Depression and mood swings may happen at any time for women, but they are particularly common when hormonal changes occur. And perimenopause — the period leading up to menopause — is a time of intense hormonal changes, similar to puberty and pregnancy. These changing hormone levels might link menopause to depression.
“Women have a higher incidence of depression compared with men, and that begins in puberty, which suggests it’s related to hormones,” says Pauline M. Maki, PhD, of the departments of psychiatry and psychology at the University of Illinois in Chicago.
In fact, depression and low mood during perimenopause — the time when a woman’s menstrual cycle starts to slow down — is even more frequent than depression during pregnancy, yet it has not been as widely studied. Research written by Dr. Maki and her colleagues notes that perimenopausal women are three times more likely to have depressive symptoms than premenopausal women. And other studies have found that women are 40 percent more likely to experience depression during perimenopause than before.
Most people think a drop in estrogen levels makes a difference in mood, but studies have shown that it’s really the variation from day to day or even within a single day in daily hormones that is related to mood disruption in women.
“In other words, it’s not the fact that women’s estrogen levels are low that makes a difference, but that estrogen levels are fluctuating,” explains Maki. “Many people misunderstand how the hormones change around perimenopause. People believe that it is a gradual tapering off of estradiol, but women experience tremendous and dramatic fluctuation of estrogen. Estrogen levels can be even higher than what women experience during their regular menstrual cycle.”
A study examined estrogen levels in 73 women over two months. Researchers found that women who had the highest estrogen fluctuations were more likely to not feel joy during perimenopause.
“That means if you can control the variability, you can control the depression,” Maki notes, adding another encouraging fact: “If depression during perimenopause is due to hormonal factors and there’s no other cause of a depressive disorder, then it can be time-limited.”
“It’s vital that women who are going through this understand what’s happening, because in addition to the biological factors, recognizing the environmental factors like parenting challenges and career changes is just as important,” says Maki.
She adds that therapy and antidepressants won’t heal a faulty marriage or an elderly parent who is sick. Once in their forties, women tend to experience major life changes, including (but certainly not limited to) the following:
Children growing up and going to college
Older parents who have increased care demands
Career shifts
Marital conflict
Conflicted emotions about aging and body changes
This combination of hormonal and life changes creates a complex mix of challenges that all need addressing at the same time. Dealing with constant stress can contribute to depression at any age, especially if your tool kit for responding is limited, Maki notes. For women during perimenopause, she says, hormonal shifts may heighten the effects of these challenges.
Maki suggests that if you are experiencing depressive symptoms like feeling low or being unable to experience pleasure in your life, and you're having a hard time managing work or daily responsibilities, it might be time to seek help.
She encourages people to use the Patient Health Questionnaire, a free mental health screening tool, and talk to a doctor if they score a 10 or higher.The Menopause Society offers a downloadable handout that explains the connection between the two, which you can bring to your practitioner.The causes of midlife depression are complex. It’s not easy to separate biological causes from environmental ones. According to the most recent depression-specific perimenopause treatment guidelines, published in 2018 and coauthored by Maki, diagnosis of depressive disorders during midlife includes:
A clinical assessment of depression and other mental health issues
A review of previous psychiatric history
Identification of menopause stage
Discussion of the woman’s life stressors
An overview of sleep hygiene
The type of treatment you receive for perimenopause-linked depression will vary depending on your experience of both conditions. “Treatment should be tailored. If a woman is experiencing difficulty coming to terms with aging or life changes, an antidepressant isn’t going to take that away,” says Maki.
Your practitioner may try the following options:
Antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) or selective norepinephrine reuptake inhibitors (SNRIs)
Cognitive behavioral therapy, a form of talk therapy that helps people understand and disrupt unhelpful thought and behavior patterns
Treatment for vasomotor symptoms (hot flashes and night sweats), such as hormone therapy or paroxetine, a type of SSRI — especially if these symptoms are affecting sleep
Hormone replacement therapy (HRT) or birth control pills (these are not effective for treating depression in postmenopausal women)
A review found that hormone therapy for perimenopausal women was effective at reducing feelings of depression as well as cognitive decline. The paper argues for more robust research around its efficacy to treat depression during menopause since it is a transition all women experience.
Maki also recommends focusing on improving sleep if you’re finding that perimenopause has made it challenging to get enough rest. “We are beginning to understand more and more how important quality sleep is in helping women to maintain mood, especially positive well-being,” she says. “We recommend cognitive behavioral therapy for insomnia — it's available online in a number of platforms, and it really works."
While Maki insists the evidence does not suggest there is a substitute for evidence-based psychotherapy and medical treatments, she says, “we are recognizing the importance of things like mindfulness-based stress reduction, yoga, exercise, and a good diet.”
Maki suggests that for women whose depression isn’t severe — it’s not affecting their home or work life — yoga could help improve mood a little bit. “But really, the only thing that has been shown to help is aerobic exercise.” A review of 16 randomized controlled trials found that exercise programs lasting longer than 12 weeks that involved 60- to 90-minute sessions significantly reduced depressive symptoms during perimenopause.
Maki adds that one of the best complements to therapy and medicine is engaging in something that allows you to be an active participant in your own life. “That can be very rewarding for people who are depressed,” she says, “and it’s usually a by-product of cognitive behavioral therapy.”
Rapid hormonal changes have links to an increased risk of depression during perimenopause, but midlife is often a stressful time, and it can be difficult to distinguish biological causes from life stressors.
If your mood swings or poor sleep are making it hard to get through the day, you can use a quick mental health screening tool and talk to your doctor to get a tailored treatment plan.
Antidepressants, hormone therapy treatment for perimenopause symptoms, talk therapy, and even sticking to a regular exercise routine for a few months can help with depressive symptoms.
This life stage brings significant changes, but perimenopausal depression is often temporary and can be managed with the right medical help and lifestyle support.
Additional reporting by Jordan M. Davidson.
