What You Should Know About Depression in the Menopause

Hello all. This may feel like an oddly specific topic for someone in their early 20’s to be writing about however my Master’s dissertation this year was focused on establishing whether hormone replacement therapy (HRT) was an effective treatment for depression and low mood in the menopause.

My research has since sparked a passion for sharing the reality of the effects that the menopause can have on mental health. There is so little understanding out there about the menopause in relation to mental health and I feel it is about time that people really start talking about it.

I have expanded much more deeply into the ins and outs of HRT as a treatment for menopausal depression in another blog post, but I thought I would begin by shedding some light on where the research is at in its understanding of menopausal depression.

I would like to preface this post by emphasising that the menopause is not necessarily a female-specific phenomenon. Trans men and non-binary people can also experience the menopause. Where I use the terms women/woman/female I am usually trying to talk about the influence of biological sex rather than chosen gender however I apologise if I misuse the terms.

A Brief Overview of the Menopause

The menopause is where the menstrual cycle comes to an end due to naturally declining levels of hormones. It typically begins around the ages of 45-50 and lasts for an average of 4-5 years[1] however the age of onset and duration is unique for each person going through it. The menopause itself is actually split into different transitory stages, beginning in the perimenopause where the cyclical nature of menstruation becomes irregular, and ending in the postmenopausal period which is signposted by the experience of no bleeding (amenorrhoea) for 12 consecutive months.

While some will experience little to no difficulty during this time, many unwelcome symptoms can accompany the menopausal transition such as hot flushes/flashes, night sweats, insomnia, vaginal dryness and itching, sexual dysfunction, anxiety and depression.

Across the world, prevalence studies have reported that depression is experienced by 28-40% of menopausal woman[2] [3] [4]. When split into the transitory stages, the prevalence is the lowest in the premenopausal period and is relatively similar across the perimenopause and the postmenopausal period [5] [6] [7]. Sadly, there is very little research surrounding menopausal depression even though it can be debilitating for those who experience it.

What is the cause?

Unfortunately, there is no one established cause of menopausal depression at the moment. There is however research attempting to explain and understand how depression emerges during this period of time.

It is well established in scientific research and literature that, between the sexes, women are far more likely to suffer from depressive illnesses than men[8] [9] [10]. One proposed reason for this is the presence of oestrogen, progesterone and other female-associated hormones [11] [12].  

Most of the evidence for this comes from cases of premenstrual dysphoric disorder (PMDD) and postpartum depression (PPD), or from intervention studies where depressed women are given hormones to help with the depression [13] [14] [15] [16]. It is also well known that oestrogen is closely linked with the functions of serotonin (the hormone otherwise known as the ‘happy hormone’). Unfortunately, due to a general lack of research, the evidence for hormones inducing depression isn’t strong however many medical professionals are hopeful that with more research, hormones could be established in the aetiology behind menopausal depression.

Other factors that have been suggested to be involved in the emergence of depression during the menopause include difficulty coping with the stressors of mid-life, difficulty with a partner, age, employment status and struggling with the other menopausal symptoms such as hot flushes or insomnia [17] [18] [19] [20] [21] [22].

After all of my research so far, I truly believe that the cause for depression in the menopause will be unique for everyone who comes to experience it and that there is no one cause of menopausal depression, instead, that it is a combination of factors coming together to create a very difficult menopausal transition.

So, what can be done about it?

As the research out there is lacking, there is no established or perfect treatment for menopausal depression. There is research to suggest that hormone replacement therapy (HRT) is both good and bad for treating menopausal depression. I hope to write a more in-depth blog post later on (which can now be found here) about the use of HRT to treat menopausal depression but for this blog post, I can’t say that HRT is the solution, even though I know many medical professionals hope it will be.

There is research also supporting and refuting the use of antidepressants and talking therapies. The only promising research is where there is a combination of antidepressants and HRT however there still isn’t enough research out there to suggest that this is a be-all-end-all treatment or that it works for everyone.

If you or someone you know is struggling with menopausal depression, I would suggest seeking advice from a GP as well as a medical professional who specialises in areas such as the menopause or female health. It is important to talk through the symptoms you experience, your history, your lifestyle and all the options available to you. The treatment you receive may not be perfect first-time round, but there will be something that works for you.

Dealing with depression during the menopause can be extremely tough and isolating. It is important to remember that you are not alone in what you are experiencing and there is help out there.

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References

[1] Nelson, H, ‘Menopause’, Lancet, 371 (2008), 760–70.

[2] C. Callegari and others, ‘Incidence of depressive symptoms in women attending a menopause clinic: A preliminary study. [Italian]’, Minerva Psichiatrica, 48.1 (2007), 11–19.

[3] Ju-Yu Yen and others, ‘The Associations between Menopausal Syndrome and Depression during Pre-, Peri-, and Postmenopausal Period among Taiwanese Female Aborigines’, Psychiatry and Clinical Neurosciences, 63.5 (2009), 678–84 <https://doi.org/10.1111/j.1440-1819.2009.02001.x&gt;.

[4] Liang-Nan Zeng and others, ‘The Prevalence of Depression in Menopausal Women in China: A Meta-Analysis of Observational Studies’, Journal of Affective Disorders, 256 (2019), 337–43 <https://doi.org/10.1016/j.jad.2019.06.017&gt;.

[5] Sermin Timur and Nevin Hotun Şahin, ‘The Prevalence of Depression Symptoms and Influencing Factors among Perimenopausal and Postmenopausal Women’:, Menopause, 2010, 1 <https://doi.org/10.1097/gme.0b013e3181cf8997&gt;.

[6] Hui-Ling Wang and others, ‘Depressive Symptoms in Taiwanese Women during the Peri- and Post-Menopause Years: Associations with Demographic, Health, and Psychosocial Characteristics’, Maturitas, 75.4 (2013), 355–60 <https://doi.org/10.1016/j.maturitas.2013.04.021&gt;.

[7] Joyce T. Bromberger and others, ‘Depressive Symptoms during the Menopausal Transition: The Study of Women’s Health Across the Nation (SWAN)’, Journal of Affective Disorders, 103.1–3 (2007), 267–72 <https://doi.org/10.1016/j.jad.2007.01.034&gt;.

[8] David R. Rubinow and Peter J. Schmidt, ‘Sex Differences and the Neurobiology of Affective Disorders’, Neuropsychopharmacology, 44.1 (2019), 111–28 <https://doi.org/10.1038/s41386-018-0148-z&gt;.

[9] M Weissman, ‘Sex Differences in Rates of Depression: Cross-National Perspectives’, Journal of Affective Disorders, 29.2–3 (1993), 77–84 <https://doi.org/10.1016/0165-0327(93)90025-F&gt;.

[10] J Breslau and others, ‘Sex Differences in Recent First-Onset Depression in an Epidemiological Sample of Adolescents’, Translational Psychiatry, 7.5 (2017), e1139–e1139 <https://doi.org/10.1038/tp.2017.105&gt;.

[11] O. P. Almeida, ‘Sex Playing with the Mind. Effects of Oestrogen and Testosterone on Mood and Cognition’, Arquivos De Neuro-Psiquiatria, 57.3A (1999), 701–6 <https://doi.org/10.1590/s0004-282×1999000400028&gt;.

[12] Ellen W. Freeman, Mary D. Sammel, Hui Lin, and others, ‘Associations of Hormones and Menopausal Status With Depressed Mood in Women With No History of Depression’, Archives of General Psychiatry, 63.4 (2006), 375 <https://doi.org/10.1001/archpsyc.63.4.375&gt;.

[13] Olivia Tania Hernandez-Hernandez and others, ‘Role of Estradiol in the Expression of Genes Involved in Serotonin Neurotransmission: Implications for Female Depression’, Current Neuropharmacology, 17.5 (2019), 459–71 <https://doi.org/10.2174/1570159X16666180628165107&gt;.

[14] U. Halbreich, ‘Role of Estrogen in Postmenopausal Depression’, Neurology, 48.5 Suppl 7 (1997), S16-19 <https://doi.org/10.1212/wnl.48.5_suppl_7.16s&gt;.

[15] J. T. Bromberger and others, ‘Predictors of First Lifetime Episodes of Major Depression in Midlife Women’, Psychological Medicine, 39.1 (2009), 55–64 <https://doi.org/10.1017/S0033291708003218&gt;.

[16] Jennifer L. Payne, Jennifer Teitelbaum Palmer, and Hadine Joffe, ‘A Reproductive Subtype of Depression: Conceptualizing Models and Moving Toward Etiology’, Harvard Review of Psychiatry, 17.2 (2009), 72–86 <https://doi.org/10.1080/10673220902899706&gt;.

[17] Ellen W. Freeman, Mary D. Sammel, Li Liu, and others, ‘Hormones and Menopausal Status as Predictors of Depression in Womenin Transition to Menopause’, Archives of General Psychiatry, 61.1 (2004), 62 <https://doi.org/10.1001/archpsyc.61.1.62&gt;.

[18] M. Hickey, C. Bryant, and F. Judd, ‘Evaluation and Management of Depressive and Anxiety Symptoms in Midlife’, Climacteric, 15.1 (2012), 3–9 <https://doi.org/10.3109/13697137.2011.620188&gt;.

[19] N. E. Avis and others, ‘A Longitudinal Analysis of the Association between Menopause and Depression. Results from the Massachusetts Women’s Health Study’, Annals of Epidemiology, 4.3 (1994), 214–20 <https://doi.org/10.1016/1047-2797(94)90099-x&gt;.

[20] Farhat Jamil and Ruhi Khalid, ‘Factors Contributing to Depression during Peri Menopause: Findings of a Pakistani Sample’, Journal of Research, 75.11–12 (2016), 612–22 <https://doi.org/10.1007/s11199-016-0690-2&gt;.

[21] Josephine Vivian-Taylor and Martha Hickey, ‘Menopause and Depression: Is There a Link?’, Maturitas, 79.2 (2014), 142–46 <https://doi.org/10.1016/j.maturitas.2014.05.014&gt;.

[22] Nancy Fugate Woods and others, ‘Depressed Mood during the Menopausal Transition and Early Postmenopause: Observations from the Seattle Midlife Women’s Health Study’, Menopause, 15.2 (2008), 223–32 <https://doi.org/10.1097/gme.0b013e3181450fc2&gt;.