Depression During Perimenopause

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Depression during perimenopause is a complex, multifaceted issue that impacts millions of women. This transitional phase leading up to menopause brings not only physical changes but also the risk of other hormonal imbalances and significant emotional challenges. While often overshadowed by better-known symptoms like hot flashes, sleep problems, and irregular periods, depression can be one of the most debilitating symptoms at this time in a woman’s life. In this article, we explore the causes, symptoms, and various treatment options for depression during perimenopause, with a focus on both medical and lifestyle interventions.

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Perimenopause is the transitional period leading up to menopause, typically occurring between the ages of 40 and 55. (Menopause is defined as the point when it’s been a whole year without a menstrual period.) During perimenopause, women experience significant hormonal fluctuations that can impact their physical and mental well-being. Research also indicates that a subset of women are particularly vulnerable to depressive disorders or symptoms during this period.

Studies estimate that up to women in perimenopause are 40% more likely to experience depression symptoms, with roughly 20% of women in perimenopause meeting the criteria for major depressive disorder (MDD) at some point during this phase.

Research from the Study of Women’s Health Across the Nation (SWAN) highlights a two- to four-fold increase in depressive symptoms during perimenopause, especially in women transitioning from regular to irregular menstrual cycles. These rates underscore the vulnerability women face during this time.

Perimenopausal depression can present with a range of symptoms, some of which are shared with general depression and others that are distinctively tied to this transitional life stage. Understanding these symptoms is crucial, as they can often be mistaken for other conditions or dismissed as typical aspects of aging. The MENO-D questionnaire, a specialized tool for identifying depression during perimenopause, outlines common symptoms of depression during perimenopause, which include:

• Low energy: You may feel a persistent lack of vitality, making it difficult to complete everyday tasks or enjoy activities you once found fulfilling.
• Irritability or hostility: You may feel more sensitive to minor frustrations and react more strongly to stressors. This irritability can strain your personal and professional relationships.
• Decreased self-esteem: You may have feelings of inadequacy or self-doubt, sometimes worsened by physical changes or societal expectations surrounding aging.
• Isolation: You may withdraw socially due to emotional fatigue or the belief that others might not understand your experiences.
• Anxiety: You may feel anxious, ranging from mild worry to intense episodes of panic, often related to fears about health, aging, or family responsibilities.
• Paranoid thinking: You may have thoughts of mistrust or suspicion that are not always grounded in reality and can contribute to feelings of alienation.
• Somatic symptoms: You can experience physical complaints such as headaches, stomach pains, or muscle tension that don’t have an identifiable medical cause.
• Sleep disturbances: Insomnia, difficulty staying asleep, or waking up feeling unrefreshed are common and often linked to night sweats or hormonal fluctuations.
• Weight gain: You may notice changes in your weight during this time, which can affect your self-image and overall well-being.
• Decreased sexual interest (low libido): Shifts in hormone levels, combined with physical and emotional stress, often lead to reduced sexual desire or enjoyment.
• Problems with memory and concentration: Often referred to as “brain fog,” this symptom includes difficulty focusing, forgetfulness, and trouble completing tasks efficiently.

It’s important to recognize that symptoms such as concentration issues, paranoia, and heightened irritability are frequently more pronounced in perimenopausal depression compared to major depressive disorders experienced by younger women or men. This distinction underscores the need for tailored assessment and treatment strategies.

Note: If you’re concerned about your mental health during perimenopause, the MENO-D questionnaire can be a valuable resource. It offers a structured way to identify symptoms and their impact, providing a basis for conversations with your healthcare providers. You can download a PDF copy of the Meno-D questionnaire here, which will let you conduct a self-assessment and share the results with your provider to facilitate a more informed and personalized approach to care.

There are several potential causes of depression for women during the perimenopausal transition.  

Reproductive hormonal changes

Hormonal changes are at the core of many perimenopausal symptoms. During perimenopause, estrogen, progesterone, and testosterone levels fluctuate unpredictably, leading to downstream effects on your neurotransmitters like serotonin, dopamine, and norepinephrine. These neurotransmitters are central to mood regulation.

Estrogen, in particular, plays a crucial role in regulating your mood and cognitive function. Lower estrogen levels have also been linked to increased vulnerability to depression due to their role in serotonin synthesis and receptor sensitivity.

Fluctuating hormones during perimenopause may also reduce your threshold for depression in the presence of adverse life events, perhaps due to these neurochemical changes.

Hypothyroidism

Your thyroid gland often plays an overlooked role in depression during the perimenopausal transition. The thyroid gland produces hormones that regulate metabolism, energy levels, and mood. Hypothyroidism, which becomes more common in women after age 40, can cause or worsen symptoms like fatigue, low mood, and cognitive sluggishness. In fact, an underactive thyroid may mimic or contribute to depressive symptoms of perimenopause, complicating your diagnosis. The overlap between thyroid dysfunction and hormonal changes in perimenopause is critical to understanding the root cause of mood disturbances in some women.

Symptoms of hypothyroidism that may mimic or exacerbate depression include:

• Low energy, fatigue
• Anxiety
• Depression
• Sleep disturbances
• Weight gain
• Decreased sexual interest (low libido)
• Problems with memory and concentration

If you’re a perimenopausal woman experiencing depression, thorough screening for thyroid dysfunction is always recommended as part of your evaluation.

Sleep disruption

Sleep disturbances, including insomnia and frequent nighttime waking due to hot flashes, are common in perimenopause. Chronic sleep deprivation has a direct link to mood disorders, including depression and anxiety. Reduced REM sleep, the restorative phase of sleep, amplifies emotional dysregulation and can worsen depressive symptoms.

Genetics and personal history

If you have a personal or family history of depression or mood disorders, you may find that perimenopause triggers a recurrence. Research shows that genetics influence how women metabolize hormones and respond to stressors during this time, further heightening vulnerability in some individuals.

Nutritional deficiencies

Key nutrient deficiencies in magnesium, vitamin D, and omega-3 fatty acids are known to affect your mood. Perimenopausal women often have suboptimal levels due to dietary habits, reduced absorption, or lack of supplementation. These deficiencies, coupled with hormonal shifts, can create a “perfect storm” for depression.

Psychosocial factors

While hormonal changes and physical issues play a significant role in perimenopausal depression, it’s also crucial to consider the broader context of your life during this transition. New or worsening depressive symptoms during perimenopause can be triggered by various psychosocial factors, including:

• Family stress: caregiving for aging parents, raising children, facing empty-nest syndrome
• Work stress: including career transitions
• Social stress: changes in relationships or social roles, lack of social support networks, political changes
• Financial stress
• Physical stress: Body image concerns related to aging, chronic illness

These external factors can compound the physical changes, making you more susceptible to depression.

Research suggests that multiple “hits,” including genetic risk factors and psychosocial stressors, may be required to unmask the risk for major depressive disorder during perimenopause.

Diagnosing perimenopausal depression can be challenging due to the overlap of symptoms with other hormonal changes and the potential delay between psychological and physical symptoms. You and your healthcare provider should consider the following questions when evaluating perimenopausal depression:

1. What stage of perimenopause are you in?
2. Do you have any co-occurring psychiatric symptoms?
3. Do you have perimenopause/menopause symptoms?
4. What psychosocial stressors are present in your life? (Family stress, work stress, social stress, financial stress, other physical stressors)
5. What possible differential diagnoses apply to you, including thyroid disease and other medical conditions?
6. What tests do you need (i.e., thyroid-stimulating hormone/TSH, free triiodothyronine/free T3, free thyroxine/T4, estrogen, follicle-stimulating hormone/FSH, adrenal stress panel) to rule out thyroid dysfunction or other hormonal imbalances?

There are a variety of ways healthcare providers treat depression during perimenopause. Let’s look at antidepressants, hormone replacement therapy, thyroid treatment, and cognitive behavioral therapy.  

Antidepressants

One of the front-line treatments for depression during perimenopause – particularly for moderate to severe symptoms – are selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). According to research, these antidepressant medications can be effective in treating depressive symptoms during perimenopause.  

Research has also demonstrated that certain antidepressants can help alleviate vasomotor symptoms, such as hot flashes, which often accompany depression during perimenopause. The most effective antidepressants for reducing hot flashes include:

Several antidepressants have shown efficacy in treating menopausal hot flashes. The most effective options based on clinical studies include:

• Paroxetine (Paxil): Demonstrated the most significant overall reduction in hot flashes (40.6% at 10 mg and 51.7% at 20 mg) compared to placebo. A low-dose form (7.5 mg) is FDA-approved specifically for treating hot flashes.
• Escitalopram (Lexapro): Significantly reduced hot flash frequency (47% vs. 33% for placebo) and severity (24% vs. 14% for placebo). It showed superior efficacy compared to other SSRIs in a mixed-treatment comparison analysis.
• Citalopram (Celexa): Studies have shown significant reductions in vasomotor menopausal symptoms compared to placebo.
• Venlafaxine (Effexor): Identified as a first-line SNRI agent, it shows the fastest onset of symptom relief (41% reduction alone by one week).

These antidepressants are generally well-tolerated, with modest improvements in hot flash severity and frequency. However, they may cause typical SSRI and SNRI side effects. The choice of medication should be individualized based on your personal factors and potential side effects.

It’s important to note that while these medications can be effective, they may also have side effects, such as nausea and constipation, which typically improve after the first week of treatment.

Hormone replacement therapy (HRT)

While not approved specifically for treating perimenopausal depression, hormone replacement therapy (HRT) can be a cornerstone treatment for depression during perimenopause. The antidepressant effects may be particularly helpful for women who also have vasomotor symptoms like hot flashes and night sweats.

Estrogen therapy – particularly transdermal, bioidentical applications like patches, gels, and creams – has shown to be effective in reducing depressive symptoms. Combined hormone therapy with progesterone is also used but requires careful monitoring. These hormonal treatments may be considered for women with first-onset major depressive disorder or elevated depressive symptoms who are at low risk for adverse effects.

However, not all women are candidates for HRT due to contraindications like a history of breast cancer or cardiovascular disease. For these women, other treatments may be prioritized.

Thyroid hormone replacement

Women diagnosed with hypothyroidism during perimenopause often see improvements in depressed mood and energy levels with thyroid hormone replacement therapy. This treatment involves taking thyroid hormones to restore normal thyroid gland function, optimize thyroid hormone levels, and alleviate symptoms associated with an underactive thyroid. The primary thyroid hormone replacement drugs include levothyroxine and natural desiccated thyroid. Given the overlap between thyroid dysfunction and perimenopausal symptoms, checking thyroid levels is an essential step in the diagnostic process.

Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy (CBT) is a widely used psychotherapeutic approach that focuses on identifying and changing negative thought patterns and behaviors to improve mood and coping skills. For women experiencing depression during perimenopause or due to hypothyroidism, CBT can be an effective treatment option.

CBT typically involves working with a therapist to recognize distorted thinking patterns, challenge negative thoughts, and develop more balanced and realistic perspectives. The therapy also emphasizes problem-solving skills and behavioral activation, encouraging patients to engage in activities that can improve their mood and overall well-being.

Research has shown that CBT is highly effective in treating depression across various populations. A comprehensive review of meta-analyses found that CBT has support for treating anxiety disorders, somatoform disorders, bulimia, anger control problems, depression, and general stress.

In a large-scale study examining long-term outcomes:

• 61.38% of patients showed total remission of anxiety disorders immediately after CBT treatment
• 63.64% maintained remission at long-term follow-up
• Significant improvements were observed in severity, anxiety, impairment/burden, and quality of life measures

Another study focusing on different CBT delivery formats found that individual, group, telephone, and guided self-help CBT were all significantly more effective than waiting list and care-as-usual control conditions. 

While specific data on CBT’s effectiveness for depression during perimenopause, the menopausal transition, or hypothyroidism is limited, the general efficacy of CBT for depression suggests it can be beneficial for these populations. Women experiencing perimenopausal depression may benefit from CBT’s focus on managing mood swings, sleep disturbances, and anxiety often associated with hormonal changes.

For individuals with hypothyroidism-related depression, CBT can help address the cognitive symptoms often experienced, such as difficulty concentrating and memory problems. The therapy can also assist in developing coping strategies for fatigue and other physical symptoms that may contribute to depressive feelings.

A study examining the long-term effects of CBT found that its benefits persisted well after the end of treatment:

• 43% of patients who received CBT reported at least a 50% reduction in depressive symptoms over 46 months
• These improvements were observed, on average, 40 months after therapy ended

This suggests that CBT can offer lasting benefits for individuals struggling with depression, including those experiencing perimenopausal or hypothyroidism-related symptoms.

Alternative and complementary therapies for perimenopausal depression have gained attention as potential options for managing symptoms. Here’s an overview of some useful approaches.

Nutrition and diet

A balanced diet rich in whole foods, lean proteins, and omega-3 fatty acids can support overall health and potentially improve mood. Key dietary strategies include:

• Increase omega-3 fatty acid intake through fatty fish (salmon, mackerel, sardines) or supplements.
• Consume magnesium-rich foods like leafy greens, nuts, and seeds to support mood regulation.
• Ensure adequate vitamin D through sun exposure, fortified foods, or supplements.
• Incorporate foods high in B vitamins, such as dairy products, leafy green vegetables, and beans, which may be particularly beneficial for mood support.
• Limit caffeine and alcohol intake, as these can exacerbate mood swings and sleep disturbances.

Supplements

Several vitamins and minerals are essential to support health during perimenopause and may help relieve perimenopausal symptoms, including depression. These include:

• B vitamins: Adequate intake of B vitamins, particularly B6, B12, and folate, is vital for mental and emotional well-being during perimenopause.
• Calcium and vitamin D: These nutrients are crucial for bone health and may also affect mood regulation.
• Omega-3 fatty acid supplements: If dietary intake is insufficient, supplements may help support brain health and mood.

While more research is needed, some women find relief with other dietary supplements for perimenopausal symptoms such as depression. These supplements include:

• Maca: Maca root may help balance hormones and alleviate symptoms such as hot flashes, depression, mood swings, and fatigue. Its adaptogenic properties can also support stress management, which is beneficial for both perimenopausal and thyroid patients.
• Melatonin: Melatonin effectively improves sleep quality, which can indirectly help manage mood disorders and fatigue related to sleep disturbances. As a “master conductor” of other hormones, melatonin can also relieve some symptoms of perimenopause, including erratic periods.
• Red clover and soy: These supplements contain phytoestrogens that may help balance hormones and reduce hot flashes and mood swings. However, their effects on thyroid function are controversial, so thyroid patients should consult a healthcare provider before use.
• Dong quai: Dong quai is traditionally used to manage menstrual irregularities and menopausal symptoms, with potential mood-stabilizing effects. Its impact on thyroid function is not well-studied, warranting caution for thyroid patients.
• Evening primrose oil: Evening primrose oil may reduce inflammation and hormone-related symptoms like breast pain and mood swings.
• Ashwagandha: Ashwagandha, an adaptogen, may help manage stress and balance hormones, benefiting both perimenopausal women and thyroid patients. Some studies suggest it could improve thyroid function, but more research is needed.

Remember that it’s crucial to consult with a healthcare provider before starting any new supplement regimen, as some supplements can interact with medications or have side effects.

Acupuncture

Acupuncture has shown promising results in reducing both depressive symptoms and vasomotor symptoms like hot flashes in perimenopausal women. Its calming effect on the nervous system may provide a holistic benefit. Recent studies have demonstrated:

• Acupuncture significantly reduced hot flashes and improved quality of life in women receiving endocrine therapy for breast cancer.
• A 50% or more reduction in hot flash scores was observed in 64% of women who received immediate acupuncture compared to 18% in the control group.
• Acupuncture’s effects on hot flashes can persist for up to 6 months after treatment cessation.
• While acupuncture may not be as effective as hormone therapy for hot flash frequency, it significantly improves hot flash severity.

In addition to medical treatments, various lifestyle modifications and non-pharmacological interventions can help manage perimenopausal depression.

Regular exercise

Regular physical activity is one of the most potent natural antidepressants. Physical activity – including aerobic exercise and resistance training -- has been shown to affect mood positively and can help alleviate depressive symptoms. Regular exercise releases serotonin and endorphins, which can improve overall well-being. Aim for at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week, along with muscle-strengthening activities at least twice a week.

Sleep habits

Prioritizing good sleep is essential, and it can significantly impact your mood and overall health. Some good habits to adopt include:

• Maintaining a consistent sleep schedule and bedtime routine
• Creating a cool, dark, and comfortable sleep environment
• Reducing screen time and avoiding electronic devices before bedtime

Cognitive behavioral therapy for insomnia – known as CBT-I – may also benefit women with persistent sleep disturbances.

Mindfulness and relaxation techniques

Mindfulness activities and relaxation techniques -- like breathwork, gentle yoga, tai chi, qi gong, and meditation – can help reduce stress and anxiety associated with perimenopausal depression. Research shows that 15 minutes a day of mindfulness practice can help lower stress levels and improve overall emotional well-being.

Social support

Research has found that maintaining strong social connections and seeking support from friends, family, or support groups can be invaluable during the perimenopausal transition. Sharing experiences and coping strategies with others going through similar challenges can provide emotional relief and practical advice.

Recognizing when depression during perimenopause requires medical intervention is critical to ensuring timely and effective support. While mood swings and emotional fluctuations are common during this transitional phase, persistent symptoms that go beyond regular hormonal shifts should not be ignored. Depression during perimenopause often manifests as overwhelming sadness, feelings of hopelessness, or a pervasive lack of energy and motivation. These symptoms can gradually erode your quality of life, making it difficult to maintain relationships, perform well at work, or engage in once enjoyable activities. Understanding when to seek help can make a significant difference in managing your mental health during this transitional time.

It is essential to distinguish between temporary emotional challenges and clinical depression requiring professional treatment. If symptoms such as chronic fatigue, irritability, or a sense of disconnection persist for weeks or months, they may signal a deeper issue. Additionally, feelings of worthlessness, extreme guilt, or an inability to find pleasure in everyday activities often accompany depressive episodes. In severe cases, if you have thoughts of self-harm or suicide, please seek immediate or emergency medical care. These signs indicate that hormonal changes alone cannot explain your distress, and a medical evaluation is necessary to explore underlying causes and appropriate treatment options.

Seeking medical help for perimenopausal depression is not a sign of weakness but an act of self-care and empowerment. Treatments may include hormone therapy to balance fluctuating estrogen levels, counseling, or antidepressant medications tailored to the individual’s needs. Early intervention can prevent symptoms from worsening and help restore emotional well-being. By addressing these challenges head-on, you can regain control of your life and navigate the perimenopausal transition with greater resilience and support.

Perimenopausal depression is a multifaceted condition shaped by hormonal changes, psychosocial factors, and individual health circumstances. Recognizing the unique presentation of depression during this transitional life stage is essential for you to get an accurate diagnosis and effective treatment.

At Paloma Health, we specialize in providing personalized care for women navigating hypothyroidism, perimenopause, and menopause. Our approach integrates medical interventions—such as tailored antidepressants, hormone therapy when appropriate, and hypothyroidism treatment and management—with lifestyle modifications and non-pharmacological treatments. This comprehensive strategy helps you improve your physical and emotional well-being, empowering you to regain control of your health and quality of life.

Our dedicated healthcare providers understand the increased risk of depression during perimenopause and are committed to systematic screening and creating tailored treatment plans. By addressing the physical, emotional, and hormonal aspects of this critical transition, we help you move through this challenging period with greater ease and resilience.

As research advances, the promise of more targeted interventions grows, but relief is already possible with the right care. If you’re experiencing depressive symptoms during perimenopause, with or without hypothyroidism, Paloma Health is here to help. As a Paloma member, you and your care team will work together to develop a plan that meets your unique needs so that you can thrive throughout perimenopause and beyond. 

• Recognize that depression can be a symptom of reproductive hormonal changes, hypothyroidism, and other factors that are more common in women aged 40+ in perimenopause.
• Get comprehensive health screening: Have a thorough evaluation that includes thyroid function tests (TSH, free T3, free T4), reproductive hormone levels, and a mental health assessment using tools like the MENO-D questionnaire.
• Consider targeted treatment options, such as low-dose antidepressants, hormone replacement therapy (if medically appropriate), and thyroid hormone replacement (if hypothyroidism is detected).
• Consider cognitive behavioral therapy (CBT) to identify and challenge negative thought patterns and develop better coping strategies.
• Address nutritional deficiencies that can significantly impact mood during perimenopause, including vitamin D, magnesium, and omega-3 fatty acids.
• Prioritize quality sleep and a regular stress management practice.
• Recognize that depression can manifest differently in perimenopause, with more pronounced irritability, concentration difficulties, anxiety, and social withdrawal.

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