UNC Health Care
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Depression During Perimenopause

Perimenopause usually occurs in your 40s when your hormones shift as you approach menopause, or the end of menstruation. It’s often marked by hot flashes, irregular periods and vaginal dryness.

Unfortunately, perimenopause can spur mental health symptoms as well. It’s not uncommon for women to experience minor mood problems during this time. For some women, the symptoms progress to anxiety and depression, or a worsening of existing depression symptoms. This is called perimenopausal depression.

There is growing awareness of this condition in the medical establishment; late last year, the North American Menopause Society and the Women and Mood Disorders Task Force of the National Network of Depression Centers released the first guidelines for the evaluation and treatment of perimenopausal depression.

David Rubinow, MD, chair of psychiatry at UNC School of Medicine, is an internationally known expert in the evaluation and treatment of women with mood disorders that occur during times of hormonal change. We talked to him to learn about perimenopausal depression and how to get help.

Signs of Perimenopausal Depression

The signs and symptoms of perimenopausal depression overlap with the symptoms of depression unrelated to perimenopause, but there are some unique elements.

“Regular depression is characterized predominantly by sadness accompanied by not eating, not sleeping, not enjoying things and difficulty concentrating,” Dr. Rubinow says. “Perimenopausal women experience a lot of anxiety and worry, and they often begin to disconnect from other people. They gradually don’t enjoy things that they’re supposed to enjoy, and that’s a terrible source of guilt for them.”

Other symptoms include:

  • Lack of energy
  • Irritability
  • Emotional flatness
  • Crying for no reason or tearfulness
  • Insomnia

“Some women even complain of cognitive difficulties (such as memory loss or lack of concentration), although it’s a little bit difficult to separate that from the cognitive complaints that most people have when they reach midlife,” Dr. Rubinow says.

The Role of Hormones

As you age, your estrogen levels fluctuate more widely and irregularly, and estrogen levels drop dramatically at menopause. These times of intense hormonal fluctuation can cause increased vulnerability to depression.

“Estrogen is one of the most powerful regulators of brain function that you can find,” Dr. Rubinow says. “It is capable of inducing these dysphoric behavioral states.”

In other words, dropping levels of estrogen can affect the brain and thus cause you to feel unhappy, uneasy or dissatisfied. But not all women are so affected: Dr. Rubinow says that if you withdraw estrogen from a woman with a history of perimenopausal depression, it will trigger a depression. But if you withdraw estrogen from a woman who does not have a history of perimenopausal depression, it does not affect her mood.

Treatment Options for Perimenopausal Depression

If you are experiencing sadness, difficulty with mood, increased worry and a lack of pleasure in daily activities, be careful not to falsely attribute that to other variables, such as a normal part of aging or, for a parent, sadness that your kids have left the nest.

It’s normal to be sad that your kids are getting older. But because symptoms of perimenopausal depression can appear gradually, you may not recognize them as part of a reversible disorder and instead interpret them as a permanent change in your life.

“The symptoms tend to be very insidious in their onset, so they become incorporated into a new self-image that the person has rather than viewing it as a treatable disorder,” Dr. Rubinow says. “And so the first thing that someone should do is say, ‘You know what? I’ve really felt kind of crappy for the last X number of months.’ Then go get an evaluation.”

Hormone therapy can help, he says.

“If somebody is depressed and they’re having hot flashes or vaginal dryness, the first step, in my opinion, should be to see whether a gynecologist will give them a trial of hormone therapy, which may treat all of the perimenopausal symptoms,” he says. “Alternatively, you can talk to your doctor about medication specifically for depression, but get help.”


 If you’re concerned about perimenopausal depression, ask your doctor to evaluate you. Find a doctor near you.