Am I depressed or menopausal?

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Many women are given antidepressants during the menopause but it’s important to distinguish between low mood and clinical depression…

• Symptoms of perimenopause and menopause and clinical depression can be similar
• Women can also be clinically depressed and menopausal at the same time
• Discover how to determine what’s going on with you and how to get help

Content warning: this article contains themes of suicide and mental health

If you are a perimenopausal or menopausal woman, it’s likely you’ve noticed a dip in your mood. In a Newson Health survey, an overwhelming 95 per cent of respondents said they’d experienced a negative change in their mood and emotions, with stress and anxiety, feeling more easily overwhelmed, feeling low or tearful and feeling angry or irritable all being frequently cited [1].

During perimenopause, hormone levels fluctuate and it is often during this time (which can last for a decade) symptoms are worse than during menopause.

Perimenopausal and menopausal symptoms, both physical and mental, can be challenging – if you’re struggling with genitourinary symptoms, hot flushes, aching joints or lack of sleep, your mood will likely be affected. Menopause can also come at a tricky stage of life – you might have elderly parents to care for or children still at home, as well as a career to balance.

We also know that there is a significant increase – approximately three times higher – in the likelihood of depressed mood during the perimenopause and menopause than in other life stages [2]. And women with a history of depression are nearly five times more likely to receive a major depression diagnosis during menopause [3].

With so much going on, you might wonder if your feelings are due to your hormones or if you are clinically depressed.

RELATED: Mental health issues and hormones: introducing Newson Health’s psychiatrist Dr Louisa James

Similarities of clinical depression and menopausal low mood

Dr Louisa James is a psychiatrist with a wealth of experience in treating perimenopausal and menopausal women, and she offers appointments to Newson Health patients. She says:

‘There is an overlap between menopausal low mood and clinical depression. For instance, while many people think depression is feeling sad, it can be a whole-body experience, just as menopause can be.

‘One example is change in appetite. Some people who are depressed lose their appetite, but others may binge eat, or comfort eat in the evenings. This can reflect diurnal variation in mood – traditionally low mood is worse in the morning and eases as the day goes on. As mood improves, hunger increases. Constipation is something else which is common in menopause but also a lesser known symptom of depression.

‘Poor sleep is common with both clinical depression and menopause. Often with clinical depression people wake early and those with anxiety find it more difficult to get off to sleep. With perimenopause and menopause people often describe waking in the early hours, often associated with irrational thoughts.

‘And then there’s symptoms like a general loss of confidence, self-doubt or being indecisive. Anxiety is a big problem that goes hand in hand with both menopause and depression.’

Differences between clinical depression and low mood

The differences between clinical depression and low mood associated with changing hormones can be really subtle, as Louisa explains. ‘With perimenopause and menopause, women recognise that something’s wrong, and they have a hunch that it’s related to their hormones or that it’s associated with other symptoms.’ You might not experience hot flushes but there are numerous other menopause symptoms – this can help you identify that the way you are feeling might be related to your hormones.

RELATED: Menopause symptom checker

Louisa has observed that: ‘Often people with a very severe clinical depression won’t be wearing their make-up. They may look a bit dishevelled or be neglecting themselves. Whereas with hormonal low mood, women come in with what we classically call a “smiling depression” – despite feeling awful inside they are well presented, wearing make-up, they’re smiling and trying really hard. The washing’s done, the shopping lists are made. All that sort of general functioning is done, whereas it tends to slip away with a clinical depression. For perimenopausal and menopausal women, that loss is more one of sense of self and identity.

‘The rage is different as well. You can get irritability with a clinical depression or feel more short tempered, but that irrational thinking and the feeling that everything’s out of perspective and the rage, that tends to be worse with the hormonal type depression.’

Also consider your history – if you’ve had episodes of depression in the past, consider how you have felt and what might have triggered this. Similarly, have you experienced any previous hormone-related issues or illnesses such as PMS, PMDD, postnatal depression or postpartum psychosis?

RELATED: My story of hormonal depression: when my hormones change, I change

‘Often, patients who had an episode of clinical depression in the past will know how that feels and they’ll be able to say this feels similar or this feels completely different,’ says Louisa. Similarly, if you’ve suffered during previous instances of hormonal dysregulation (such as PMDD) this can be a clue on how best to treat your symptoms.

It’s also important to note that you can have more than one diagnosis. Louisa says: ‘Women can get pigeonholed into oh, this is menopausal/hormonal, or this is psychiatry. But it’s possible to be menopausal and suffer from clinical depression too.’ A healthcare professional should be able to help you determine, diagnose and treat accordingly.  

How to get the right treatment

Treatment for perimenopausal and menopausal symptoms and/or clinical depression can include a combination of medications, talking therapies and lifestyle adjustments.

HRT

If your low mood is predominantly being caused by low oestrogen, progesterone and testosterone levels in your brain, which occurs during perimenopause and menopause, the NICE menopause guidelines state that HRT is the first-line treatment.

‘At Newson Health we see a huge number of women who, once they have their hormones replaced, their symptoms resolve,’ says Louisa. ‘It’s not a one-size-fits-all package though. A lot of the women who come to Newson Health have already started HRT with their GP but are feeling a bit disheartened that it hasn’t been the magic ticket that they were hoping for. But often it’s because they’re on too low a dose, the combination isn’t correct, or the testosterone component is lacking.

‘When women are given the right hormones in the right doses, some can get relief quite quickly, within a week or two. Others find it takes a little bit longer, even several months.

‘My experience with testosterone is that the benefits can take a little bit longer. Testosterone can be important for energy levels, for being able to feel excited or have that enjoyment from life and for memory and brain fog.’

RELATED: Menopause, depression and anxiety

Antidepressants

Research suggests that antidepressants can be helpful for people with moderate or severe depression [4]. As with HRT, it can take time to be effective. ‘We always tell our patients that it’s going to take at least two weeks for them to start to feel better; four weeks before they’ll start to get a really good effect; and for some antidepressants, they will continue to get improvements up to eight weeks later or even longer,’ says Louisa.

If you are diagnosed with mild depression, your GP might suggest waiting a short time to see if it gets better without medication and you’ll usually be reviewed again in 2-4 weeks.

Lifestyle

There is evidence that exercise can help people with clinical depression and NICE recommends group exercise for people with mild to moderate depression. Similarly, there is plenty of research on the positive impact of physical activity on health around menopause [5]. According to the Mental Health Foundation, regular movement is one of the most important things you can do to help protect your mental health – it can increase your energy, reduce stress and anxiety, and boost your self-esteem.

RELATED: How walking can ease your mind

Similarly, diet can influence the gut-brain axis, which can affect your mood. Eating a healthy, balanced diet such as the Mediterranean diet can help ease depression symptoms [6] and can reduce the severity of menopausal symptoms [7].

RELATED: How the Mediterranean diet can help menopausal symptoms

There is also evidence that good quality sleep and spending time in nature can help your mood, as can talking therapies such as CBT.

Your questions answered

‘I’ve been given antidepressants, but I don’t think I’m depressed – I’m menopausal.’

In a survey for Dr Louise Newson’s book, more than a third (38 per cent) of respondents who sought help from a healthcare professional about their perimenopause or menopause symptoms said they were offered antidepressants instead of HRT.

Ask your GP why you have been prescribed them. ‘GPs see patients in 10-minute appointments so the patient may only get time to talk about their most pressing symptom,’ says Louisa. If you’re experiencing other perimenopausal or menopausal symptoms, beyond low mood and anxiety, be sure to let your GP know. Sometimes antidepressants are prescribed for hot flushes and night sweats caused by perimenopause or menopause if a woman can’t take HRT, so again, find out why it’s been prescribed.

There is no evidence that antidepressants will help with low mood associated with menopause, and when given inappropriately they can cause side effects such as blunting of mood and loss of libido.

If you don’t want to question your GP, Louisa advises finding a knowledgeable person within your GP practice – many surgeries have menopause specialists. If not, ask your friends if they know any local GPs who have been a bit more sympathetic to hormones.

‘How do I come off antidepressants?‘

Louisa advises: ‘I would caution against stopping antidepressants without medical support – instead do it with the supervision of a medical practitioner. This is largely because some antidepressants cause physical withdrawal symptoms so you need to stop them very gradually. There are other actions that you could take, for example, talking therapy is really important and there are support groups, counselling and mental health practitioners available at some GP clinics.

‘When you are stopping, educate yourself. Monitor things really carefully – perhaps keep a mood diary, even if it’s just scoring your mood out of 10, twice a day, to make sure that things aren’t slipping without you realising it.

‘And if you think your symptoms are hormonally driven, it is better to get them stabilised on a hormone replacement before you start reducing your antidepressants. What we often see in clinic is that women feel like the antidepressants aren’t doing anything, but they are, and if they’re taken away too quickly, you can end up in difficulty.

‘This applies to all sorts of medications as it’s not just antidepressants that women can end up on, for instance atypical antipsychotic medications are often added to manage anxiety, poor sleep or to boost the effect of antidepressants that aren’t working very well. Sleeping tablets are commonly prescribed for insomnia.’

RELATED: Antidepressants and menopause factsheet

‘I’ve had suicidal thoughts – could perimenopause or menopause be to blame?‘

Louisa says: ‘One factor that gets women referred to psychiatrists such as myself is suicidality. A woman might go to her GP complaining of suicidal thoughts and be referred to a psychiatrist but not all psychiatrists would automatically think about hormones, which is when patients end up on antidepressants.

‘A lot can go on during perimenopause and menopause – irrational thoughts, impulsivity, losing your sense of self and feeling that you’re not succeeding anymore and it all feeds in together. You might also have physical symptoms of perimenopause and menopause – the hot flushes, genitourinary symptoms such as recurrent UTIs or the vaginal dryness, the loss of libido. You can see how it makes women feel desperate. Women put up with a huge amount of emotional distress and they often will think it’s normal to feel stressed or anxious or not to sleep and so they tolerate a lot, which means they delay asking for help.

‘At Newson Health we can have long appointments with a patient to ask them everything, even things they don’t think are relevant, to build up a picture of what’s going on and determine the appropriate treatment.’

RELATED: When you’re not OK

Contact the Samaritans for 24-hour, confidential support by calling 116 123 or email jo@samaritans.org.

Psychiatry services at Newson Health

References

1. Experiences of the perimenopause and menopause, December 2022
2. Freeman EW. Associations of depression with the transition to menopause. Menopause. 2010;17(4):823-827. doi: 10.1097/gme.0b013e3181db9f8b
3. Freeman EW. Associations of depression with the transition to menopause. Menopause. 2010;17(4):823-827. doi: 10.1097/gme.0b013e3181db9f8b
4. NHS: Overview: antidepressants
5. Maria Hybholt. (2022), ‘Psychological and social health outcomes of physical activity around menopause: A scoping review of research’, Maturitas, Volume 164, pp88-97, https://doi.org/10.1016/j.maturitas.2022.07.014
6. Bizzozero-Peroni B., Martínez-Vizcaíno V., Fernández-Rodríguez R., Jiménez-López E., Núñez de Arenas-Arroyo S., Saz-Lara A., Díaz-Goñi V., Mesas A.E. (2024), ‘The impact of the Mediterranean diet on alleviating depressive symptoms in adults: a systematic review and meta-analysis of randomized controlled trials’, Nutrition Reviews; https://doi.org/10.1093/nutrit/nuad176
7. Vetrani C., Barrea L., Rispoli R., Verde L., De Alteriis G., Docimo A., Auriemma R.S., Colao A., Savastano S., Muscogiuri G. (2022), ‘Mediterranean Diet: What Are the Consequences for Menopause?’, Front Endocrinol (Lausanne). 25;13:886824. doi: 10.3389/fendo.2022.886824