First-ever guidelines for detecting, treating perimenopausal depression

It is well-recognized that women are at increased risk of depression during the postpartum period when hormone levels are changing, but the risk of depression associated with perimenopause — the years surrounding the final menstrual period when female hormones are in flux — remains under-recognized and clinical recommendations on how to diagnose and treat this kind of depression in women have been lacking until now.

Because of that, researchers have published the first-ever guidelines for the evaluation and treatment of perimenopausal depression, co-led by Dr. Pauline Maki, member of the UICDR and professor of psychiatry, psychology and obstetrics and gynecology at UIC and Dr. Susan Kornstein professor of psychiatry and obstetrics and gynecology at Virginia Commonwealth University. The guidelines were developed by a panel of clinicians and scientists convened by The North American Menopause Society and the National Network on Depression Centers Women and Mood Disorders Task Group.

“The reason these guidelines are needed is because depression during the perimenopause can occur along with menopausal symptoms, and these two sets of symptoms are hard to tease apart, which makes it difficult for clinicians to appropriately diagnose and treat these women,” said Dr. Maki. “Many women experience a new onset of depressive symptoms. If there is underlying low-level depression to begin with, perimenopause can increase the intensity of depressive symptoms.”

The need for expert consensus as well as clear clinical guidance regarding how to evaluate and treat depression in women during the perimenopause was long overdue.

 “These new clinical recommendations address this gap and offer much-needed information and guidance to health care practitioners so that they can provide optimal care and treatment for midlife women,” said Kornstein.

The task force, co-chaired by Maki and Kornstein focused on five areas: epidemiology, clinical presentation, therapeutic effects of antidepressants, effects of hormone therapy and efficacy of other therapies such as psychotherapy, exercise and natural products.

Perimenopause refers to the three- to four-year period immediately prior to menopause when periods become irregular and eventually stop, as well as the first year after the final menstrual period. Symptoms such as hot flashes and sleep disturbances often begin at this time and can co-occur and overlap with symptoms of depression, the new guidelines state.

During perimenopause, women often juggle multiple responsibilities and face multiple stressors. They care for their own children, experience children leaving the home, help aging parents, retain primary responsibility for the home, and face increasing job demands at a time when they may be approaching the peak of their career. All of this can be extremely stressful, Dr. Maki explained.

“Relationships can be taxed and the realities of aging can become quite apparent,” she said. “Life stressors, low social support and physical health problems are strongly related to depression during perimenopause. When you add in hormonal changes that can affect the brain’s ability to cope with these stressors, it’s no surprise that depression is a common occurrence in midlife women. The good news is that there are effective treatments.”

The root causes of perimenopausal depression can be hard to identify, said Dr. Maki. Women with a history of depression have a 56% chance of recurrence during the perimenopause and it is recommended that the same treatment used to help her symptoms before menopause be used again, with antidepressants and psychotherapy as first-line agents.

Maki explains that while it is common for women with menopausal symptoms to experience depressive symptoms, most of the time those symptoms do not meet the criteria for a diagnosis of depression. But, she said, even low-level depressive symptoms can lower quality of life and strain relationships, and hormone therapy might help. Hormone therapy is especially useful for women who experience hot flashes and related sleep disturbance. 

“It is important for women and their health care providers to recognize that these symptoms are common during perimenopause and can be treated,” she said.

 “Perimenopause is a window of vulnerability for the development of both depressive symptoms and major depressive episodes, and reflects the seriousness of mental health issues in midlife women, a group that has shown a 45 percent increase in suicide rates over the past 15 years.”

Click here for the guidelines: