Perimenopausal Depression Risk Is High; Special Guidelines Will Help Women

The field of medicine has really grown in its appreciation for the need to understand factors that contribute to women’s vulnerability to depression. For example, there is much more understanding, outreach, and treatment for depression during pregnancy and postpartum today compared with 20 years ago.

But depression during perimenopause is even more frequent than depression during pregnancy, yet very little is known about it. The good news: The North American Menopause Society (NAMS) and the Women and Mood Disorders Task Force of the National Network of Depression Centers have released the first-ever guidelines for the evaluation and treatment of perimenopausal depression, published online on September 4, 2018, simultaneously in the journal Menopause and the Journal of Women's Health. These guidelines have also been endorsed by the International Menopause Society.

Related: 7 Common Myths About Depression

Breaking the Stigmas for Better Depression Care

“There is a lot of stigma around menopause generally, and we wanted to bring attention to this as another contributor to women’s higher prevalence of depression disorders,” says co-lead author Pauline M. Maki, PhD, of the department of psychiatry and the department of psychology at the University of Illinois in Chicago.

Depression Risk Is Higher During Perimenopause Than After a Women Reaches Menopause

Dr. Maki reports that data uniformly show that there is an increased risk in the years around the final menstrual period, as compared with the many years following the final menstrual period, because of this fluctuation. Estrogen levels may be low during menopause but at least they are somewhat stable. “That being said, the largest longitudinal study of women did indeed show that the risks do persist into the postmenopausal period,” she cautions.

According to Maki, an analysis of data from the Study of Women’s Health Across the Nation (SWAN), in a report published in June 2015 in the journal Psychological Medicine, found that of perimenopausal and menopausal women, the risk for new onset depression (women who have never experienced depression before) is about 28 percent. For women who have a history of depression, that figure is 59 percent.

Determining Exactly When a Woman Reaches Menopause Is Tricky

Typically, menopause is diagnosed in hindsight, after a woman has not had a menstrual period, or any spotting, for 12 consecutive months.

What Is the Connection Between Perimenopause and Depression?

Most people think that the estrogen levels are what make a difference in moods, but studies have shown that it’s really the change 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. Many people misunderstand how the hormones change around the 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 regular menstrual cycles,” explains Maki.

Hormones Flux May Mess With Menstrual Cycles, Healthy Sleep

The fluctuating hormones can also cause sleep problems because of issues such as hot flashes. Lack of sleep can lead to mood disturbances.

Women’s Life Changes in Forties Also Affect Mood Cycles

“The main thing is that women who are going through this understand what is happening because in addition to the biological factors, it is just as important to recognize the environmental factors,” says Maki. Women at midlife are experiencing big life changes: children growing up and taking off, taking care of elderly parents (sometimes both at the same time), career shifts, martial conflict, conflicted emotions about aging and body changes, and more. This combination of hormonal and life changes creates a complex causality that needs to be addressed in its totality.

Get Your Physician to Pay Attention to You

If you are suffering from depression and are perimenopausal, make sure your healthcare professional can connect the dots so he or she can correctly prescribe therapy for you. The North American Menopause Society offers a downloadable handout that you can bring to your practitioner that explains the connection between the two.

Related: Women, Hormones, and Depression

Diagnosis of Perimenopausal Depression

The causes of midlife depression are complex; it’s not easy to tease out what is biology and what is environment. According to the new guidelines, diagnosis of depressive disorders during midlife includes:

Clinical assessment of depression and other mental health issues
Review of previous psychiatric history
Identification of menopause stage
Discussion of the woman’s life stressors
Overview of sleep hygiene

You’ve Been Diagnosed With Depression — Now What?

“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.

Therapeutic options for depression include:

Antidepressants, especially SSRIs
Cognitive behavioral therapy, a form of talk therapy that teaches you how to retrain your brain
Treatment for vasomotor symptoms (hot flashes and night sweats), particularly if sleep is affected

Do Complementary and Alternative Approaches for Midlife Mood Issues Help?

NAMS has studied those as well, says Maki: “We are recognizing the importance of things like mindfulness-based stress reduction, yoga, exercise, and a good diet. For women whose depressive symptoms don’t reach the threshold for clinical episode of depression — its not keeping them at home — yoga could help to improve mood a little bit. But really the only thing that has been shown to help significantly in the alternative area is exercise. Aerobic is good, and literature shows that it’s even better if you do it with people or outside.”

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