SSRI and HRT - can I ask for both?

[Tamfs]

I have an appointment with a GP specialising in menopause next week and I just wondered about others experiences. I have not been on anything for menopause before, I'm 45 and my periods are still regular but heavier than they used to be and I get more cramps. I am getting hot flushes now (I have never been more grateful for the icy weather arriving and could be found in a vest in the garden for a bit yesterday!) and a bit of sleep disturbance.

But it's the mood swings that are really getting me. I have a history of anxiety disorder episodes right back to my teens (when I started my periods incidentally) and have had SSRIs at times although I try not to take anything. But my moods are now quite scary, and I can suddenly feel totally removed from everyone and everything, that everything is totally pointless, that I just want to crawl into bed and never leave it, or even some quite dark thoughts. I'm as anxious as I ever was but I think I'm catastophising even more and it's quite hard to deal with. And then suddenly, it lifts and I feel almost hyper. I haven't had anything quite like that before.

I want to try HRT but I'm nervous of it, having not had good experiences of hormonal contraception. I am now at the stage where the low times are worrying me so much I would like some SSRIs again. Will the GP give me both? Or will I have to try one then the other? I just want the dark clouds to lift or to just feel more stable. I'm not bothered about the physical symptoms as much.

I developed really debilitating anxiety a couple of years ago when I was 48 and assumed I was perimenopausal. The first doctor prescribed HRT which did nothing frankly. Saw a second doctor after a while who prescribed low dosage of citalopram which has been life changing for me, I feel normal again. She said ADs would be her first approach rather than HRT for menopausal anxiety. I’m still on it now.

@Tamfs NICE Meno guidance says SSRIS are not to be prescribed for mood/depression/anxiety linked to menopause. It's that simple.
They also say that talking therapies and CBT are to be used as well or instead of SSRIs.

HRT is the prescribed medication to try first and keep tweaking the dose or the type until you feel better.

You can't get the right dose of HRT while using other drugs like anti depressants as you won't know which if any is working.

HRT is not the same as hormonal contraception (many women don't realise this.) Hormonal contraception is made with synthetic hormones and the doses are far higher than HRT.
HRT is now made to be exactly the same as your own hormones and just tops them up.
It also gives you the benefits of maintaining bone density and heart health which SSRIs don't.

However, some GPs ignore the guidance often because they are not experienced in prescribing HRT and it's an 'easy option.' I'm very surprised that your GP has that opinion @CaramelEmporium because it's contrary to all the medical advice which is based on up to date research. If your first type and dose of HRT did nothing, did your GP offer other types and doses? NICE covers this and says the type and dose needs to be changed until symptoms are under control. The problem is some GPs aren't aware of this or know enough about HRT.

Thank you both for sharing your knowledge and experiences, I really appreciate it. It sounds like you are both saying that using SSRIs/HRT concurrently isn't a thing or the best plan, which does make sense. I think I'm coming at it from the thought of SSRIs made me feel better before and hormonal contraception made me feel awful, and I just want to feel better.

@JinglingSpringbells thank you, I'm not too familiar with the difference between contraceptive hormones and HRT so that has reassured me a bit.

I’m on HRT and AD’s for anxiety - which I only started during peri-menopause.

It could be that HRT will help you, but why would you not take the SSRIs if you know they work?

Adjusting HRT is not a quick process - why prolong the way you are feeling when you know what helps?

That’s interesting @JinglingSpringbellsI’m not at all up to speed on all things menopausal/HRT and what the guidelines are. The doctor that prescribed the HRT in the first place did it over the phone, this was in latter stages of pandemic times, no test or anything. All I can say is that the citalopram saved me. I’ve never experienced anxiety like that in my life, it utterly floored me so right or wrong I’m grateful!

The NICE guidance first came out 15 years ago and was updated about a year ago.

There is a very strong drive not to prescribe ADs for women as they are potentially addictive, have their own side effects, don't give bone or heart protection and don't replace the hormone that is causing the problems.

There have been TV progs and radio interviews for some time on the 'disservice' by GPs giving women ADs as a 'go away and take these, they will calm you down/pick you up ' rather than providing correct treatment.

But the medical guidance IS that HRT is tweaked.
The clinical research is that SSRIs don't work and in around 40% of cases are a placebo.
In your case, you would not or should not be given ADs because NICE says that ADs are only to be used for pre-existing depression or anxiety that was clinically diagnosed before peri menopause.
There are many reasons not to take SSRIs- short and long term side effects, possible addiction, and the fact many people experience the placebo effect (which has been proved.)

I didn't get on well with the pill when I was younger but oestrogen gel and progesterone pills as HRT were life changing. Mood was one of my main symptoms. Irritability (aka rage and fury), feeling very negative, not feeling like myself. It has helped a lot, particularly the progesterone. There's no reason you can't use both, but if you start with both you could be taking medication you don't need. HRT is trial and error at the start, so you could start there and add in SSRIs if you still need them. But HRT helped me to feel better and then also make life changes that just made me feel even better - starting to exercise, giving up alcohol, changing jobs, etc.

@Tamfs if you can track your mood in terms of your cycle you might have a better understanding of what tweaking needs to be done to dosage of HRT, if any. It can make a very big difference to mood very quickly.

Thank you @SparkFinder (love the name, I'd like to find mine again too!) that's helpful as with mood being the main symptom I have been telling myself that I'm just using menopause as an excuse when really I'm just an unstable moody cow. I'm also a bit scared of starting HRT as it's kind of a watershed moment I guess?

@Apileofballyhoo this is a great suggestion actually, are there any apps that work well for this?

If you have an iPhone apparently the tracker in the health app is good. Any period tracking app you can add a short note to would be fine. I just kept brief notes on my phone calender eg, Day 24, v anxious, bad joint pain.

I tried HRT first with various tweakings but although it relieved my physical symptoms, did nothing for my awful anxiety. I went back and was prescribed anti depressants which worked wonders. My doctor said that if you have a preexisting condition of anxiety which HRT is exacerbating as opposed to creating, you may need SSRIs as well.

As you (like me) have preexisting anxiety, SSRIs may work better for you. As the person above has said, they were literally a life saver for me. I still take HRT but mainly for bone health.

Thank you for the further replies, it's interesting to hear everyone's experiences and given me lots to think about. It's also made me feel a little less alone, so an evening bigger thank you for that.

Same as @Verite1 , I had pre existing anxiety. I’m on Citalopram 20mg and will take it FOREVER it’s just life changing.
my anxiety definitely peaked with peri, so I tried HRT- didn’t touch the anxiety and I put on weight almost overnight.
so I went on the citalopram and ditched the HRT and my anxiety feels completely managed now.
i had night sweats for a while, and found sage tablets (from A Vogel) eradicated these.

im a psychologist and psychotherapist and work alongside psychiatry, so I have a lot of experience with medication for mental health.
its just not as straightforward that anxiety may be caused by hormone deficiency so you shouldn’t take an SSRi.eg A headache is not caused by lack of paracetamol, but paracetamol will be devised to very effectively target and reduce the symptoms.

Have you never tried stopping to see how you are @Twoshoesnewshoes

https://www.themenopausecharity.org/wp-content/uploads/2021/05/Antidepressants-and-Menopause.pdf

I agree with others, in that I wouldn't choose hrt as my first port of call if you have pre- existing anxiety. Peri made my m/ h spiral out of control, much like you I'd jump from feeling flat to hopelessly depressed to an anxious jittery mess to suddenly feeling almost manically positive. Hrt didn't help at all, but antidepressants have helped somewhat to stabilise me. I'll add in hrt at some point once I get to the correct dose, but this is more for the night sweats, and joint pain. Imo, peri exacerbates mental ill health but isn't the cause, in cases where you've had anxiety/ depression before.

This is not aimed at you but...
So many drs not following guidance after years of experts trying to educate them, producing guidance and help women.

Most HRT 'fails' because GPs are not qualified (meno training is optional) and women are not being given what they need.

The guidance is clear that for pre existing MH issues, women will already be on medication but even then, the drive is to get women off drugs and onto talking therapies like CBT.

It's really time for GPs to get up to speed. NICE produced a guide 15 years ago but it seems many GP aren't aware of it.

I'm very fortunate in that my current gp is extremely well informed and up to date - he was the first to suggest using progesterone vaginally for example, whereas I know other women have to use it on the ' down low '! I'm also extremely lucky in that my appointments often stretch to 30-40 mins slots, God knows why but I'm grateful all the same. I agree though that until moving to this area, my experience with gps were mostly abysmal and often dismissive of " women's problems ". It's a postcode lottery really.

yes of course
four disastrous times, once for a year

My appointment is this afternoon and I'm feeling really nervous about it, that I won't be able to explain it clearly or I'll just get told to get on with it. This is really horrible.

Hope it goes/went okay @Tamfs- could you write down some bullet points to prompt your thoughts?

Thank you @Twoshoesnewshoes I did write down bullet points after your suggestion and then when I got the GP phone call I just babbled them all out at her and then burst into tears 😳

Thankfully she was probably used to all this and was very kind to me, she did give me the option of trying citalopram again but also that my symptoms on the whole suggested it was more perimenopause and that I will likely have a predisposition to the anxiety/mood symptoms feeling the worst of anything. She advised that I try HRT for a month, and if it hasn't helped or if my mood symptoms get worse then we can review and consider whether an SSRI might help too or different HRT. I think the best thing she said was that we didn't have to know the answer right away but that I would be supported through it all as it's all so individual. She is going to call back in a month.

Thank you to everyone who replied on this thread because I took something from every single post, I learned a lot and mostly I just felt less alone, which really helped. I'm really grateful @Apileofballyhoo @CaramelEmporium @Frannieisnthappy @InTheMoodToHuff @JinglingSpringbells @SparkFinder @Twoshoesnewshoes

Fab news op, I'm so glad your gp listened to you and is takin you seriously. You must feel so relieved - I understand how difficult it is to open up a gp and pray that they'll not fob you off. It sounds like a plan and like she said, if the hrt doesn't help then you can reconsider ssris. I bet you're feeling slightly better already!