Pauline M. Maki
An expert panel offered the first-ever clinical recommendations to health care professionals on how to identify, characterize and treat depression during the menopause transition in a guideline document published simultaneously in Journal of Women’s Health and Menopause.
The panel, convened by The North American Menopause Society and the National Network on Depression Centers Women and Mood Disorders Task Group, found that although the main causes of perimenopausal depression are difficult to identify, proven therapeutic options for depression (ie, antidepressants and psychotherapy) are the front-line treatments in this patient population.
"The reason these guidelines are needed is because depression during the perimenopausal phase can occur along with menopausal symptoms, and these two sets of symptoms are hard to tease apart, which makes it difficult for clinicians to appropriately treat these women," Pauline M. Maki, PhD, professor of psychology and psychiatry at University of Illinois College of Medicine, said in a press release. "Many women experience a new onset of depressive symptoms. If there is underlying low-level depression to begin with, perimenopause can increase the intensity of depressive symptoms."
The panel, endorsed by the International Menopause Society, reviewed scientific literature on depressive disorders and symptoms in perimenopausal women, focusing on epidemiology, clinical presentation, therapeutic effects of antidepressants, effects of hormone therapy and efficacy of other therapies like psychotherapy and exercise.
The researchers found that, in general, most middle-aged women who experience a major depressive episode during perimenopause have experienced a prior episode of depression. They also found that depression at midlife often presents with classic depressive symptoms in combination with menopause symptoms — like hot flashes and sleep disturbances — and psychosocial challenges. These menopause symptoms complicate, co-occur and overlap with the presentation of depression, according to the results.
"Eighty percent of women in menopause experience hot flashes, and when they occur at night, also known as the 'night sweats,' sleep can be interrupted,” Maki said in the release. “Persistent sleep disturbances caused by hot flashes contribute to the development or exacerbation of depressive symptoms.”
The panel advised that clinicians consider treating co-occurring sleep disturbance and night sweats as part of treatment for menopause-related depression.
Furthermore, women face multiple life and work responsibilities and stressors during the perimenopausal period, which can adversely affect mood, Maki explained in the press release.
"Relationships can be taxed and the realities of aging can become quite apparent. Life stressors, low social support and physical health problems are strongly related to depression during perimenopause,” Maki said in the press release. “When you add in hormonal changes that can affect the brain's ability to cope with these stressors, it's no surprise that depression is a common occurrence in midlife women.
To diagnose perimenopausal depression, Maki and colleagues recommend clinicians:
- identify the menopausal stage;
- assess co-occurring psychiatric and menopause symptoms;
- consider psychosocial factors common in midlife and differential diagnoses; and
- think about using validated screening instruments.
Although the main causes of perimenopausal depression can be hard to detect, proven therapeutic options for depression — such as antidepressants, cognitive behavioral therapy and other psychotherapies — are the front-line treatments for depressive episodes during perimenopause, according to the guidelines.
Estrogen therapy is not approved as a treatment for perimenopausal depression; however, some prior evidence has shown its antidepressant effects in perimenopausal women, especially in women with concomitant vasomotor symptoms. The panel also noted that data on estrogen plus progestin are limited. There is also not enough evidence to support botanical or alternative approaches for treating depression related to perimenopause, according to the press release.
"Perimenopause is a window of vulnerability for the development of both depressive symptoms and major depressive episodes," Maki said in the release. "It is important for women and their health care providers to recognize that [depressive] symptoms are common during perimenopause and can be treated.” – by Savannah Demko
Disclosure: Maki reports honoraria from Mylan. Please see the study for all other authors’ relevant financial disclosures.