What Is Perimenopausal Depression?

Perimenopause, the transition period before menopause, is known for causing mood swings and depressive symptoms. There is a common misconception that when entering your menopausal years you should accept that it is normal to feel depressed. But serious depression should never be considered normal. If you experience depression at any point in your life you should seek out medical help with the same attention as you would other medical conditions.

Menopause is the time when periods end because the ovaries have stopped producing the hormones that make menstrual cycles possible. During perimenopause, abnormal menstrual cycles, hormone fluctuations, and sleep problems are common. Many people also experience unpleasant hot flashes and night sweats.

Here is what you need to know about perimenopausal depression, including prevalence, causes, symptoms, diagnosis, and treatment.

Prevalence

Research shows women generally experience depression more often than men, with a lifetime prevalence risk of 21%, compared to 12% of men. One 2017 report notes the rate of major depression in women of reproductive age is double that of their male counterparts. Depression in women also increases around reproductive events­—following childbirth, menstrual cycle disorders, and the transition towards menopause. 

More than 80% of women will experience physical or psychological symptoms around menopause to some degree and severity. Depression, mood changes, hot flashes, and sleep problems are the most commonly reported menopausal symptoms. Depressive illness around perimenopause seems to be up to 30%, but it is very possible that these percentages are much higher as many perimenopausal women are not reporting depressed mood amongst the effects of this transition period on them.

For the most part, much of the research—while limited—does confirm women experience more depressive symptoms during perimenopause than they did before the start of their transition and in comparison to women who have not entered the transition to menopause.

Perimenopausal Depression Symptoms

Depression ranges in seriousness from mild to temporary episodes, and to severe and persistent. Clinical depression is the most severe type of depression. It is also known as major depression or major depressive disorder. Fortunately, despite the severity, all types of depression are treatable. And regardless of whether a person experiences depression during perimenopause or at any point in life, the symptoms tend to be similar in type although severity and intensity vary.

Symptoms of depression may include:

• Fatigue and lack of energy
• Feeling restless or slowed down
• Struggles with focus and remembering things
• Lack of interest in activities you once enjoyed
• Feeling helpless, hopeless, or worthless
• Recurrent thoughts of death or suicide

Reduced levels of female hormones during perimenopause may cause additional depressive symptoms, such as:

• Mood swings
• Irritability
• Crying for no reason or feeling tearful often
• Increased anxiety
• Feeling profound despair
• Sleep problems related to hot flashes and night sweats

Premenopausal depression may present somewhat differently than clinical depression. For example, research finds premenopausal depression causes more irritability, and more frequent mood changes, while feeling sad and tearful are less often experienced.

When to See a Healthcare Provider

As you enter perimenopause, it is important to let your healthcare provider know if you have suffered from depression in the past, or if you have been particularly sensitive to hormonal and reproductive changes. In addition, pay attention to mood changes you experience. Are changes mild and non-life altering or are they severe and debilitating to the point where they affect your ability to perform daily activities and enjoy your life?

Anytime depressive symptoms start causing you problems in your relationships and at work, and there are no clear solutions to what you are experiencing, you should seek help from your practitioner or mental health professional. Talking to a mental health provider or your practitioner can prevent symptoms from getting worse, especially if symptoms have been around for a long period of time.

It is important to note feeling sad from time to time does not mean you have depression. Depression not only affects your mood, but it also affects other physical aspects of your health, including your sleep, energy, appetite, motivation, and concentration. If you are experiencing these types of physical symptoms and find you are experiencing depressive mood symptoms most of the time for days and weeks at a time, you should see your healthcare provider.

Causes

There are several causes of, and risk factors associated with, perimenopausal depression. Causes may include dropping levels of estrogen, stressful life events, mood swings, previous history of depression, and more.

Estrogen Decreases

Most researchers believe fluctuating levels of the female hormone estradiol are a predictor of perimenopausal depression. Estradiol is the most potent type of estrogen the body makes during the reproductive years. Symptoms of menopause are believed to be caused by the natural declines of estradiol.

Stressful Life Events

Anyone dealing with stressful life events, such as divorce, death of a parent, job loss, or any other life event common during the perimenopausal years is at an increased risk for depression. These types of life events are known—even under the best circumstances—for triggering depression.

Mood Swings

It is not unusual for perimenopausal individuals to experience mood swings related to fluctuating hormone levels. When estrogen levels are constantly changing, brain chemicals serotonin and norepinephrine are affected.

Serotonin, norepinephrine, and dopamine are chemicals in the brain that play a direct role in regulating mood. They can make a person feel happy by reducing anxiety, improving sleep, regulating memory and metabolism, and more. A person experiences a general state of calmness and well-being when these chemicals are balanced.

Hormone imbalances may inhibit the ability of serotonin and norepinephrine to do their jobs. The result is mood swings that eventually lead to depression.

Previous History of Depression

Individuals with a previous history of major depression are at higher risk during perimenopause, especially if they are particularly sensitive to hormonal fluctuations. If you have a personal history of depression, talk to your healthcare provider especially if you find you are struggling with your emotions and mood during perimenopause.

Other Risk Factors

Additional risk factors associated with perimenopausal depression include:

• Family history of depression
• Prior history of sexual abuse or violence
• Severe menopausal symptoms
• Having a sedentary lifestyle
• Smoking
• Being socially isolated
• Struggling with self-esteem
• Having negative feelings about aging and menopause
• Feeling disappointed about not being able to have children (or more children)

Diagnosis

Despite depression in perimenopausal women occurring frequently, it can be difficult to recognize. In 2018, two prominent organizations—The North American Menopause Society (NAMS) and the Women and Mood Disorders Task Force of the National Network of Depression Centers—released guidelines for the evaluation and treatment of perimenopausal depression. These guidelines, which have made it helpful to distinguish perimenopausal depression from other types of depression, were published in the Journal of Women’s Health and have since been endorsed by the International Menopause Society.

According to the guidelines of the NAMS and the Women and Mood Disorders Task Force, a diagnosis of perimenopausal can be made relying on specific assessments, many of which are related to midlife. These diagnosis guidelines include:

• Clinical and symptom assessment of depression and other mental health disorders, as well as physical symptoms
• Review of a woman’s psychiatric history
• Menopause stage identification—this includes a physical exam and bloodwork to evaluate the function of ovaries
• Thyroid gland function may also be checked using bloodwork and a physical exam, as an underactive thyroid may contribute to depression.
• Discussion of life stressors
• Any problems with sleep or the concurrence of a sleep disorder

It should be noted that although a high number of women experience depression as they go through menopause, more than a third of gynecologists are not screening for it, according to a survey reported in 2020 by the journal Menopause. The survey of 500 practicing gynecologists finds while most can recognize perimenopausal depression, many did not feel confident in their ability to treat depressed patients.

These findings suggest gynecologists need more training in diagnosing and treating depression. They also mean individuals entering menopause need to understand that their risk for depression is higher during this period, and because their healthcare providers are not screening, it is important to be aware of symptoms of depression, which can be different and less obvious during perimenopause.

Treatment

Treatment for depression that occurs in connection with perimenopause is dependent on how severe the person's symptoms are and whether they have suffered from depression in the past.

Generally, treatment for perimenopausal depression includes:

• Antidepressant medications to manage depressive symptoms
• Talk therapy and cognitive behavioral therapy—psychotherapy techniques that work to change thoughts and behaviors
• Hormone replacement therapy (HRT) for mood swings or hot flashes and night sweats if they are affecting sleep

If depressive symptoms are severe, researchers have recommended that treatment with antidepressants be combined with HRT, either with both estrogen and progesterone or with estrogen alone. This combination treatment is recommended for severe cases of perimenopausal depression, whether or not a woman has a history of depression.

If symptoms of perimenopausal depression are mild and the person has no history of depression, there is no single best way to treat the depression, but researchers do suggest trying hormones or an antidepressant—one at a time—to treat symptoms. HRT alone can relieve mood swings and hot flashes that may contribute to depression. However, for individuals with few physical symptoms of perimenopause, or those who want to avoid hormones, an antidepressant is recommended.

A Word From Verywell

The outlook for most women who experience perimenopausal depression is good. While treatment cannot always make depression go away completely, it usually makes symptoms more manageable.

Because the risk for depression during the time of transition to menopause is high, it is a good idea for women in perimenopause to keep an eye out for symptoms and to recognize when it is time to seek help. Whether symptoms are mild or if you think you are living with clinical depression, make an appointment with your healthcare provider to determine what treatments might help.

And if you feel treatments are not helping, do not hesitate to right out to your practitioner once again. Your healthcare provider can find a different plan that may work better in managing perimenopausal depression and its causes during this transition period.