for depression in euthyroid patients and T4 for bipolar depression in euthyroid patients. Different thing altogether and the endocrinologists balk at it. T3 augmentation has only been shown to be effective when added to a TCA or MAOI and the vast majority of patients on T3 for depression are not either of these classes of drugs.

I think it is appropriate for psychiatrists to check hormones in patients (remembering it is often 0800 levels) and refer appropriately.

In my neuropsychiatry clinic I check as routine in my TBI patients and neurosurgery patients TSH, T4, FSH, LH, 0800 cortisol, 0800 estradiol/testosterone, prolactin, and IGF-1. However I refer to endocrinology for treatment of any NED.
 
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psych md jd

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On the otherhand, I check my chemically castrated pts to make sure they have low T.
 

whopper

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HRT has it's place but I've noticed that a lot of my patients are getting testosterone without my recommendation nor thinking it was appropriate. While it's died down somewhat there was a big push a few years ago by pharm companies to testosteron-ize men hitting their 40s+.

Something else I noticed is some patients I've seen had low T (again cause it seems pharm companies have gotten docs to test for it quite a lot) in men that were in their 20s-30s that were on an SSRI. Led me to think maybe the SSRI was lowering their testosterone.
 

shan564

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I don't think we should be prescribing hormones for the aforementioned reasons, except for T3/T4 augmentation.

You should screen for hyperprolactinemia in patients taking antipsychotics.
You should look for corticosteroid treatment as a possible cause of psychiatric symptoms.
If you're concerned for Cushing's or Addison's, just look at their blood pressure and their latest electrolyte profile before checking hormone levels.
If the patient has opiate use disorder, I think it's reasonable for a psychiatrist to monitor sex hormone levels, especially if you're prescribing methadone/suboxone.
I don't think I'm qualified to prescribe sex steroids. We should ask about endocrine problems in our ROS, and if you suspect something specific, refer to somebody who knows more about that problem (even a PCP). If I think the endocrine problem is contributing to the psychiatric problem, I might go so far as to order a test (if I know the right test to order) and refer only if it's abnormal.

I'm sure we've all had patients whose psychiatric illness was mismanaged by a well-meaning neurologist or endocrinologist or PCP who is trying to do the best for the patient, but doesn't have the training to manage it correctly. You don't want to be the psychiatrist who does the same thing for somebody's endocrine problem.
 
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Nasrudin

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Thanks yall. I have a fascinating patient who had early ovarian failure, though not that early, and who's female hormone levels are low. She's depressed but struggles with a very specific delusional disorder that isolates her from human contact. She did much better on an SSRI but self stopped and doesn't want to take an antidepressant right now.

She's regressed in functioning but still taking a very small dose of zyprexa that is at least making it possible for her to function well enough on her own.

She's also eccentrically "holistic" and "natural." And believes in all sorts of alternative therapies. She had a keen native concern about her hormone levels.

So I was just curious if there was another route to lifting her moods via endocrine augmentations.

Based on this discussion, I'll try to convince her to take a referral to our Endo clinic.
 

Shikima

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HRT has it's place but I've noticed that a lot of my patients are getting testosterone without my recommendation nor thinking it was appropriate. While it's died down somewhat there was a big push a few years ago by pharm companies to testosteron-ize men hitting their 40s+.

Something else I noticed is some patients I've seen had low T (again cause it seems pharm companies have gotten docs to test for it quite a lot) in men that were in their 20s-30s that were on an SSRI. Led me to think maybe the SSRI was lowering their testosterone.
Check for OSA causing lower levels of T and cortisol dysfunction.
 

MamaPhD

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She's also eccentrically "holistic" and "natural." And believes in all sorts of alternative therapies. She had a keen native concern about her hormone levels.

So I was just curious if there was another route to lifting her moods via endocrine augmentations.
There is far more hype than evidence in this arena. I know a physician who is making a killing catering to women like this in his boutique practice, prescribing compounded hormones left and right. He claims to be practicing "anti-aging" medicine (I knew him from his days practicing in a legitimate specialty).

For reference, here are clinical recommendations from the North American Menopause Society (note the absence of recommendation re: hormone therapy):

PSYCHOLOGICAL SYMPTOMS
Key Points
  1. Most women do not become clinically depressed during the menopause transition; however, psychological symptoms, including depressed mood, anxiety, and decreased sense of well-being are common.
  2. Women with a history of a mood or anxiety disorder and early childhood stressful life events are at higher risk of increased psychological symptoms during the menopause transition. A history of premenstrual syndrome or postpartum depression is a strong risk factor for mood symptoms at midlife.
  3. Life stressors are common at midlife and often coincide with the menopause transition.
Recommendations for Clinical Care
  1. Healthcare providers should screen for psychological symptoms at midlife and treat psychological problems when indicated or provide appropriate referrals. (Level II)
  2. Mild depressive symptoms respond well to psychotherapy. Moderate or severe depressive symptoms generally require pharmacologic treatment in addition to psychotherapy. (Level I)
  3. Nonpharmacologic methods, including counseling and stress-reduction techniques, should be considered to reduce the adverse effects of stressors that commonly occur at midlife. (Level II)
  4. Education is key in helping women understand and cope with mood symptoms related to the menopause transition. (Level II)
 

Nasrudin

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Has she gained a lot of weight as well?
Nope. Perfectly healthy. Thin, but not malnourished. She looks like a 30 year old. I was so confused when I met her I had to look at her chart again to make sure the age was correct and I had the right patient.
 

birchswing

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HRT has it's place but I've noticed that a lot of my patients are getting testosterone without my recommendation nor thinking it was appropriate. While it's died down somewhat there was a big push a few years ago by pharm companies to testosteron-ize men hitting their 40s+.

Something else I noticed is some patients I've seen had low T (again cause it seems pharm companies have gotten docs to test for it quite a lot) in men that were in their 20s-30s that were on an SSRI. Led me to think maybe the SSRI was lowering their testosterone.
I've been trying to find any answer to my low testosterone. I had all the symptoms so I asked to be checked. It was 100 something the first time. The highest it's been is low 200. Last test was 81. I want to find the root cause (it's not primary) but psychiatrist insists it is not psych drugs (which include Paxil since age 15). It's the weirdest thing too because when I started Paxil I had this strange intrusive thought, "I wonder if this will stop me from going through puberty." I mean that's a pretty random thought to have, but I did have it. And I did in fact end up only going part way through, meaning I don't have a lot of secondary sex characteristics and spent years trying to figure out my sexual orientation which never appeared. I simply seem to not have one, which is actually rather confusing in and of itself. Maybe at 81 ng dl that's normal. I'm only 32, btw, and I first got tested for testosterone around age 28 or so I think. Haven't treated it due to a number of factors, fear being at the center of them all. I have it re-checked every time I have my blood drawn (about 3-4 times a year) and it won't go up with exercise/diet, etc. I have low levels of whichever hormones tell the testicles to make testosterone (I think FSH and LH).

I even showed my doctor info on how the SSRIs affect the HPA axis and thus possibly the testosterone (I had this whole theory I can't remember now), but it was dismissed.

Might bring it up again with her because she wants me off Paxil eventually anyway, whereas I had thought I should go up since I have OCD that's never gotten better and I've never gone above 30 mg and recently read a higher dose is needed for OCD. She doesn't want me to use SSRIs at all going forward because of her genetic test but her reasoning is never spelled out (nothing in the genetic test I've seen says I shouldn't be on SSRIs).

Anyhow, this is very interesting anecdotal evidence on your part. I realize it would require a study to connect the two, but interesting nonetheless.

Edit: I wanted to edit to add I am not inferring anything from your experience with patients that I would apply to myself. I merely found it interesting/relevant as it coincides with two of the factors, being on an SSRI and having low testosterone, that I have.
 
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