What is the link between menopause and depression in midlife women?

Depression is such a big issue, especially around menopause. Yet, even now, people often feel it’s not something to talk about, or that they should ‘just snap out of it.’ This is crazy because depression is one of the most common menopausal symptoms, with half of all women feeling depressed at this time. Anything that gets us talking about depression is welcome.

Menopause and depression: Is there a link?

One in five women will suffer from major depression at some point in their life, but many more will experience depressive symptoms. There’s no doubt that depression is more common in the time leading up to menopause, peaking in late perimenopause when you’re between two and five times more likely to experience depression than before. The high-risk period runs from just before until two to four years after your final period. 

The stresses of mid-life are critical

It doesn’t help that perimenopause typically comes along at a time when many things are changing. It can be a time of peak responsibility and stress at work; children may be leaving home, relationships with partners can be strained or being re-evaluated, and it may be a time of house moves, caring for elderly parents, divorce or even bereavement. Add in all the physical symptoms of perimenopause, and it can seem more than anyone can bear.

These stressful life events have a much stronger effect on your likelihood of becoming depressed than your stage of menopause.

There’s a strong association between depression and surgical menopause. There are likely two reasons for this. Firstly, having your ovaries removed means that estrogen and progesterone levels fall rapidly, and this makes all the symptoms of menopause worse. Secondly, such surgery commonly occurs as a treatment for serious conditions like cancer. Chemotherapy and radiotherapy can also bring about a rapid menopause. Coping with a serious diagnosis like cancer and collateral effects like a sudden and unexpected loss of fertility, compounded by severe menopausal symptoms, can make you very vulnerable to depression.

How much do hormones contribute to depression?

There are major hormonal changes around menopause. Estrogen and progesterone levels swing up and down before settling to their new, low levels. Yet, despite this clear increase in the risk of depression around menopause, there’s no clear relationship to estrogen or progesterone levels.  Higher natural levels of testosterone are associated with higher rates of depression, but testosterone replacement therapy doesn’t increase the risk.

Maybe you can blame your parents!

Genetics plays a crucial role in the likelihood of you becoming depressed. Between 35 and 40% of your chance of developing depression comes from the genes you inherit from your parents. If you’ve inherited an increased risk of depression, there’s usually no shortage of stressful life events around this time that can push you over the edge and cause depression.

You’re more at risk if you’ve been depressed before

Menopause may be the first time you experience depression, but if you have a history of depression, you’re more likely to have it recur. In fact, a large proportion of women suffering from perimenopausal depression have had it before.

How do you know if you’re depressed?

As you know all too well, menopause can affect your moods. Mood changes are a common feature of perimenopause. Besides, we all have bad days when we feel fed up, but how do we know if we are depressed?

There are warning signs that your low mood may have progressed to clinical depression. Key warning signs are symptoms like:

• You continually feel sad, hopeless and helpless
• You’re feeling tearful
• You may feel anxious or worried
• Your self-esteem is at a low ebb
• You may feel full of guilt
• You have no interest or motivation to do anything
• You feel as though you have no energy
• You struggle to make decisions
• You may be irritable or intolerant of others
• You find it difficult to fall asleep, or you wake early
• You may be having thoughts of suicide or self-harm
• You have no energy
• You’ve lost interest in sex
• You’re neglecting family and friends

If you have a continuous low mood for two weeks or more or have thoughts of suicide or self-harm, you should see your doctor.

Can I do anything to reduce my risk of depression over the menopause transition?

Yes, you can. You’ll see from the graphic below that there are many risk factors for depression. Some factors that increase your risk for depression, those on the left, are difficult or impossible to control. However, other factors that can cause an increase in depression we do have some control over – those on the right.

Critical things you can do to reduce your depression risk are:

• Stop smoking
• Don’t drink more than 14 units of alcohol per week
• Maintain a healthy weight
• Make sure you get enough sleep
• Try to reduce your daily hassles
• Build a support network.  Identify and nurture your close confidantes
• Try not to be unduly negative or stressed about menopause
• Don’t allow yourself to focus on worrying or negative thoughts
• Get treatment for severe menopause symptoms
• Ensure any chronic illnesses or pain are properly managed

What if my doctor says I’m depressed, but I don’t think I am?

Many women feel their doctors are too quick to put their symptoms down to depression when they don’t feel depressed; they’re just struggling with all their menopausal symptoms. You may need to remind your doctor that you are menopausal. However, antidepressants are also excellent treatments for some menopausal symptoms, such as hot flashes. It could be that your doctor feels an antidepressant would be good for your hot flashes rather than to treat depression. So, ask your doctor why they are suggesting antidepressants before drawing any conclusions.

What’s the treatment for depression?

If you’ve noticed that your mood is on a downward path, there’s plenty you can do to turn things around. We’re going to look at the most effective options. It’s important to understand that depression is an illness just like asthma, diabetes or a broken arm. You wouldn’t think twice about seeing your doctor to get help for those, and you should do the same for depression. If you’ve had that low mood for a couple of weeks without a break, or if you’re thinking about suicide or self-harm, talk to your doctor or another healthcare professional without delay. The Samaritans are also there if you need someone to talk to – you don’t have to be suicidal to talk to them.

So, what are the effective ways to tackle menopausal depression?

Being active

Exercise is great for relieving the symptoms of mild to moderate depression. Being outside in daylight, and ideally in a green space, is also excellent at lifting your mood. A minimum of three weekly exercise sessions lasting 45 minutes to an hour is recommended. This could be any type of exercise, but if social isolation contributes to your low mood, you may benefit from a group exercise class. Find something you can enjoy and keep doing regularly. Any movement counts. This may include going for a brisk walk with a friend or while listening to music.

Talking things through with a friend or family member

Often just talking through your situation and how you are feeling with someone you trust can significantly affect how you feel. If you don’t want to talk to a friend or family member, there may be self-help groups in your area or your family doctor could refer you to a therapist or counsellor.

Engage your social support network

Appropriate social support from family, friends and work colleagues reduces the risk of depression and helps you to get through a depressive episode. There are three types of social support. The first is to have someone help you out with chores. The second is being around people so you are not left alone to dwell on negative feelings. The third and most effective is having one or two people you can talk to and confide in.

Having strong social relationships is vitally important not just for our emotional health, but for our general health too. In an eye-opening review of over 300,000 people from 148 studies, researchers found that over the time they were followed, those with stronger social relationships were 50% more likely to survive. That’s incredible. It means having poor social relationships is worse for our health than not exercising, being obese, drinking excessively and comparable to smoking 15 cigarettes a day.

Build those relationships before you face depression or other difficulties. We all need one or two people we can count on when the going gets rough – people we can call at 3 am. Find yours, and nurture them.

Talk to a counsellor

In counselling, a trained therapist will help you better understand your feelings and thought processes and help you work through solutions to your problems. A counsellor usually does not offer advice but instead helps you figure out the answers for yourself.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is centred on the concept that if we can change how we think about situations and events, we can change how we respond to them. CBT involves looking at how we feel and react to situations and exploring whether these are our most helpful feelings and responses. Understanding that we can respond differently allows us to choose these healthier responses. CBT has proven to be very helpful in mild to moderate depression. CBT is available through a trained therapist, but there is also online CBT using a mixture of artificial intelligence and therapists.

Antidepressants

Antidepressants are generally used for moderate to severe rather than mild depression. There are several different families of antidepressants available. Those most commonly prescribed are the selective serotonin reuptake inhibitors (SSRIs). Examples are fluoxetine, citalopram and sertraline (Prozac, Celexa and Zoloft). Another family of antidepressants sometimes prescribed for perimenopausal depression are the serotonin-noradrenaline reuptake inhibitors (SNRIs) such as venlafaxine and duloxetine (Effexor and Cymbalta).

It may take several weeks before you feel the full effects of antidepressants. You may find it helpful to use some of the other treatment options discussed here both while you are waiting for the results of antidepressants to be felt and also for their added benefit whilst taking antidepressants.

Menopausal hormone replacement therapy

Studies have shown conflicting results on the effectiveness of menopausal hormone replacement therapy (mHRT) for perimenopausal depression. Some studies suggest it helps and can improve the response to antidepressants, while others have shown no effect. At least one study suggests that being on mHRT can reduce the risk of depression related to menopause.

Because the evidence is conflicting, mHRT is not prescribed solely for treating depression during perimenopause. However, if you have other symptoms like hot flashes, which would benefit from mHRT,  then mHRT may be prescribed and may also help with depression.

Depression is common during menopause. In fact, feeling depressed is as normal a part of menopause as hot flashes, brain fog and disturbed sleep, and every bit as worthy of treatment. Get support from your family and social network, and talk to your doctor so you can get the proper treatment.