A multi-institutional panel of scientists have developed the first-ever guidelines for the evaluation and treatment of perimenopausal depression. Their recommendations are published in the journal Menopause and the Journal of Women’s Health.
Perimenopause refers to the three- to four-year period immediately prior to menopause when periods become irregular and eventually stop, as well as the first year after the final menstrual period. It typically begins in a woman’s 40s but can start even earlier.
Women are at greater risk of depression after the birth of a child when hormone levels are changing, but the risk of depression associated with perimenopause still remains under-recognized. Clinical recommendations on how to diagnose and treat this kind of depression in women have been lacking until now.
“The reason these guidelines are needed is because depression during the perimenopausal phase can occur along with menopausal symptoms, and these two sets of symptoms are hard to tease apart, which makes it difficult for clinicians to appropriately treat these women,” said Dr. Pauline Maki, professor of psychology and psychiatry in the University of Illinois at Chicago College of Medicine and co-lead author of the new guidelines.
“Many women experience a new onset of depressive symptoms. If there is underlying low-level depression to begin with, perimenopause can increase the intensity of depressive symptoms.”
The panel was co-chaired by Maki and Dr. Susan Kornstein, professor of psychiatry and obstetrics & gynecology at Virginia Commonwealth University and executive director of the Institute for Women’s Health at Virginia Commonwealth University.
The team reviewed the scientific literature on depressive disorders and symptoms in perimenopausal women and focused on five areas: epidemiology, clinical presentation, therapeutic effects of antidepressants, effects of hormone therapy, and efficacy of other therapies such as psychotherapy, exercise and natural products.
Perimenopause symptoms such as hot flashes and sleep disturbances often begin at this time and can co-occur and overlap with symptoms of depression, the new guidelines state.
“Eighty percent of women in menopause experience hot flashes, and when they occur at night, also known as the ‘night sweats,’ sleep can be interrupted. Persistent sleep disturbances caused by hot flashes contribute to the development or exacerbation of depressive symptoms,” said Maki.
In addition, perimenopausal women often juggle multiple responsibilities and face multiple stressors. They care for their own children, experience children leaving the home, help aging parents, retain primary responsibility for the home, and face increasing job demands at a time when they may be approaching the peak of their career.
All of this can be extremely stressful, Maki explained.
“Relationships can be taxed and the realities of aging can become quite apparent,” Maki said. “Life stressors, low social support and physical health problems are strongly related to depression during perimenopause.
“When you add in hormonal changes that can affect the brain’s ability to cope with these stressors, it’s no surprise that depression is a common occurrence in midlife women. The good news is that there are effective treatments.”
The root causes of perimenopausal depression can be hard to identify, said Maki. “Are women experiencing low energy because they are having night sweats and losing sleep? If so, treating with hormones may be the best bet,” she said.
“Alternatively, is a woman with a past history of depression having another depressive episode? In that case, antidepressant therapy might be most effective. Is the issue primarily due to family and job burden? If so, cognitive behavioral therapy with or without an antidepressant might be best.”
Maki added that while it is common for women with menopausal symptoms to experience depressive symptoms, most of the time those symptoms do not meet the criteria for a depression diagnosis. However, even low-level depressive symptoms can lower quality of life and strain relationships, and hormone therapy might help.
“It is important for women and their health care providers to recognize that these symptoms are common during perimenopause and can be treated,” she said.
Some of the findings of the panel include:
- Perimenopause is a window of vulnerability for the development of both depressive symptoms and a diagnosis of major depressive disorder;
- The risk for depressive symptoms is elevated during perimenopause even in women with no prior history of depression;
- Clinicians should consider treating co-occurring sleep disturbance and night sweats as part of treatment for menopause-related depression;
- Hormonal contraceptives may improve depressive symptoms in women approaching menopause.
“Perimenopause is a window of vulnerability for the development of both depressive symptoms and major depressive episodes,” Maki said.
“The recent suicide of Kate Spade at 55 years of age shows the seriousness of mental health issues in midlife women, a group that has shown a 45 percent increase in suicide rates over the past 15 years,” said Maki.