Perimenopause is defined as the early and late menopause transition stages as well as early menopause. This typically lasts 4-8 years. It has been identified as a vulnerable time for development of depressive symptoms and major depressive episodes. It is therefore important for providers in primary care to be aware of the risk of depressive symptoms during perimenopause and know what the next steps are in terms of assessment and treatment.
Many women experience some depressive symptoms during perimenopause and there is some overlap between menopausal symptoms and depressive symptoms that can occur during this stage in a woman’s life (ie: sleep disturbance, fatigue, mood swings, difficulty with concentration, decreased interest in intimacy). The symptoms of major depression during perimenopause are not different than the symptoms of major depression in general. Most women who experience a depressive episode during perimenopause have had a previous episode of depression earlier in their lives. New onset major depression in perimenopause is less common. Women with a history of Major Depression Disorder (MDD) are more likely to experience a depressive episode during perimenopause than women without a history of MDD.
The differential diagnosis of depression during the menopause transition includes MDD, subsyndromal depression, adjustment disorder, bipolar depression and general medical causes of depression. It is important to assess for other psychosocial stressors that could be contributing factors. There does not seem to be a clear association with severity of vasomotor symptoms of menopause and presence of depressive symptoms.
The treatment for major depression is the same for women in perimenopause. For milder cases, therapy is a good first line treatment option. For more moderate-severe cases, antidepressant medication and therapy is the recommended treatment. The SSRIs and SNRIs are a good first line option and doses do not need to be adjusted because a woman is in perimenopause. In women with a history of MDD, a prior adequate response to a particular antidepressant should guide treatment selection if MDD recurs during perimenopause. There are some small open label studies that support that estrogen therapy can be effective for depressive symptoms for women in menopause either on its own or as an adjunctive to an antidepressant, but its use is not recommended clinically because of concerns about risks. The decision should be made on a case-by-case basis depending on other menopausal symptoms and presence of other risk factors. Hormonal contraceptives have been shown to alleviate mild depressive symptoms in perimenopausal women.
An expert panel, including members from the North American Menopause Society (NAMS) and the National Network of Depression Centers Women and Mood Disorders Task Group (NNDC), was convened to review the scientific literature and to establish guidelines for the evaluation and treatment of depression during perimenopause. Their recommendations include:
- Proven treatments for depression such as antidepressant medications and psychotherapy are the first line recommendations for treating major depressive episodes during perimenopause
- Existing data supports that antidepressant medications can be prescribed to women in perimenopause with depression at the doses typically prescribed to adults. Dose adjustments are not necessary because of perimenopause.
- There is some evidence that estrogen therapy can have antidepressant effects when given to women in perimenopause with depression. However, estrogen therapy has been shown to be ineffective as a treatment for major depression for postmenopausal women.
- Hormonal contraceptives may improve depressive symptoms in women in perimenopause.
It is our hope that this primer on depression during perimenopause has been helpful. Please feel free to call the SmartCare BHCS provider line to discuss specific cases. 858-880-6405