Nichola Walker, PhD student at Keele University and Dr Andrew Finney, senior lecturer at Keele University discuss low mood associated with perimenopause and strategies to be considered.
There has never been such public awareness of menopause and its debilitating symptoms as there is today. This has been attributed partly to the campaigning of TV celebrities such as Davina McCall whose Channel 4 documentary gained significant interest, and TV appearances from menopause specialists such as Dr Louise Newson.
Women experiencing perimenopausal symptoms are seeking medical support more than ever before, which has contributed to the significant shortages in supplies of hormone replacement therapy (HRT). While treatment for physical symptoms such as hot flushes are being more openly discussed, the management of women’s mental health through the transition period is less well established.
The perimenopause is the woman’s journey towards the menopause, which marks the end of her reproductive life.1 Perimenopause is characterised by irregular cycles of ovulation and menstruation and ends 12 months after the last period.2
With the average length of perimenopause in the UK being four years, symptoms associated with this can have an overwhelmingly negative impact on a woman’s mental health and wellbeing.3 These symptoms occur at a time when women have important roles in society, within the family and the workplace, and can negatively affect their quality of life (QoL).
Mental health and perimenopause
The National Institute for Health and Care Excellence (NICE) guideline: Menopause: diagnosis and management [NG23]2 does not recommend the prescribing of SSRIs or SNRIs to relieve symptoms of low mood in patients who have not been diagnosed with depression. Symptoms of generalised depression and anxiety do partially overlap with those experienced by women during perimenopause. For example, feelings of hopelessness, feeling worthless and having thoughts of deliberate self-harm or suicide can be experienced in both generalised and perimenopausal mental health decline.
However, the pattern and duration of generalised depression and anxiety symptoms differ from those experienced during times of low mood during perimenopause. In generalised depression, symptoms last over two weeks and are present every day; whereas Generalised Anxiety Disorder (GAD) generally manifests as anxiety and worry that the patient recognises as excessive and inappropriate, where symptoms can last several weeks.
By contrast, anxiety and depression during perimenopause can often be related to climacteric symptoms such as hot flushes, night sweats, vaginal dryness and dyspareunia. This helps to differentiate anxiety and depression experienced during the perimenopause from that of generalised mood disorders. The duration of symptoms often increases along with fluctuations in levels of hormones such as oestrogen, and perimenopausal women are more likely to report anxiety or depressive symptoms during these fluctuations. While there is a good understanding of the role of these hormones in the early reproductive phases, there is less known of the role of falling hormone levels during perimenopause. However, it is common throughout the female reproductive cycle for women to experience mood swings triggered by falling oestrogen and progesterone levels.
In addition, as well as regulating the reproductive cycle, oestrogen and progesterone are also thought to have important influences on cognition, mood, sleep and mental wellbeing.4,5 Fluctuating oestrogen levels may affect the neurotransmitters in the brain which act on the limbic system, an area of the brain responsible for mood regulation.
During the perimenopause, women often experience feelings of exhaustion and fatigue due to disturbed sleep secondary to vasomotor symptoms. This can result in increases in anxiety and depression, low mood, overthinking, irrational thoughts and feelings of distress. There can also be a loss of positive body image and reducing self-esteem due to middle age body changes.
Supporting women with their mental health during the perimenopause
Perimenopausal women often demonstrate a real interest in gaining more information about their symptoms and how to improve them. Despite their mood changes, women will often say they do not feel depressed. There is a need to support them and provide good, evidenced-based information about their physical and psychosocial health for them to recognise and relate these symptoms to perimenopause.
Assessing mental health during perimenopause
To help assess declining mental health properly during perimenopause, it is imperative that objective assessment tools are fit for purpose. Adopting the correct mental health assessment tool could reduce, and possibly eliminate, the risk of an inappropriate lifelong diagnosis of depression.
Validated mental health assessment tools for measuring anxiety and depression in the general population, such as PHQ-9 and GAD tools, may be less applicable for women during the perimenopause due to fluctuating hormones.
This poses a clinical dilemma for healthcare professionals faced with assessing, diagnosing and treating patients during the perimenopause who present with mood changes. The use of generalised mental health assessment tools is more likely to lead to prescribing of antidepressants, which may contribute to worsening of symptoms, for example blunting of emotions, adding to loss of libido, and cause further distress and increased social isolation.
Indeed, some evidence shows that consultations for low mood may lead to unnecessary prescribing of antidepressants in perimenopausal women.
Assessment and treatment options are as follows:
- The Meno-D rating scale for perimenopausal depression has recently been developed for the diagnosis of low-mood disorders in perimenopausal women, This assessment tool is a self-reporting or clinician rated questionnaire, designed to rate the severity of symptoms of perimenopausal depression and distinguish between low mood associated with perimenopause and low mood associated with depression.7
- Treatment options should include an understanding of the individual perimenopausal experiences of women and the impact those symptoms are having on their day-to-day lives.
There should be a multidimensional approach to treatment.
NICE guidance recommends:
- Cognitive Behavioural Therapy (CBT) in perimenopausal women to help develop coping and self-management strategies and to address the brain/hormone imbalances
- HRT can offer an effective treatment option when managing low mood with perimenopausal women. HRT can ‘top up’ oestrogen and progesterone levels, improve QOL and low mood and prevent long-term depression. If antidepressants are considered first-line options for women within this age bracket, then dual therapy could be considered, for example HRT and antidepressants can be prescribed sequentially if mono therapy only provides partial benefit. Patients with a diagnosis of bipolar disorder, for example, and under the care of the psychiatrist may be prescribed antipsychotics and HRT. Combining HRT and antidepressants or antipsychotics help to stabilise the brain and mood.
- Testosterone is a vital hormone in women, especially for brain function. When testosterone levels reduce, this can impact a woman’s libido, clarity, concentration, fatigue and memory. Although not currently licensed for these indications in the UK, testosterone can be prescribed by a specialist in the field of menopause.
In summary, antidepressants may offer little benefit in reducing symptoms of mood disorders associated with perimenopause.6 It is vital that validated assessment tools and perimenopause symptoms guide healthcare providers towards more appropriate treatment plans. Empowering women during the perimenopause through education and developing coping strategies could allow a more positive approach to symptom control, and women will continue into their later years with a better understanding of their mental health.
- Menopause Matters. Menopause: What and when is menopause menopause matters.co.uk
- NICE. Menopause: diagnosis and management nice.org.uk/guidance/ng23/chapter/recommendations#individualised-care/ends
- Neves-E-Castro M, Birkhauser M, Samsioe G, Lambrinoudaki I, Palacios S, Borrego RS, Llaneza P, Ceausu I, Depypere H, Erel CT, Pérez-López FR, Schenck-Gustafsson K, van der Schouw YT, Simoncini T, Tremollieres F, Rees M. EMAS position statement: The ten point guide to the integral management of menopausal health. Maturitas. 2015; May;81(1):88-92.
- Llaneza P, García-Portilla M, Llaneza D, Armott B, Perez-Lopez F. Depressive disorders and the menopause transition. Maturitas. 2012; 71(2):120–130.
- SWAN. Investigating Health for Midlife and Older Women swanstudy.org/
- FEMAR. Menopause and mental health maryonstewart.com/2021/05/13/menopause-and-mental-health/
- Kulkarni J, Gavrilidis E, Hudaib AR, Bleeker C, Worsley R, Gurvich C. Development and validation of a new rating scale for perimenopausal depression-the Meno-D. Transl Psychiatry. 2018 Jun 28;8(1):123.
Balance. Antidepressants and menopause factsheet balance-menopause.com