So you’ve hit perimenopause, the transition from your reproductive years into menopause. This happens to most women in their 40s when hormone levels begin to decrease. It’s normal for perimenopause to bring about changes in your body and life. But depression doesn’t have to be one of them.
About 1 in 5 women experience depression during this time, says UNC School of Medicine psychiatrist David R. Rubinow, MD. But you don’t have to just suffer through it.
“Mood disorders during perimenopause are real,” he says. “They are biologically based. And they are treatable.”
Depression Is Not a Normal Part of Aging
Women sometimes think mood changes during perimenopause are permanent or inevitable, Dr. Rubinow says.
“They may think, ‘This is who I am now. I’m someone who is just not as interested in social activities as I used to be,’” he says. “They think they’re no longer able to enjoy things that previously gave them pleasure. Rather than recognizing this as a treatable, reversible disorder, they believe this is a new personality that aging presents them with.”
People often think their sadness or anxiety comes from external changes, such as kids growing up and leaving home, but it’s important to understand that these feelings can be a response to normal hormonal changes.
Symptoms of Depression During Perimenopause
Perimenopausal depression generally comes on gradually.
“It’s not the case that you wake up one morning and feel depressed,” Dr. Rubinow says. “It’s a slow erosion in your sense of enthusiasm and a slow increase in a sense of worry and anxiety.”
The signs and symptoms of perimenopausal depression overlap with the symptoms of depression generally, but there are some unique elements.
“Regular depression is characterized predominantly by sadness accompanied by changes in eating or sleeping habits, 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.”
Sometimes, women find themselves being forgetful or having more trouble concentrating than they used to, known as brain fog.
“It’s not uncommon for women to experience some cognitive slowing, feeling that their cognitive processing is slower, and their brain is a little foggier,” he says. “It’s scary, and a little difficult to disentangle from changes that happen as part of aging. However, this can also be a sign that you are depressed.”
Hormones and Depression During Perimenopause
As you reach perimenopause, 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. “Changes in estradiol (estrogen made by the body) can induce these dysphoric mood states.”
Hormonal changes resulting in mood disturbances are common during menstrual cycles, childbirth, postpartum and perimenopause, he says. However, experiencing depression during your menstrual cycle or after giving birth does not predict whether you will have perimenopausal depression, he says.
Treatment for Perimenopausal Depression
Symptoms of depression in some women are relieved with hormone therapy, especially in women who are experiencing other symptoms of perimenopause, including hot flashes, vaginal dryness, decreased libido and insomnia associated with hot flashes. Hormone therapy, which involves taking estrogen in a pill, patch or other form, may reduce all these symptoms.
“If depression appears in the context of those other perimenopausal symptoms, it makes perfect sense to see if the depression responds to hormonal therapy before you try any other treatments,” he says.
For women who are not experiencing other symptoms of perimenopause, antidepressants may be more effective at treating mood disorders, he says.
Advocating for Yourself During Perimenopause
Whether you are seeing a gynecologist or primary care doctor for perimenopausal symptoms or a psychologist or psychiatrist for mood disorders, don’t be afraid to speak up about your experience, he says.
“If you’ve been experiencing menstrual cycle irregularity, that’s important to convey to whatever physician you are seeing,” he says. “Ask them if your mood disorder could be related to perimenopause.”
Some types of hormone therapy have been shown to increase risks of developing breast cancer if the therapy is taken for four years or longer. Untreated depression also brings health risks, of course. Together, you and your doctor can weigh the risks and benefits of treatment.
“We help patients understand that this is about managing risks, not avoiding risks,” he says. “We want to enable the patient to make the best decision she can make.”
If you are perimenopausal and experiencing symptoms of depression, talk to your doctor or find one near you.