The average age at which menopause is reached has not changed in recent years, remaining around 52 years old. However, there has been a significant demographic shift, as women's life expectancy has increased tremendously in recent centuries, currently standing at around 83 years. Therefore, women will enjoy many years past our reproductive age—years that can be highly productive and fulfilling, especially for those who put their careers on hold due to motherhood. For this reason, it is crucial that menopause-related symptoms are treated appropriately, both medically and psychologically.
Hormonal Changes and Perimenopause
Estrogen levels fluctuate regularly during a woman's reproductive years. During the years leading up to the final menstruation, called perimenopause, these fluctuations become much more irregular, and they cease to exist in postmenopause (the phase in which estrogens drastically decrease).
As estrogen fluctuations become unpredictable, the brain signals the pituitary gland to produce FSH and LH hormones in an attempt to restore previous estrogen levels.
These irregularities in hormonal fluctuations have been linked in various studies to the depression women experience during this stage of life.
Perimenopause is precisely characterized by the onset of these fluctuations in a woman's hormone levels and can begin up to 10 years before entering menopause—defining menopause as the point when 12 months have passed since the last menstruation.
How can a woman know if she is entering perimenopause?
In some countries, FSH levels are checked three days after the start of menstruation for two consecutive cycles. If the FSH level is elevated, it suggests that the woman has already begun perimenopause. However, a normal FSH value does not rule out being in this stage, as it could just mean that the woman ovulated during that specific cycle, even if it happens occasionally rather than monthly.
The Link Between Hormones and Depression
Over the last few decades, there has been growing interest in understanding the relationship between the hormonal changes occurring in perimenopause and depression.
Among the most relevant research is the SWAN study, which found a connection between fluctuations in FSH levels and mood changes; it was also proven that as FSH levels decreased again with hormone therapy, mood improved.
The Penn study found that the greater the variability in FSH levels, the higher the probability of depression.
General depressive disorders are characterized by emotional symptoms (sadness, irritability, feelings of worthlessness, etc.) and neurovegetative symptoms (sleep disturbances, weight changes, low libido, low energy, difficulty concentrating, etc.).
Menopause symptoms overlap with the neurovegetative symptoms of depression, with the addition of vasomotor symptoms (hot flashes, sweating, and epithelial—and therefore vaginal—dryness). When facing depression in a woman between 45 and 60 years old, professionals will not know if her depression is related to menopause unless we explicitly ask about vasomotor symptoms. This is very important because a proper diagnosis is fundamental for adequate treatment.
Theories Explaining Perimenopausal Depression
There are several theories that explain perimenopausal depression:
- Neurobiological theory: Argues that hormones are psychoactive substrates in the brain and may be responsible for affective changes in perimenopause.
- Domino effect theory: Links sleep disturbances, weight and libido changes, as well as vasomotor symptoms (hot flashes, night sweats, and epithelial dryness), to an increased risk of depressive symptoms.
- Psychosocial theory: Considers that environmental factors (difficulties in this stage of life such as dealing with teenage children or empty nest syndrome, relationship issues, caring for sick parents, or dealing with the first signs of declining personal health) contribute to perimenopausal depression.
Treatment Options for Perimenopausal Depression
What treatment do we choose for perimenopausal depression?
Here we also have three complementary options.
The first would be psychotherapy, a space where the woman can put her internal anxieties and fears into words in order to find paths that lead to better self-knowledge and a better relationship with herself.
Regarding the pharmacological option, we have antidepressants and perhaps hormone replacement therapy.
The preferred drugs for perimenopausal depression are antidepressants.
Paroxetine is the only one approved by the FDA (Food and Drug Administration) to treat perimenopausal depression, although other antidepressants such as escitalopram, citalopram, venlafaxine, or desvenlafaxine have been used successfully for these clinical symptoms. Ultimately, we will choose a specific one based on the different associated symptoms. If there is insomnia, anxiety, or vasomotor symptoms, paroxetine is usually a good option. If there is concern about weight gain, escitalopram might be a better candidate.
Hormone therapy (with estrogen or progesterone) reduces vasomotor symptoms (it is approved for hot flashes and vulvovaginal atrophy symptoms) and prevents depression in perimenopausal women exposed to life stressors. However, a risk-benefit balance must always be assessed. It is known that hormonal therapies increase the risk of breast cancer, endometrial cancer, and stroke in women over 60. Therefore, the use of estrogen and progesterone should be done in low doses, for a short duration, in women under 60 whose menopause has occurred recently (no more than 10 years ago), and under close medical supervision.
Therefore, and as a summary, if you are a woman between 45-60 years old and you feel depressed, ask yourself if there have recently been changes in your menstrual cycle, if you have vasomotor symptoms, or changes in your libido or orgasms. If so, you could be suffering from perimenopausal depression, for which there are several therapeutic options that can help you regain your stability.
