Does Perimenopause Cause Depression in Midlife Women?

During perimenopause, women are especially vulnerable to mood swings or depression. Here’s why and what you can do about it.

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middle-aged mature woman depressed looking out the window sitting on the floor
If you are experiencing poor sleep, have little to no appetite, or are having a hard time dealing with daily responsibilities, it might be time to seek help.Getty Images

Depression and mood swings may happen at any time for women, but they are particularly common when hormonal changes occur, as during puberty, pregnancy (including postpartum), and menopause.

“Women have a higher incidence of depression compared with men, and that begins in puberty, which suggests it’s related to hormones,” says Pauline M. Maki, PhD, of the departments of psychiatry and psychology at the University of Illinois in Chicago.

In fact, depression and moodiness during perimenopause — the time when a woman’s menstrual cycle starts to slow down — is even more frequent than depression during pregnancy, yet it has not been as widely studied. "The Guidelines for the Evaluation and Treatment of Perimenopausal Depression," published in February 2019 in the Journal of Women’s Health and written by Dr. Maki and her colleagues, note that perimenopausal women are 3 times more likely to have depressive symptoms than premenopausal women.

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The Estrogen Connection

Most people think a drop in estrogen levels makes a difference in moods, but studies have shown that it’s really the variation from day to day or even within a single day in daily hormones that is related to mood disruption in women. “In other words, it’s not the fact that women’s estrogen levels are low that makes a difference but that estrogen levels are fluctuating,” explains Maki. “Many people misunderstand how the hormones change around perimenopause. People believe that it is a gradual tapering off of estradiol, but women experience tremendous and dramatic fluctuation of estrogen. Estrogen levels can be even higher than what women experience during their regular menstrual cycle.”

A study published September 2022 in the journal Psychoneuroendocrinology looked at the estrogen levels of 73 women over two months. Researchers found that women who had the highest estrogen fluctuations were more likely to not feel joy during perimenopause.

“That means if you can control the variability, you can control the depression,” Maki notes, adding another encouraging fact: “If depression during perimenopause is due to hormonal factors and there’s no other cause of a depressive disorder, then it can be time limited.”

Life Changes in Your Forties May Affect Mood

“The main thing is that women who are going through this understand what is happening, because in addition to the biological factors, it is just as important to recognize the environmental factors like parenting challenges and career changes,” says Maki.

She adds that therapy and antidepressants won’t heal a faulty marriage or an elderly parent who is sick. Once in their forties, women tend to experience major life changes: children growing up and going to college, taking care of elderly parents (sometimes both at the same time), career shifts, marital conflict, conflicted emotions about aging and body changes, and more. This combination of hormonal and life changes creates a messy mix of challenges that all need to be addressed together.

Dealing with persistent stress can contribute to depression at any age, especially if we can’t respond well, Maki notes. “Their effect is heightened when hormones are fluctuating,” she says.

When to Seek Professional Help

If you are experiencing symptoms like poor sleep, have a loss of appetite, or are having a hard time managing work or daily responsibilities, it might be time to seek help, according to Maki.

She encourages people to use the Patient Health Questionnaire, a free mental health screening tool, and talk to a doctor if they score a 10 or higher.

The North American Menopause Society offers a downloadable handout, which you can bring to your practitioner, that explains the connection between the two.

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Diagnosing Perimenopausal Depression

The causes of midlife depression are complex; it’s not easy to tease out what is biology and what is environment. According to the 2018 treatment of perimenopause guidelines, diagnosis of depressive disorders during midlife includes:

  • Clinical assessment of depression and other mental health issues
  • Review of previous psychiatric history
  • Identification of menopause stage
  • Discussion of the woman’s life stressors
  • Overview of sleep hygiene

You’ve Been Diagnosed With Depression — Now What?

“Treatment should be tailored. If a woman is experiencing difficulty coming to terms with aging or life changes, an antidepressant isn’t going to take that away,” says Maki.

Your practitioner may try the following options:

A review published in 2022 in Drugs & Aging found that a handful of studies showed that hormone therapy for perimenopausal women was effective at reducing feelings of depression as well as cognitive decline. The paper argues for more robust research around its efficacy to treat depression during menopause since it is a transition all women experience.

Do Complementary and Alternative Approaches Help?

While Maki insists the evidence does not suggest there is a substitute for evidence-based psychotherapy and medical treatments, she says, “we are recognizing the importance of things like mindfulness-based stress reduction, yoga, exercise, and a good diet.”

For women whose depression isn’t severe — it’s not keeping them at home — yoga could help improve mood a little bit. “But really the only thing that has been shown to help is exercise.” A meta-analysis published in the journal Mauritius looked at 11 studies and found that a 12-week to yearlong exercise program significantly reduced depressive symptoms in midlife and older women.

Maki adds that one of the best complements to therapy and medicine is engaging in something that allows you to be an active participant in your own life. “That can be very rewarding for people who are depressed,” she says, “and it’s usually a byproduct of cognitive behavioral therapy.”

Additional reporting by Jordan M. Davidson.