Perimenopausal Depression

Introduction

Definition and overview of perimenopausal depression

Psychological symptoms such as feeling depressed, having low self-esteem, and mood swings are common symptoms of perimenopause and menopause. Perimenopause describes the time frame during which a person experiences symptoms of menopause before their periods cease. The age at which perimenopause begins (and ends) varies between individuals.¹  

Perimenopausal depression refers to a person experiencing decreased mood or depression as a result of the hormonal changes that occur during perimenopause. Depressive symptoms may include poor concentration, feeling low or tearful, poor self-confidence and self-esteem, or feeling isolated.² According to The Menopause Charity, more than 50% of perimenopausal individuals report an increase in depressive symptoms.³ 

Importance of understanding perimenopausal depression

Perimenopausal depression can be a debilitating illness and severely impact the quality of life of affected individuals. Professor Arianna Di Florio, a Professor in Psychological Medicine and Clinical Neurosciences at Cardiff University, describes the association between neuropsychiatric conditions and menopause as ‘often misunderstood’. The yet-unclear link between menopause and depression forms the basis of her research, which ultimately seeks to determine whether perimenopause/menopause is a period of increased risk of mental illness.⁴ 

Depression is a common mental health disorder, affecting approximately 280 million people in the world each year.⁵ As perimenopause and menopause can increase the risk of depression, it is important to raise awareness of the condition to help ensure that individuals who may be affected can identify symptoms and receive appropriate medical support. Furthermore, women aged 50 or over accounted for 26% of all women and girls worldwide in 2021. 

Understanding perimenopause

Definition and characteristics of perimenopause

As previously mentioned, perimenopause is defined as the period that a person experiences symptoms of menopause before their periods cease. Symptoms of menopause are wide-ranging and individuals may experience many or few of the following typical symptoms:⁶

• Hot flushes and night sweats
• Vaginal dryness
• Difficulty sleeping
• Weight gain
• Joint and muscle pain
• Mood swings
• Feeling depressed

For some people, perimenopause symptoms will be severely disruptive to their everyday lives, whereas others may experience no symptoms at all. Most people who go through menopause will enter perimenopause between the ages of 45 and 55 and may remain in perimenopause for many months or years.⁷ During this time, hormone levels will fluctuate and the production of eggs by the ovaries will slow down. Once a person hasn’t had a period for over 12 months, they are considered to have reached menopause.⁸ 

Hormonal changes during perimenopause

During perimenopause, the amount of oestrogen produced by the ovaries changes, altering your menstrual cycle and making it unpredictable. 

During your reproductive years, the first phase of the menstrual cycle is characterised by the release of the hormone oestrogen, which causes the lining of the uterus to thicken. Following the release of an egg at ovulation, levels of another hormone named progesterone rise -  preparing the lining of the uterus to receive a potentially fertilised egg. When both oestrogen and progesterone levels decrease, the lining of the uterus is shed and the person has a period.⁹ 

As people age, egg production slows down, and their ovaries may not release an egg during every cycle. Consequently, the levels of oestrogen and progesterone being produced become unpredictable - resulting in the symptoms associated with menopause. Figure 1 (below) shows the hormonal fluctuations that occur during perimenopause which contribute to symptoms such as hot flushes.⁸ Also included in the figure is a representation of the regular hormone cycles of oestrogen and progesterone that occur during a person’s ‘reproductive years’.

Figure 1: Diagram showing the typical levels of oestrogen and progesterone during the reproductive years, perimenopause, and menopause.⁸

If your symptoms are affecting your daily life, your healthcare professional may recommend treating you with Hormone Replacement Therapy (HRT) to help replace the oestrogen and progesterone levels that are depleting due to menopause. 

Prevalence and risk factors of perimenopausal depression 

Prevalence of perimenopausal depression

As previously mentioned, The Menopause Charity says that over half of perimenopausal people experience depressive symptoms.³ Estimating the prevalence of menopausal depression is challenging, with studies declaring varying prevalences usually between 20% - 40%.^10,11 

In September 2021, a UK survey of 1004 perimenopausal/menopausal individuals found 53% to have experienced depressive symptoms.¹² The reasons for the lack of data on the prevalence of perimenopausal depression are wide-ranging but may include stigmatisation, poorly informed healthcare workers, and disparities in healthcare access to specialist services.¹³

Factors contributing to perimenopausal depression

Two studies in the early 2010s examining the prevalence of perimenopausal depression found that people in perimenopause and early menopause were at a two to five times higher risk of developing depression compared to those in pre-menopause.^14,15 Entering perimenopause increases the risk of both the first occurrence and relapse of depression. However, a history of depression has been identified as a predictor of perimenopausal depression in most studies.^15,16 

There are few studies to suggest factors that may contribute to the development of perimenopausal depression but these likely overlap with the risk factors associated with depression (outside of perimenopause/menopause) including:¹⁷

• Relationship issues
• Family history of depression: people with a first relative with depression are three times more likely to experience it themselves
• History of other mental illnesses
• Female sex
• Older age 

It is important to remember that perimenopause,  while a natural stage of life, can be a major change to day-to-day life and can potentially contribute to challenging personal and social circumstances that may also increase the risk of developing depression.

Symptoms and diagnosis

Common symptoms of perimenopausal depression

Experiencing the following symptoms for at least two weeks or more may be a sign of perimenopausal depression:¹⁸

• Persistent feelings of sadness, anxiety, or ‘emptiness’
• Feelings of hopelessness or pessimism
• Loss of interest in activities or hobbies that you usually enjoy
• Difficulty concentrating or remembering things
• Sleeping problems - such as difficulty getting to sleep, waking up early, or oversleeping
• Irritability
• Thoughts of suicide or self-harm
• Changes in appetite and weight gain/loss

Diagnosis and assessment of perimenopausal depression

Diagnosis and assessment of depression during perimenopause are essential to improving the quality of life for individuals affected and should involve the standard diagnostic criteria and assessment tools used to diagnose depression. For many people, their general practitioner (GP) will be their first point of contact in a primary care setting to talk about perimenopause and their mental health. 

Impact on mental health

Psychological effects of perimenopausal depression

The psychological effects of perimenopausal depression are wide-ranging and may differ in severity between individuals due to the diverse range of symptoms that are associated with depression. For some individuals, feelings of hopelessness and thinking about suicide may be severe and cause a significant disturbance in day-to-day life including the capacity to work or practice self-hygiene. In others, perimenopausal depression may lead to poor sleep, exacerbating feelings of fatigue and irritability. The information and symptoms listed above should help to identify the potential psychological effects of perimenopausal depression. 

Relationship between perimenopausal depression and other mental health disorders

The risk of developing depression, both within and outside of perimenopause, is associated with having other pre-existing mental health disorders. However, the hormonal fluctuations that take place in perimenopause may also contribute to the development of mental illnesses such as anxiety. 

Anxiety can have both psychological and physical symptoms and may develop due to the changes to day-to-day life that occur for some people during perimenopause.¹⁹ The psychological symptoms of anxiety include feelings of dread, difficulty concentrating, feeling on edge or panicked, and irritability.²⁰ It is common for people to experience both anxiety and depression.²¹

Management and treatment

Psychological therapies and counselling

Different types of psychological therapies and counselling may be suitable for the management and treatment of perimenopausal depression. Below is a breakdown of some of the most common therapies available. 

Cognitive behavioural therapy (CBT)

CBT is a talking therapy commonly used for the treatment of anxiety and depression. This type of therapy explores the link between feelings and thought patterns, encouraging patients to identify negative thinking patterns and break them down to help improve the way they feel.²²  

Counselling

Counselling is another type of talking therapy that is used to help manage and treat depression, as well as to help people cope with upsetting life events. This practice enables people to speak about their feelings with a licensed counsellor, helping them to cope in their daily lives.²³

Pharmacological treatments and hormone therapy

Hormone replacement therapy (HRT)

HRT may be offered to you by a healthcare professional to help your perimenopause symptoms become more manageable. HRT involves taking progesterone and oestrogen to replace the levels of these hormones that are depleting as you approach menopause.²⁴ 

Antidepressants

Antidepressants may also be offered to you by a healthcare professional if HRT is not suitable for you or is ineffective. There are various types of antidepressants, but they are believed to all work by changing the levels of neurotransmitters in the brain to help mediate your mood.²⁵

Summary

Perimenopausal depression is a common psychological condition that can affect people experiencing perimenopause. If you are concerned that you may be experiencing this condition, please speak to a healthcare professional.