What is the best treatment for mood disturbances in permenopause in a woman with a mirena IUD?

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Elsevier ClinicalKey Clinical Overview

Treatment Intravaginal estrogens relieve symptoms of vaginal atrophy and dryness in perimenopausal or menopausal patients (eg, cream, vaginal ring, intravaginal tablet, or insert) Low- and ultralow-dose vaginal estrogen preparations are usually ideal for patients with isolated genitourinary symptoms and can be continued for as long as required No requirement to combine with systemic progestogens for endometrial protection, because they do not result in significant systemic absorption or endometrial hyperplasia Prasterone (dehydroepiandrosterone) reduces symptoms of dyspareunia in patients with vulvovaginal atrophy due to menopause Not approved for use in patients with breast cancers Improvements last up to 1 year Ospemifene reduces symptoms of dyspareunia associated with vaginal atrophy in postmenopausal patients Suitable for those with estrogen-sensitive cancers (eg, breast cancer) for whom exogenous estrogen use is contraindicated Improvements occur within 1 month and endure for up to 1 year; hot flashes may temporarily worsen Systemic hormone therapy given for vasomotor symptoms may be adequate, but addition of low-dose vaginal hormone therapies may be needed for persistent genitourinary symptoms Affective disorders associated with perimenopause and menopause Venlafaxine (serotonin-norepinephrine reuptake inhibitor) is useful both to reduce hot flashes and to improve mood Other selective serotonin reuptake inhibitor and serotonin-norepinephrine reuptake inhibitors found to be beneficial for management of vasomotor symptoms include paroxetine, escitalopram, citalopram, and desvenlafaxine, and may also be useful for females with affective symptoms

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Santoro, Nanette, Neal-Perry, Genevieve (2024). In Goldman-Cecil Medicine (pp. 1628). DOI: 10.1016/B978-0-323-93038-3.00222-7

Therefore long-term treatment may be required to preserve quality of life.For vaginal symptoms or the genitourinary syndrome of menopause, vaginal moisturizers (which must be used regularly to achieve effectiveness) and vaginal lubricants, which are specifically helpful during intercourse, can be recommended.-A vaginal hyaluronidase-based gel is as efficacious as 10-µg estradiol tablets twice weekly for relief of the most bothersome symptom.Little attention has been paid to the exact composition of these products, which are available over the counter. Women should be advised to choose products that are pH balanced (i.e., relatively acidic) with a physiologic osmolality.Fortunately, long-term use of local estrogen compounds appears to be safe and well tolerated (Table 222-5). Systemic absorption of estrogen through vaginal administration of pills, capsules, and rings is minimal, but vaginal creams are more likely to increase circulating estradiol levels temporarily. Dehydroepiandrosterone can be used vaginally to treat dyspareunia. Ospemifene, a selective estrogen receptor modulator that has estrogen receptor beta stimulation properties, is available as a nonestrogenic treatment; however, it is administered systemically. Laser treatment of the vagina does not improve the symptoms of the genitourinary syndrome of menopause.Sleep and Mood DisordersNonhormonal treatment of adverse mood includes psychotherapy and antidepressants (Table 362-5), with or without antianxiety medication (Table 362-9) as needed.For moderate to severe mood disturbances, hormonal therapy should not be used as a first-line treatment.Difficulty sleeping can be addressed behaviorally. Telephone-based cognitive-behavioral therapy can benefit about 85% of postmenopausal women with moderate insomnia.A self-help smartphone app (https://mobile.va.gov/app/cbt-i-coach) is available to enable patients to implement such treatment.

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Selective Serotonin Reuptake Inhibitors (SSRIs), Elsevier ClinicalKey Drug Class Overview

Content last updated: April 3, 2020.

* SSRIs have been used in the treatment of premenstrual dysphoric disorder (PMDD); the SSRIs may be used continuously or just during the luteal phase for PMDD symptoms[44059]. [43999][28343] * Other clinical uses for SSRIs include treatment of premature ejaculation and the treatment of hot flashes associated with menopause. Paroxetine (Brisdelle) is approved by the FDA for the treatment of moderate to severe vasomotor symptoms associated with menopause[55186].