Hormones & Depression; Janet's story

Janet had suffered from a major depressive disorder, involving suicidal feelings, insomnia, a negatively charged mood & anhedonia (the inability to enjoy life) since the age of adrenarche.  Adrenarche is the event, occurring several years before puberty when the adrenals start making androgenic sex hormones such as DHEA, thus fueling the growth of sexual body hair.
 The arrival of puberty & of her ovarian estrogens brought no respite for Janet & life became an ongoing “uphill battle”.  She went through years of failed, symptoms-directed psychoactive drug therapy without benefit.  A high-resolution functional MRI showed excessive activation in the areas associated with major depressive disorder (MDD) and OCD, accurately defining what was going on with Janet's brain networks.  Finally Janet came to us at age 23 when her internist wondered about a hormonal link to her depression.  She seemed like a down to earth, well-grounded, modestly overweight young woman of strong character trying to survive in the face of a serious, long-term depression.  Some mild physical markers for insulin resistance & androgen excess were present, including an unwarranted obesity, skin tags, some darkening of the skin around the neck & under the breasts, cystic acne & excessive body hair.  These stigmata were a tip-off to what was going on for Janet hormonally, forming the basis for my working diagnosis.
I got her to quit the oral contraceptive pills she'd been taking & tested her ovarian function once the influences of the pill were out of her system, suspecting the presence of polycystic ovary syndrome (PCOS), a pretty common hormonal disturbance causally linked with insulin resistance.  And sure enough, PCOS & insulin resistance were shown to be present, so I started her on metformin in low dosage, while getting a local gynecologist to position a Mirena-IUD in lieu of her oral contraceptives.  And we started Janet on a low dose of spironolactone, which blocks the influences of excessive androgens.

Once the Mirena had been positioned I could safely treat Janet with patches of natural estradiol, which happens to be a potent natural anti-depressant, without fear of endometrial thickening or break-through bleeding.  And as we slowly increased Janet’s dose of estradiol, she was able to taper off of her anti-depressant drugs entirely.  To Janet’s astonishment, even though at the time she was under considerable stress due to a family illness, she became dramatically less depressed than she had been for many years.  
Only one problem remained, the presence of insomnia, so I treated her for 2 weeks with a cortisol-lowering drug so as to re-calibrate her stress response machinery.  This controlled her insomnia in a permissive rather than a forceful manner & the benefit remained long after this drug was discontinued, because her brain networks had now been re-calibrated in a systems’ manner.  Now her depression was resolved along with the insomnia & her day-time energy level went way up.  Janet did well in the long term, even in the face of ongoing social stressors although we did have to give her one more brief pulse of the cortisol lowering drug.
The moral of Janet’s story is that disturbances in the sexual hormones can seriously contribute to the major mood disorders.  When women suffer chronically from mental disturbances instead of shooting from the hip with the heavy-handed use of psychoactive drugs, we should at least make some effort to search for hormonal disorders such as PCOS, which are associated with hormonal glitches capable of driving mental disturbances all the way from depression to psychosis, depending on the kinds of inherited brain vulnerabilities one have inherited in the first place.

Janet's depression had been caused by inheriting a depression-prone brain which was then triggered by a hormonal imbalance relating to PCOS with insulin resistance & an excess of androgens plus a deficit of estrogen.  But what happens when a women inherits a vulnerable brain but isn't so hormonally wigged-out?  For the answer. go to the next patient case study, & the story of Sally.