Women are at double the risk then men for depression during their life span (after puberty). Particularly vulnerable times include those where hormones are at play. Puberty, pregnancy and postpartum and perimenopause. Perimenopause is the period of declining hormones leading up to menopause. It can last for 2-10 years.
Before the onset of puberty, women have a low but rising level of estrogen. When girls experience puberty most of us experience a cyclical variation of levels of hormones ( hormones increase followed by a drop). During pregnancy, women experience a rise in hormones followed by a decrease. Perimenopause, however, is associated with the most unpredictable pattern of hormonal fluctuation, making it a vulnerable and unsettling time for women.
Studies have shown that women are at greater risk for depression during perimenopause and that as hormones fluctuate more towards later perimenopause that risk increases.
The Penn Ovarian Aging Study, which studied 231 perimenopausal women with no history of depression over 7 years, found that perimenopause did, in fact, bring with it an increased rate of depression. With early perimenopause, there was an increase in depression, but with later perimenopause ( when there was more fluctuation in hormones) there was an even greater increase. This study also found that after menopause occurred the rates of depression dropped.
Shmidt showed similar results in his study. This study demonstrated a 14 fold increased risk during perimenopause of depression, and specific vulnerability during later perimenopause when hormones are fluctuating the most. Late perimenopause was defined as the 2 years surrounding the final menstrual period.
Never had depression before?
You may suddenly have a depressive episode of depression during perimenopause even if you have no history of depression. If you are experiencing perimenopause and depression you may have normal signs of depression but may present with some distinct differences. Women with perimenopausal depression report more signs of irritability and mood swings than those with depression of the non perimenopausal variety. Additionally, their sleep is more often impacted. Difficulty falling asleep and staying asleep are common symptoms unique to this group.
We aren't sure why depression gets worse in perimenopause. The Domino Theory suggests that estrogen withdrawal creates hot flashes and night sweats which cause sleep problems which in turn cause mood disturbance. Another theory suggests that estrogen has effects on various neurotransmitter systems and brain regions involved in major depression and that these systems are altered and impacted when the levels decline.
Estrogen replacement therapy has been found to be the most effective therapy for depression during perimenopausal depression. Many studies show estrogen is helpful for mood however only 2 studied actual depression. Randomized control studies show that estradiol with depressed women perimenopausal or early menopause who received treatment with estrogen responded dramatically to this treatment. However, the estrogen used in these studies was not administered in a way that could be used long term. Estrogen has also been found less effective or not effective at all in treating women who are depressed and post-menopausal.
Additionally, in 1993. a study called the Women's Health Initiative explored the use of estrogen replacement therapy to prevent the risk of various diseases to perimenopausal women. Unfortunately, several years later it was found that estrogen increased the risk for breast cancer, dementia, stroke to name a few. At that time, the study was closed down, and most doctors stopped prescribing Hormone replacement therapy (HRT) for women. Some studies suggest that it may be safer than we originally thought and there may be ways to deliver HRT to certain groups of women that can benefit from it. Some doctors will prescribe estrogen therapy for a short period of time in cases of perimenopausal depression.
Two large studies support the use of Pristiq or desvenlafaxine for perimenopausal women but your doctor may choose from many other drugs that based on other factors in your personal history, as they can all be effective. Some other drugs your doctor might pick are
Women on antidepressants report that they receive relief from all symptoms including hot flashes, anxiety, and pain. SSRI's and SNRI's. Postmenopausal women also benefit from antidepressants.
Doctors will choose from another menu of drugs based on the symptoms accompanying your depression.
They may choose some of the drugs below to target other symptoms.
Gabapentin might be chosen to address pain or hot flashes, night sweats, and flushing. Usually, this drug will be given in doses between 300- 1200 mg to limit side effects.
Sleep disturbance may also be severe enough to be treated with medication. Your doctor has a wide array of options for this and may even refer you to a therapist for CBT.
Alternative treatments such as black cohosh, herbal remedies soy products have not been shown to be effective, however, women still purchase them and use them at high rates often reporting that they are effective.
Note: Information about medication was taken from the MGI workshop on The Menopausal Transition
Schmidt PJ, Haq N, Rubinow DR: A longitudinal evaluation of the relationship between reproductive status and mood in perimenopausal women. Am J Psychiatry 2004; 161:2238–2244
Joffe, H., Hall, J. E., Soares, C. N., Hennen, J., Reilly, C. J., Carlson, K., & Cohen, L. S. (2002). Vasomotor symptoms are associated with depression in perimenopausal women seeking primary care. Menopause (New York, N.Y.), 9(6), 392–398. https://doi.org/10.1097/00042192-200211000-00003
Massachusetts General Hospital. (February 2020)Week 4:The Menopausal Transition and Depression.Psychiatric Disorders in Women: Diagnostic and Treatment Considerations Across the Female Lifespan. Retrieved from https://lms.mghacademy.org/.