Evidence-Based Reviews

Perimenopausal depression: Covering mood and vasomotor symptoms

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Hormones, antidepressants, or psychotherapy—what would you recommend?



Symptoms of perimenopausal depression are not inherently different from those of depression diagnosed at any other time in life, but they present in a unique context:

  • Hormonal fluctuations may persist for a long duration.
  • Women experiencing hormonal fluctuations may be vulnerable to mood problems.
  • Psychosocial/psychodynamic stressors often complicate this life transition.

Managing perimenopausal depression has become more complicated since the Women’s Health Initiative (WHI) studies found fewer benefits and greater risks with hormone replacement therapy (HRT) than had been perceived. This article discusses the clinical presentation of perimenopausal depression, its risk factors, and treatment options in post-WHI psychiatric practice.

Who is at risk?

Perimenopausal depression is diagnosed when onset of major depressive disorder (MDD) is associated with menstrual cycle irregularity and/or somatic symptoms of the menopausal transition.1 Diagnosis is based on the overall clinical picture, and treatment requires a thoughtful exploration of the complex relationship between hormonal function and mood regulation.

Presentation. For many women, perimenopause is characterized by mild to severe vasomotor, cognitive, and mood symptoms (Table 1). Thus, in your workup of depression in midlife women, document somatic symptoms—such as hot flushes, vaginal dryness, and incontinence—and affective/behavioral symp toms such as mood and sleep disturbances.

Table 1

Vasomotor, cognitive, and mood symptoms of perimenopause

VasomotorCognitive and mood
Hot flushesDecreased concentration
Heart palpitationsIrritability
Painful intercourseMood lability
Vaginal dryness and discomfortMemory difficulty
Sleep disruption

Explore psychiatric and medical histories of your patient and her close relatives. Ask about depression, dysthymia, hypomania, or mood fluctuations around hormonal events such as menses, pregnancy, postpartum, or starting/stopping oral contraceptives. In the differential diagnosis, consider:

  • Is low mood temporally connected with hot flushes and disturbed sleep?
  • Is low mood secondary to stressful life events?
  • Does the patient have another medical illness (such as thyroid disorder) with symptoms similar to depression?
  • Is low mood secondary to anxiety or another psychiatric disorder?

Screening. Menopause is considered to have been reached after 12 months of amenorrhea not due to another cause. Median ages for this transition in the United States are 47.5 for perimenopause and 51 for menopause, with an average of 8 years between regular cycles and amenorrhea.2 Therefore, begin talking with women about perimenopausal symptoms when they turn 40.

Evidence supports screening perimenopausal women for depressive symptoms even when their primary complaints are vasomotor. The Greene Climacteric Scale3 is convenient for quantifying and monitoring perimenopausal symptoms. It includes depressive symptoms plus physical and cognitive markers. The Quick Inventory of Depressive Symptomatology—Self Report (QIDS-SR)4 questionnaire:

  • takes minutes to complete
  • is easy to score
  • quantitates the number and severity of depressive symptoms (see Related Resources).

Psychosocial factors can predict depression at any time in life, but some are specific to the menopausal transition (Table 2).5 The “empty nest syndrome,” for example, is often used to explain depressive symptoms in midlife mothers, but no evidence links mood lability with the maturation and departure of children. What may be more stressing for women is supporting adolescents/young adults in their exit to independence while caring for aging parents.

Table 2

Risk factors for depression in women

Predictive over lifetimeHigh risk during menopausal transition
History of depressionHistory of PMS, perinatal depression, mood symptoms associated with contraceptives
Family history of affective disordersPremature or surgical menopause
InsomniaLengthy menopausal transition (≥27 months)
Reduced physical activitiesPersistent and/or severe vasomotor symptoms
Weight gainNegative attitudes toward menopause and aging
Less education
Perceived lower economic status
Perceived lower social support
Perceived lower health status
Stressful life events
History of trauma
Marital dissatisfaction
PMS: Premenstrual syndrome

Sociocultural beliefs about sexuality and menopause may play a role in how your patient experiences and reports her symptoms. In some cultures, menopause elevates a woman’s social status and is associated with increased respect and authority. In others, such as Western societies that emphasize youth and beauty, women may view menopause and its physical changes in a negative light.6

Therefore, give careful attention to the psychosocial context of menopause to your patient and the social resources available to her. Questions to ask include:

  • Has your lifestyle changed recently?
  • Have your husband, family members, or close friends noticed any changes in your functioning?
  • Is there anyone in your life that you feel comfortable confiding in?

Explaining the complexity of this life transition may ease her anxiety by normalizing her experience, helping her understand her symptoms, and validating her distress.

What might be the cause?

Although the exact pathophysiology of perimenopausal depression is unknown, hormonal changes,7 general health, the experience of menopause,8 and the psychosocial context2 likely work together to increase vulnerability for depressive symptoms (Figure).


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