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Perimenopausal Depression: What we now know, and how to treat it

With our body going through so many changes, it is no surprise that for some women they notice (or those closest to them notice) that their mood and mental health is affected by perimenopause and menopause. For a long time, it was just accepted that as women got older and went through "the change" that they became sad or angry or both, and those women had to cope and "just get on with it" on their own. More recently, Australian statistical data show that the highest age-specific suicide rate for females in 2015 was in the 45–49 age group and the second highest rate of suicide was in women aged between 50 and 54 years. These suicides should alert us to think about contributing factors, including biological changes in hormones associated with the transition to menopause as well as social and psychological stresses in the midlife period.


Personally, there were times (and still are!) when I felt like I was losing my mind. I would be asking myself, "Am I going crazy?" when I would feel happy one minute and then raging with anger for no good reason the next. And then there were the times when I would burst into tears while watching some ad on television with a dog or a kid in it. My ability to focus and concentrate was up and down, and then there were the memory lapses, being unable to "find the words". I felt like I was developing dementia. What the hell was going on? They're not joking when they say that perimenopause is like your second puberty!


Hormones and our brain are so very interlinked, so when our hormones drop and change with perimenopause and menopause, it makes a lot of sense that our psychological and mental health is impacted in some way. Just like so many of the symptoms of peri and menopause, not everyone will experience mental health symptoms, however I believe that it is important for everyone to be aware of perimenopausal depression and to recognise the signs of depression and anxiety so you can seek the best treatment from your medical professional. As someone who suffers from depression and is medicated, when I went through perimenopause, I did suffer some depressive relapse episodes and with the help of my psychiatrist, I had medication adjusted and changed and got back to feeling more myself again. For women who have never experienced depression or anxiety before, and if there hasn't been a major event or trauma to explain it, it is not unreasonable to want to investigate the possibility of perimenopausal depression and/or anxiety with your medical professional. Perimenopausal depression is still a relatively new condition recognised by the medical profession, so you may need a second or third opinion, so don't be afraid to see more than one GP or specialist if you don't feel satisfied with what you are told or the treatment you are recommended or prescribed. You know your body and your mind, and you know what is "normal" for you.


Sad woman sitting on couch

The World Health Organisation defines perimenopause as ‘the time immediately preceding the menopause, beginning with endocrine, biologic and clinical changes, and ending a year after the final menstrual period’. The diagnosis of perimenopausal depression is therefore often made retrospectively. To complicate matters the physical symptoms of the menopause often present much later (up to five years) than the psychological symptoms. This delay can make the diagnosis of perimenopausal depression difficult. It is important for health professionals to consider whether women who experience depressive and anxiety symptoms for the first time in their mid-40s are actually experiencing depression related to the perimenopausal hormone fluctuations. Similarly, women who experience an exacerbation of a previously well-controlled depression may also be experiencing a perimenopausal relapse.


Perimenopausal depression includes a wide range of symptoms and can fluctuate in severity, thus adding to the difficulty in diagnosis. The common symptoms in perimenopausal depression are detailed in a questionnaire called the MENO-D, a self-reporting or clinician rated questionnaire, designed to rate the severity of symptoms of perimenopausal depression. Professor Jayashri Kulkarni AM and her team at the Alfred Monash Psychiatry (AMP) Research Centre Melbourne developed the MENO-D questionnaire in 2018, and they continue research and studies into treatments for perimenopausal and menopausal women. Currently Professor Kulkarni and her team are trialling a new drug mix which they hope may lower anxiety and lift the mood of perimenopausal women.


The Meno-D provides a unique tool for clinicians and researchers to measure the presence of perimenopausal depression. Over the past decade, interest in the relationship between depression and perimenopause has increased. While a number of validated depression rating scales exist, there is no validated scale specifically designed to measure or monitor the symptom profile associated with perimenopausal depression. For example, depression scales, such as the Beck Depression Inventory II or Montgomery and Asberg Depression Rating Scale (both often used in this population) do not have questions specifically targeting paranoid thinking, memory problems or the experience (rather than impact of) physical symptoms that are specific and critical to the depression experienced in menopause. The Menopause-Specific Quality of Life (MENQOL) questionnaire captures some aspects of depression, anxiety, poor sleep, and poor memory, but does not specifically rate concentration problems, self-esteem, or social withdrawal. Hence, the aim of the study was to develop and validate a questionnaire, called the “Meno-D”, designed to capture and rate the severity of the characteristics symptoms of perimenopausal depression.


The Meno-D supports a growing research field, combining both psychiatry and endocrinology, which indicates that perimenopausal depression is a unique subtype of depression requiring a different management approach. Varied treatment options with mixed effects have been reported for perimenopausal depression symptoms. Depression medications selective serotonin reuptake inhibitors (SSRI) and serotonin noradrenaline reuptake inhibitors (SNRI) treatments remain the most popular pharmacological treatment choices for depressive symptoms during menopause, with varying outcomes. SSRI and SNRI treatments at lower doses can also help with vasomotor symptoms, such as hot flushes and night sweats in some women. However, menopausal hormone therapy (MHT) has been demonstrated to improve or even replace SSRI treatment in women aged over 50 years. A trial study showed that transdermal estradiol treatment has significant antidepressant effect in depressed perimenopausal women. Three case studies of women taking Tibolone, an oral hormone treatment, describe improved mood within 6–8 weeks of taking Tibolone.


For women who prefer not to use medication to treat perimenopausal depression, a range of cognitive-behavioral, behavioral, and mindfulness-based therapies have been found effective in reducing severity of symptoms, especially cognitive-behavioral therapy (CBT). Of these non-pharmacological trials, CBT appears to have demonstrated the most beneficial effect and has been found to reduce depressive symptoms by at least 50% for half of participants and achieve complete remission for just over 25% of participants.


The good news is that most women with perimenopausal depression respond to treatment. It is important to recognise the special symptoms of perimenopausal depression as well as the serious nature of this depression. Medical professionals need to provide a tailored management approach for these women, and it is not appropriate to deem this type of depression as minor or presume that, once the hormonal fluctuations settle, the depression will improve. The process of menopause can take many years, during which the woman’s quality of life and that of her family, may deteriorate irreparably. With education and information made available about perimenopausal depression we can prevent suicide in middle-aged women, which sadly has become a significant statistic.


Symptoms of perimenopausal depression:

  • Low energy

  • Paranoid thinking

  • Irritability or hostility

  • Decreased self-esteem

  • Isolation

  • Anxiety

  • Somatic (physical) symptoms

  • Sleep disturbance

  • Weight gain

  • Decreased sexual interest

  • Problems with memory and concentration


Resources

Monash Alfred Psychiatry research centre (MAPrc) https://www.maprc.org.au/



Australasian Menopause Society - Mood and the menopause fact sheet https://www.menopause.org.au/hp/information-sheets/mood-and-the-menopause


Hormones and the Mind Study (MAPrc) https://www.maprc.org.au/hormones-and-mind

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