全科医学中的心理健康病案研究(二十五)——更年期与心理健康

Fiona Judd，Grant Blashki，Leon Piterman，Hui Yang

1 病史

陈女士，51岁，已婚，有一个23岁的女儿。陈女士很少来你的诊所看病，而且一向身体很健康，没有什么大病。她一直在丈夫的杂货店帮忙，做一些临时性的工作。最近她有两次感觉不舒服，呼吸困难，浑身燥热，有被困住的感觉，有几次不得不跑出杂货店，去外面呼吸新鲜空气。她担心自己是不是得了什么严重的病，所以来诊所找你看病。

2 其他病史

你和她交谈，询问她一些问题。陈女士告诉你说，最近一年多来感觉自己不是原来的样子，找不到原来的那种感觉。她的睡眠变得不好，经常半夜醒来，浑身燥热出汗。她的心境变得有些烦躁，她发现自己与来杂货店买东西的一些顾客发脾气。她还担心自己的记忆出现问题，因为她发现很难记住丈夫要她做的事情。她对很多事情失去兴趣，而且想过不去杂货店帮助她丈夫打理生意。她女儿6年前离开她去澳大利亚学习，她现在没有女儿陪伴和支持。

3 体检

陈女士梳洗整洁，穿着得体。她渴望和你谈话。她有一些焦虑，不过看起来她并不抑郁。她否认自己感到抑郁，不过说自己时常感到焦虑，特别是在“有一股股热浪冲向她的时候”，会感到非常烦躁。她没有奇怪的思维内容，也没有不寻常的想法，没有周期性反复的焦虑，不过她很在意自己的健康和生活。她说她害怕自己变老，而且怀疑自己身上有些地方正在变得不正常。她的谈话中没有抑郁的主题，也没有自残或自杀想法。

躯体检查结果没有异常发现。血压120/75 mm Hg(1 mm Hg=0.133 kPa)，脉搏规律，70次/min。

4 提问

4.1 应该考虑什么诊断？

4.2 需要进一步采集哪些病史、做哪些进一步的体检和检查？

5 解答

5.1 应该考虑的诊断 陈女士说自己大约12个月来有一些新出现的症状，其中包括各种焦虑的感觉、惊恐症状以及睡眠紊乱，可能还有一些抑郁症状。当中年人出现新发的焦虑或抑郁症状时，应该考虑到引起这些症状的躯体原因的可能性。在中年女性中，更年期症状可能酷似焦虑和抑郁，或者更年期加重焦虑和抑郁症状，医生应该考虑到这一点[1]。此外，陈女士正在经历比较大的生活变化，她女儿不仅仅是离开了家，而且是移居到很远的澳大利亚。

5.2 进一步采集的病史以及进一步的体检和检查 首先，你需要采集更详细的病史，以便确定她的症状在多大程度上是由于更年期引起的以及她是否真的有焦虑症或抑郁障碍。由于焦虑、抑郁和更年期之间有些症状是相似的，比如疲劳感、集中力和记忆力问题、睡眠紊乱、性功能障碍、心悸等，因此会给诊断带来困难。

做出抑郁障碍的诊断，需要你确定病人存在典型的抑郁特征。比如持续的心境低落、缺乏兴趣、缺乏快乐、经常哭泣。还要确定病人存在抑郁的认知，比如负罪的想法、自身没有价值的想法、自残或自杀的想法。而且要确定病人是否存在日常功能受损的情况。做出焦虑障碍的诊断，需要你确定病人存在焦虑的心理学症状，比如感到激动或紧张、表现出内在性的担忧、回避引起焦虑的场景以及焦虑所具有的认知特点。要记住的一个要点是抑郁和焦虑往往同时存在。

为了澄清是否病人的更年期造成了她的临床表现或者她的临床表现与更年期有关，你需要认真和详细地采集病史，包括她的月经的频率和规律性以及更年期的症状，比如感到阵阵发热、夜间出汗、焦躁易怒、心境改变、性欲降低、阴道干燥等。

为了排除躯体原因造成病人的症状，你需要安排病人做全面的体检和实验室检查，包括全血检查、尿素和电解质检查、肝功能检查、甲状腺功能检查、维生素B12和叶酸检查、红细胞沉降率检查等。因为更年期可能造成激素的变化，你还可以安排病人做卵泡刺激素和雌二醇水平的检查。

6 随诊发现的情况

通过进一步采集病史，你了解到18个月前陈女士的月经还是有规律的。不过18个月以来，她的月经变得越来越不规律，在过去的12个月中，她只来了4次月经，而且她说最近一次月经是3个月前来的。她以前和现在都没有服用过激素。她告诉你说，她的性欲一直不强，而且一直受到阴道干燥的困扰。

你进一步和她谈论“阵阵发热”(潮热)的感觉，她说每天会出现4～5次这种感觉，而且经常浑身出汗。夜间的发热和出汗会让她从睡梦中醒来。这些感受往往不伴随焦虑的症状，只有两次感到要跑出房间去外面呼吸新鲜空气。

她的化验结果显示卵泡刺激素水平升高，雌二醇水平下降，这与更年期的发展过程相一致。她的其他检查结果都正常。

7 进一步的提问

你怎样管理陈女士的这些症状？

8 解答

陈女士的焦虑和抑郁症状是轻微的，而且这些轻微的焦虑和抑郁症状很像是更年期症状群的一部分，而不是焦虑或抑郁障碍的表现。因此，最适宜的策略是先针对更年期症状采取管理措施，然后再评估是否需要针对焦虑和抑郁症状进行治疗[1-2]。

激素替代疗法(hormone replacement therapy,HRT)对更年期症状(包括血管紧张症状)往往是有效的，并且可以改善轻度的心境症状。如果病人对激素替代疗法有禁忌证，或者对此出现严重的不良反应，则可以采用其他的药物来缓解血管紧张症状，如选择性5-羟色胺再摄取抑制剂(SSRIs)。如果效果不好，则可以采用可乐宁或加巴喷丁。

重要的是要记住，激素替代疗法并非是抗抑郁药物治疗。因此如果病人的焦虑和抑郁症状是潜在的心境障碍导致的，那么病人的焦虑和抑郁要采用另外的特定治疗措施。这是个通用的治疗原则，适用于其他年龄的病人。不过你一定要记住，中年是妇女一生中心理-社会变化最大的时期，因此给她们提供心理和社会的干预服务会有特别的效果和帮助。比如陈女士的案例，她非常思念女儿，因此采用人际治疗这种心理学治疗方法对于她应对“失去”女儿是很有效的，你可以通过人际治疗，帮助她从照顾小女孩的母亲阶段转换到一个新的人生阶段[3]。

1 Hickey M,Bryant C,Judd F.Evaluation and management of depressive and anxiety symptoms in midlife[J].Climacteric,2012,15(1):3-9.

2 Jean Hailes Foundation menopause management algorithm[EB/OL].www.jeanhailes.org.au.

3 Blashki G,Judd F,Piterman L.General Practice Psychiatry[M].Mc Graw Hill Medical,2007.

·WorldGeneralPractice/FamilyMedicine·

【IntroductionoftheColumn】 The Journal presents the Column of Case Studies of Mental Health in General Practice;with academic support from Australian experts in general practice,psychology and psychiatry from Monash University and the University of Melbourne.The Column′s purpose is to respond to the increasing need for the development of mental health services in China.Through study and analysis of mental health cases,we hope to improve understanding of mental illnesses in Chinese primary health settings,and to build capacity amongst community health professionals in managing mental illnesses and psychological problems in general practice.A patient-centred whole-person approach in general practice is the best way to maintain and improve the physical and mental health of residents.Our hope is that these case studies will lead the new wave of general practice and mental health service development both in practice and research.A number of Australian experts from the disciplines of general practice,mental health and psychiatry will contribute to the Column.Professor Blashki,Professor Judd and Professor Piterman are authors of the text General Practice Psychiatry.The Journal cases are helping to prepare for the translation and publication of a Chinese version of the book in China.We believe Chinese mental health in primary health care will reach new heights under this international cooperation.

1 History

Mrs Chin is a 51 year old married woman with a daughter now aged 23 years.She has only attended your practice occasionally,and has no major health problems.She has been working part-time in her husband′s grocery business.Recently,on two occasions she has been overcome with feelings of being unable to get her breath,feeling hot and feeling trapped and has run out of the shop to escape into the fresh air.She is worried there is something seriously wrong with her,and comes to you for help.

2 Additional history

On questioning,Mrs Chin tells you she has not felt herself for the last 12 months or so.She has been sleeping poorly,waking in the night feeing hot and sweaty.Her mood has been a little irritable,and she has found herself becoming irritated with some of the people coming into her husband′s shop.Her memory has been worrying her,as she has been finding it hard to remember things her husband asks her to do.She has been less interested in things and has thought about giving up her job helping her husband.Her daughter moved to Australia 6 years ago for further study and Mrs Chin is missing her company and support.

3 Examination

Mrs Chin is well groomed,and eager to talk to you.She is a little anxious,but does not seem depressed.She denies feeling depressed,but does admit that she feels anxious at times,especially when she has the ′waves of hotness′ come over her.Thought content reveals no odd or unusual thoughts,no recurring anxieties,but a focus on her own health and wellbeing.She mentions her fear that she is getting old and that maybe something is going wrong with her body.There are otherwise no depressive themes and no thoughts of self harm or suicide.Physical examination is unremarkable.Her blood pressure is 120/75 mm Hg(1 mm Hg=0.133 kPa),her pulse 70 and regular.

4 Questions

4.1 What diagnoses should be considered?

4.2 What further history,examination and investigations are required?

5 Answers

5.1 What diagnoses should be considered Mrs Chin is describing new onset symptoms of approximately 12 months duration.These include feelings of anxiety,including panic symptoms,as well as sleep disturbance and possibly some depressive symptoms.New onset anxiety and depressive symptoms in mid-age persons should always raise the possibility of a physical cause for these symptoms.In women of mid age,menopausal symptoms mimicking or exacerbating anxiety and depression should also be considered[1].In addition,Mrs Chin has been dealing with a major life change,or loss,as not only has her daughter left home,but she is away in Australia.

5.2 What further history,examination and investigations are required First,you need to take a more detailed history to determine to what degree her symptoms could be attributable to menopause,or whether she does have a syndromal anxiety or depressive disorder.This is made difficult by the similarity between some symptoms of anxiety and depression such as fatigue,concentration and memory problems,sleep disturbance,sexual dysfunction,and palpitations and common symptoms of menopause.

Diagnosis of a depressive disorder requires the identification of characteristic symptoms,such as persistent low mood,loss of interest and pleasure,tearfulness,as well as depressive cognitions,such as thoughts about guilt or worthlessness,or self-harm and suicide,together with impairment in day-to-day functioning.In order to identify an anxiety disorder you need to identify physiological symptoms of anxiety,such as feeling keyed up or nervous,the presence of intrusive worries,and avoidance of situations because of the anxiety they provoke as well as the characteristic anxiety cognitions.It is important to remember that depression and anxiety commonly co-exist.

In order to determine whether her menopausal status is causing or contributing to the presentation a careful history to determine frequency and regularity of menses as well as common menopausal symptoms such as hot flushes,night sweats,irritability,mood changes,fatigue,low libido and vaginal dryness is needed.

In order to exclude physical causes for her symptoms a thorough physical examination is required as well as a number of laboratory tests including FBE,U&E,LFT,thyroid function tests,vitamin b12 and folate,and ESR.Given the possibility of menopausal changes you may also order FSH and oestradiol levels.

6 Follow-up consultation

Further history confirms that Mrs Chin has had regular periods until about 18 months ago.Since that time they have been less regular,she has had only 4 periods in the last 12 months,and she indicates her last period was actually 3 months ago.She is not taking,and has not in the past taken,any hormonal therapies.She acknowledges that she has had poor libido,and has been troubled by vaginal dryness.

When you talk further to her about her ′waves of hotness′ she describes that she has 4-5 of these per day,often with sweating,and has similar episodes which wake her at night.These are not usually accompanied by feelings of anxiety,and she has only experience two episodes when she felt the need to escape into fresh air.

Her test results show a raised FSH level and low oestradiol level,consistent with progression to menopause.Her other investigations are normal.

7 Further question

How will you manage the symptoms?

8 Answer

As the anxiety and depressive symptoms are mild and are likely to be part of her constellation of menopausal symptoms rather than due to a syndromal anxiety or depressive disorder,it is appropriate treat the menopausal symptoms and then review her to determine whether the anxiety and depressive symptoms require additional treatment[1-2].

Hormone replacement therapy is frequently effective for menopausal symptoms including vasomotor symptoms,and may improve mild mood symptoms.If there are contra-indications to the use of HRT,or if HRT produces problematic side-effects,vasomotor symptoms may be helped by a range of other medications including selective serotonin reuptake inhibitors (SSRIs),or if these are not effective clonidine or gabapentin.

Importantly,HRT is not an anti-depressant,and so if anxiety and depressive symptoms are due to an underlying mood disorder they may not resolve without specific treatment.The approach to management should then follow the broad principles applied at other life stages.However,it is important to note that mid-life is a time of major psychosocial change ina woman′s life and so psychological and social interventions may be particularly helpful.For example,Mrs Chin is missing her daughter and a psychological therapy such as interpersonal therapy may be useful to help her deal with the ′loss′ of her daughter and her role transition from a mother caring for a dependant child to a new phase of her life[3].

1 Hickey M,Bryant C,Judd F.Evaluation and management of depressive and anxiety symptoms in midlife[J].Climacteric,2012,15(1):3-9.

2 Jean Hailes Foundation menopause management algorithm[EB/OL].www.jeanhailes.org.au.

3 Blashki G,Judd F,Piterman L.General Practice Psychiatry[M].Mc Graw Hill Medical,2007.