Is It Depression or is It the Menopause?
A complex interplay of factors account for women’s low mood in midlife, and treatments are multifaceted, too
This article is part of a Wise & Well Special Report: The United States of Depression.
Many women hit midlife and run into a wall of low mood, brain fog, anxiety and overwhelm, not to mention fatigue and joint pain, just as their periods are stopping and their life stressors such as sulky teenagers, aging parents and changing physicality are ramping up. Common complaints in midlife include “I don’t feel like myself any more” and “I don’t think I can cope.”
Is it simply a lack of estrogen, as a woman’s periods grind to a halt, driving all this? Is it enough to be called depression in the clinical sense? Is it permanent? Is it fixable? If so, how? The answers are more complicated than you think and the treatments may be influenced by where in the world a woman lives and what kinds of practitioners she sees.
Is it depression?
The first port of call for many women is their GPs, who receive little training in women’s hormones, especially hormonal changes in the latter part of women’s lives. A 51-year-old (the average age of onset of menopause) woman visits her GP complaining of low mood, hot flashes, feeling overwhelmed and fatigued, and her GP says, “Ah, you sound depressed. Let me give you antidepressants.” He prescribes an antidepressant such as Effexor, which actually suppresses the vasomotor effects of fluctuating hormonal levels and curbs the hot flashes, and maybe the woman feels a little bit better in herself and maybe she doesn’t. The treatment works, sort of.
But was she actually clinically depressed and were antidepressants the best treatment for this woman? If she lives in North America, the professional perspective might be “yes,” and if she lives in the UK or New Zealand, the professional stance might be different.
The North American Menopause Society waffles on and contradicts itself in its own position statement regarding depression and menopause, as well as appropriate treatment. While it notes that depressive symptoms worsen in menopause and women with a history of depression may benefit from depression screening during menopause, it stops short of saying that menopause outright affects mood. It also notes that vasomotor symptoms such as hot flashes disturb sleep and therefore can influence mood. It recommends antidepressants and therapy for women experiencing depression in menopause, though goes on to note that using estrogen therapy in perimenopausal women may be as helpful as antidepressants.
It then goes on to note further, in somewhat of a contradiction, that “estrogen-based therapies may augment clinical response to antidepressants in midlife and older women, preferably when also indicated for other menopause symptoms such as VMS.” (Vasomotor symptoms, in other words, hot flashes.)
Or is it a lack of estrogen?
Doctors in the UK and New Zealand are more likely to treat postmenopausal women with estrogen as a first line of treatment for low mood, noting that lack of estrogen can contribute to low mood, but stop short of prescribing estrogen for diagnosed clinical depression. Replacing declining estrogen (as well as the other sex hormones progesterone, and sometimes even testosterone) with bioidentical supplements in patch, pill or cream form is known as hormone replacement therapy, or HRT, for short.
“My feeling, based on the years I’ve been seeing perimenopausal and menopausal women, is that we, as doctors, have been understating the powerful effects of hormones on mental health and have been reaching too readily for antidepressants, when HRT can often provide the woman with greater mood benefits (in synergy with all the healthy lifestyle changes and psychological interventions), says Linda Dear, MD, a UK-born menopause specialist based in New Zealand. She refers in her email to the specific UK guidelines, to which she adheres in her practice: “In the UK, the national guidelines for menopause (the ‘NICE guidelines’) now state that HRT, not antidepressants — should be the first line medical treatment offered to women who have mood symptoms due to menopause or perimenopause.”
The NICE guidelines make a clear distinction between low mood and depression, and go on to state:
“Ensure that menopausal women and healthcare professionals involved in their care understand that there is no clear evidence for SSRIs or SNRIs to ease low mood in menopausal women who have not been diagnosed with depression.”
Teasing out what’s actually depression and what can be attributed to the physical symptoms of low estrogen can be a bit of a game, and there’s not always a clear demarcation.
“The time of menopause is a time of many changes — hormonal, physical, psychological, but may be a time of change in other ways — children leaving, unwell parents,” says Nancy Phillips, MD, Professor, Rutgers Robert Wood Johnson Medical School Department of Ob/Gyn. “It is important to determine if the depression is secondary to the physical changes of menopause (hot flashes causing insomnia, vaginal dryness causing difficulty in sexual function or chronic irritation) or an exacerbation of pre-existing depression, major depression or reactive depression (children leaving).”
Phillips also notes that there is a fair amount of overlap. “Depression due to menopausal symptoms is more common during the perimenopause and early menopause when symptoms may be more acute or severe,” Phillips says in an email interview. “Later in menopause unless there is clear secondary effect from menopausal symptoms, hormone therapy may be less effective. As women age, limitations to the use of hormone therapy also increase.”
All of this can be a bit of a menopausal minefield, made more complicated by the now-debunked but-still-often-referred-to Women’s Health Initiative study which overstated the health risks of estrogen therapy to women and downplayed the since-proven health effects of HRT on bone, joint, heart health and metabolic functioning, all of which can of course, in a roundabout function, contribute to overall mood and wellbeing (or lack of it).
But what happens when HRT or antidepressants, or HRT and antidepressants, aren’t enough? Or if someone simply can’t take HRT due to certain prior cancers, does not want to take HRT, or takes HRT and/or antidepressants and experiences too many side effects?
Lifestyle matters more in menopause
“I always say this to all my ladies,” explains Dear, the New Zealand menopause specialist, in an email. “‘HRT does not stand for ‘healthy-lifestyle replacement therapy!’” So whether she takes HRT or not, the premier thing a woman can do to help all her menopausal and perimenopausal symptoms, including mood symptoms, is to look at her lifestyle.
“Our bodies are trying to tell us something — and we should start listening,” Dear continues. “They want us to look after them; particularly around menopause because our bodies miss the hormones that our ovaries used to make. So we need to give our bodies good food (which means no processed or high sugar foods and aiming to eat a Mediterranean type diet), good movement (especially weight training to build up our muscles and get stronger), good sleep and good stress-relief/relaxation.”
For mood symptoms, seeing a therapist is often a great idea. A therapist can provide tools to deal with panic attacks or anxiety. “For women who are doing all this great lifestyle stuff but still struggling with mood symptoms and HRT is not an option, I would talk then to her about other non-hormonal options including antidepressants,” Dear concludes.
Hormones cause neurological symptoms, not just physical ones
For Amanda Thebe, bestselling author of Menopocalypse: How I Learned to Thrive During Menopause and How You Can Too, “The work of Dr. Lisa Mosconi is pretty integral,” she says in a video call, “because she’s shown that the perimenopausal brain changes. It shrinks. It changes shape, and it adapts to our new reproductive environment, the fact that we’re not going to be reproducing any more. And the changes in the brain really do lead women to have a ton of neurological symptoms that, to me, don’t present as being hormonal. Things like anxiety, depression, brain fog, migraines, hot flashes even, are actually because of the thermoregulatory system, but these symptoms are actually all to do with the brain changing due to the estrogen declining. And estrogens are part of the brain function.”
Thebe, a certified fitness trainer and nutrition coach, mentions taking a “360 view” to treating symptoms of menopause, which can include HRT, but also focus on healthy diet, weight training, and, if needed, psychotherapy and antidepressants.
Alli McColl Brooks, MA, psychotherapist and contributor to Nyah Health, an organization focused on multiple aspects of perimenopausal and menopausal women’s health, concurs.
“My view is that it’s always good to see a mental health professional in addition to talking to your GP if you think you’re depressed,” McColl Brooks says via email.
“Women often feel obligated to prioritize others’ needs before our own, to doubt ourselves and to be our own worst critics. Without therapy these patterns can be nearly impossible to notice or change and without changing them self advocacy in a healthcare system that historically fails women, and self-acceptance in a society that discriminates against women 40+ can be very depressing.”
And a clue for McColl Brooks in deciphering whether a woman’s depressive symptoms have a low-estrogen component is her prior mental health history and how she describes her current symptoms.
“Generally, this means sudden, new, unexplainable and accompanied by other physical symptoms of perimenopause like fatigue, migraines, insomnia, body changes etc., that can also lead to a further downward spiral,” McColl Brooks says. “HRT may not be a complete cure, but it’s an essential piece of the puzzle because hormones are neurotransmitters.”
This article is part of a Wise & Well Special Report: The United States of Depression. If you or a loved one is depressed, it’s vital to talk about it. Because depression increases the risk of suicide, consider calling the confidential National Suicide Prevention Lifeline at 1–800–273-TALK (8255) for English, 1–888–628–9454 for Spanish, or call or text 988. Global support in 44 languages is available from Befrienders Worldwide.
