It is well-recognized that women are at increased risk of depression during postpartum when hormone levels are changing, but the risk of depression associated with perimenopause -- the time right before menopause when female hormones are in decline -- remains under-recognized and clinical recommendations on how to diagnose and treat this kind of depression in women have been lacking until now.
A multi-institutional panel of clinicians and scientists convened by The North American Menopause Society and the National Network on Depression Centers Women and Mood Disorders Task Group, and endorsed by the International Menopause Society, have published the first-ever guidelines for the evaluation and treatment of perimenopausal depression simultaneously in the journal Menopause and the Journal of Women's Health .
The task force, co-chaired by Maki and Kornstein, reviewed the scientific literature on depressive disorders and symptoms in perimenopausal women and focused on five areas: epidemiology, clinical presentation, therapeutic effects of antidepressants, effects of hormone therapy, and efficacy of other therapies such as psychotherapy, exercise and natural products. Perimenopause refers to the three- to four-year period immediately prior to menopause when periods become irregular and eventually stop, as well as the first year after the final menstrual period. Symptoms such as hot flashes and sleep disturbances often begin at this time and can co-occur and overlap with symptoms of depression, the new guidelines state. "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. Persistent sleep disturbances caused by hot flashes contribute to the development or exacerbation of depressive symptoms," said Maki.
During perimenopause, women often juggle multiple responsibilities and face multiple stressors. They care for their own children, experience children leaving the home, help aging parents, retain primary responsibility for the home, and face increasing job demands at a time when they may be approaching the peak of their career. All of this can be extremely stressful, Maki explained.
The root causes of perimenopausal depression can be hard to identify, said Maki. "Are women experiencing low energy because they are having night sweats and losing sleep? If so, treating with hormones may be the best bet," she said. "Alternatively, is a woman with a past history of depression having another depressive episode? In that case, antidepressant therapy might be most effective. Is the issue primarily due to family and job burden? If so, cognitive behavioral therapy with or without an antidepressant might be best."
Maki explains that while it is common for women with menopausal symptoms to experience depressive symptoms, most of the time those symptoms do not meet the criteria for a diagnosis of depression. But, she said, even low-level depressive symptoms can lower quality of life and strain relationships, and hormone therapy might help. "It is important for women and their health care providers to recognize that these symptoms are common during perimenopause and can be treated," she said.
Some of the findings of the panel include:
"Perimenopause is a window of vulnerability for the development of both depressive symptoms and major depressive episodes," Maki said. "The recent suicide of Kate Spade at 55 years of age shows the seriousness of mental health issues in midlife women, a group that has shown a 45 percent increase in suicide rates over the past 15 years," said Maki.
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Richmond; Dr. Hadine Joffe, Dr. Geena Athappilly and Dr. Lee Cohen of Harvard Medical School; Joyce Bromberger of the University of Pittsburgh; Ellen Freeman of the University of Pennsylvania; Dr. William Bobo of the Mayo Clinic, Rochester; Leah Rubin of Johns Hopkins University School of Medicine; Dr. Hristina Koleva of the University of Iowa Carver College of Medicine, Iowa City; and Dr. Claudio Soares of Queens University School of Medicine, Ontario are co-authors of the guidelines.
Menopause