Menopause and Depression: Causes, Symptoms and Treatment

How common is depression during menopause?

For a long time, low mood in midlife was written off as stress or "the empty nest." Long-term studies that followed women through the transition have shown something more specific: the years around the final period carry a real, measurable increase in risk.

• In the SWAN study, women were two to four times more likely to have a major depressive episode when they were perimenopausal or early postmenopausal than when they were premenopausal, even after accounting for past depression, stressful life events and hot flashes (Bromberger et al., 2011).
• In the Harvard Study of Moods and Cycles, women with no history of depression who entered perimenopause were twice as likely to develop significant depressive symptoms as women who stayed premenopausal (Cohen et al., 2006).
• In the Penn Ovarian Aging Study, depressive symptoms were more than four times as likely during the transition, and a diagnosed depressive disorder about two and a half times as likely (Freeman et al., 2006).

Expert guidelines now describe perimenopause, which they define as including the early postmenopausal years, as a "window of vulnerability" for depression (Maki et al., 2018).

By the numbers

Depression risk during the menopause transition

2–4×likelier major depressive episode in perimenopause or early postmenopauseSource: Bromberger 2011

2×likelier significant depressive symptoms in women with no prior depressionSource: Cohen 2006

>4×likelier depressive symptoms during the transitionSource: Freeman 2006

Why does menopause raise the risk of depression?

Hormone fluctuations

Estrogen interacts with serotonin, dopamine and other brain systems involved in mood. In the Penn study, greater swings in estradiol and other reproductive hormones around a woman's own usual levels were linked to depressed mood (Freeman et al., 2006). Some women appear more sensitive to these shifts than others.

Hot flashes and sleep loss

Night sweats and broken sleep make everything harder, and chronic sleep loss is a strong risk factor for depression. In the Harvard study, the risk of new depression was somewhat greater in women with hot flashes (Cohen et al., 2006).

Past depression

The strongest single predictor is a previous episode. Most women who have major depression during perimenopause have had depression before (Maki et al., 2018). Some clinicians also watch more closely in women with a history of premenstrual dysphoric disorder or postpartum depression, which may reflect sensitivity to hormone changes.

Midlife circumstances

Caregiving for children and parents, divorce or relationship strain, health problems, job pressures and grief often cluster in the same years. Guidelines emphasize that these psychosocial factors are part of the picture and should be part of the assessment.

Symptoms of menopause depression

Depression is more than feeling down. According to the National Institute of Mental Health, symptoms are present most of the day, nearly every day, for at least two weeks, and include several of these:

• Persistent sad, anxious or "empty" mood
• Loss of interest or pleasure in activities you used to enjoy
• Feelings of hopelessness, guilt or worthlessness
• Irritability or restlessness
• Fatigue or low energy
• Trouble concentrating, remembering or making decisions
• Sleeping too little or too much
• Changes in appetite or weight
• Aches, headaches or digestive problems without a clear physical cause
• Thoughts of death or suicide

Around menopause, depression often shows up alongside hot flashes, night sweats and poor sleep, and the symptoms overlap. Fatigue, poor concentration and broken sleep can come from either, or both. That overlap is one reason depression in midlife women is easy to miss.

Menopause mood swings vs. clinical depression

If you recognize yourself more in the left column, our guide to perimenopause mood swings may help. If the right column sounds familiar, please talk to a clinician soon.

Warning signs that need urgent help

Get help right away, by calling or texting 988, calling 911 or going to an emergency room, if you or someone close to you:

• Talks about wanting to die or about suicide, or is looking for ways to do it
• Talks about feeling hopeless, trapped or like a burden to others
• Is giving away possessions or saying goodbye
• Is drinking or using drugs more to cope
• Can't eat, sleep or care for themselves
• Hears or sees things others don't, or has beliefs that are out of touch with reality

If someone is in immediate danger, don't leave them alone and remove access to anything they could use to harm themselves while you get help.

How is menopause depression treated?

The good news is that depression around menopause responds to the same proven treatments as depression at any age. A good evaluation looks at your mood, your menopause stage and symptoms, your sleep, your life circumstances and other medical causes such as thyroid disease or anemia.

Psychotherapy

Talk therapy, such as cognitive behavioral therapy (CBT), is a first-line treatment for perimenopausal depression (Maki et al., 2018). It can also help with the midlife stressors and losses that often come with this stage. CBT adapted for menopause can reduce how much hot flashes and sleep problems bother you as well.

Antidepressants

Antidepressants are the other first-line treatment, and they work for depression during and after the transition. Some SSRIs and SNRIs also reduce hot flashes, which can make them a good fit for women who have both (2023 nonhormone therapy position statement). It can take several weeks to feel the full effect, and finding the right medicine and dose sometimes takes more than one try. Don't stop an antidepressant suddenly without talking to your prescriber.

Lifestyle support

Regular physical activity, consistent sleep, limiting alcohol, staying connected with people you trust, and time outdoors all support recovery. They are valuable additions to treatment, but they are not a substitute for it when depression is moderate or severe.

Where does hormone therapy fit?

Hormone therapy is not a treatment for depression on its own, and it should never replace care from a mental-health professional or primary care clinician for depression. Estrogen is not FDA-approved to treat depression. That said, guidelines note evidence that estrogen has antidepressant effects in perimenopausal women, especially those who also have hot flashes, while data on estrogen combined with a progestogen are limited and inconclusive (Maki et al., 2018). In one randomized trial, transdermal estradiol with intermittent micronized progesterone reduced the chance of developing clinically significant depressive symptoms over 12 months in women who were not depressed at the start, with the benefit concentrated in the early transition (Gordon et al., 2018).

In practice, hormone therapy may be worth discussing if you also have bothersome hot flashes, night sweats or sleep disruption, as part of a plan that includes mental-health treatment. It is not right for everyone, and a history of breast cancer, blood clots, stroke or heart disease may rule it out. FDA-approved estradiol patches, gels and pills with progesterone are available through primary care and gynecology. Amie offers Amie HRT+, a compounded estradiol and progesterone cream for menopause symptoms such as hot flashes, night sweats and poor sleep, with the strength set by a licensed clinician. It is not FDA-approved and is not a treatment for depression; a clinician decides whether it is appropriate for you.

How to start the conversation

It can be hard to bring up mood with a doctor, especially if you've been told it's "just stress." These steps help:

• Write down your symptoms, how long they've lasted and how they affect daily life.
• Note your menopause symptoms too: cycle changes, hot flashes, night sweats and sleep.
• Mention any past depression, anxiety, postpartum depression or PMDD.
• List all medicines and supplements, and how much alcohol you drink.
• Say plainly if you've had any thoughts of self-harm. Clinicians ask because it matters, and it changes how quickly they help.

The bottom line