Antidepressants and menopause

While symptoms of perimenopause and menopause can be similar to that of clinical depression, they usually require different treatments

• HRT is the recommended treatment for menopause and perimenopause, while antidepressants can be helpful for women with moderate or severe depression
• You can be both perimenopausal and menopausal and depressed so treatment should be tailored to your individual symptoms
• What to do if you’ve been prescribed antidepressants but think you’re perimenopausal or menopausal, not depressed

Changes to moods, emotions and state of mind during perimenopause and menopause are extremely common; it is often the primary reason menopausal women first go to see their doctor or nurse.

In a Newson Health survey of 5,744 women, 84% reported feeling anxious or stressed since becoming perimenopausal or menopausal, while 79% felt more overwhelmed, 72% felt low or tearful, 67% felt angry or irritable, and 55% felt flat or blunted [1].

Other psychological symptoms can include low self-esteem, having reduced motivation or interest in things, panic attacks and mood swings. Many women struggle with sleep with sleep during this time, and insomnia can be closely associated with lethargy and feeling emotionally labile or tearful.

RELATED: Low self-esteem and menopause: why it happens and what to do about it

How can hormones influence mood during perimenopause or menopause?

Levels of oestradiol (oestrogen) and progesterone fluctuate during perimenopause then become low during menopause and remain consistently low. While some studies have shown that the reduction in oestradiol leads to a lowering of mood, others have shown it is the fluctuations in hormone levels that cause the problem [2, 3].

Your hormones oestradiol, progesterone and testosterone can help to regulate several hormones, for example serotonin, noradrenaline and dopamine, which often have mood-boosting properties as well as other beneficial effects in your brain.

Progesterone is commonly thought of as the “relaxing hormone” as, for most women, it has calming, anti-anxiety (anxiolytic) properties and is thought to have mood stabilising effects. It can also improve sleep.

Testosterone regulates serotonin levels and plays a role in its uptake in your brain, which can help to improve overall mood. Testosterone also stimulates the release of dopamine, another neurotransmitter responsible for your feelings of pleasure.

Some pre-existing conditions may put women at greater risk of developing mood changes during perimenopause and menopause, these include a history of premenstrual syndrome or postnatal depression, high levels of stress, and poor physical health.

RELATED: PMS, PMDD and the menopause

How is low mood or depression diagnosed during perimenopause and menopause?

It is clear to see why low mood during perimenopause and menopause could be mistaken for clinical depression. In our article Am I depressed or menopausal?, psychiatrist Dr Louisa James outlines how some symptoms can overlap, and what to consider when distinguishing between hormonal low mood and clinical depression.

Just as it’s important that healthcare professionals consider hormones when making a diagnosis of clinical depression, ‘it’s worth noting that you can have more than one diagnosis – you can be menopausal and suffer from clinical depression too,’ says Dr Louisa.

When Sam was 42 and going through a very stressful period of life, she was prescribed citalopram. She had been taking antidepressants in the past so it was diagnosed that she was experiencing a mental health issue. Yet tests showed she had a low oestradiol blood level and even when she was prescribed a different antidepressant, plus clonazepam, a type of sedative, Sam experienced suicidal thoughts, would wake in the night in a panic soaked in sweet, and was tearful.

Sam’s psychiatrist suggested ECT for treatment-resistant depression but instead Sam had private treatment of ketamine infusions, which her psychiatrist prescribed for her. For several years she continued with this but still experienced symptoms. At the age of 45 she started taking HRT. She says: ‘I have gradually felt better. I no longer burst into tears. My energy, motivation and capacity for joy is returning. I feel more sociable and I enjoy rather than fear and avoid interacting with others in social events. During the last 12 months, I’ve gradually reduced and stopped taking antidepressants and anti-anxiety medications. And I’ve increased the interval between the ketamine infusions. I have found HRT to be more effective at treating my mental illness symptoms than any of the psychiatric medications that I’ve been prescribed, with none of the side effects and lots of long-term health benefits.’ Read more about Sam’s experiences: My story of treatment-resistant depression, ketamine and HRT

Can antidepressants be prescribed for menopause symptoms?

Menopause guidelines are clear that antidepressants should not be used as first line treatment for the low mood associated with perimenopause and menopause. This is because there is no evidence that they help improve psychological symptoms of perimenopause or menopause.

Despite this clear recommendation, a Newson Health survey found that when seeking advice from a healthcare professional about their perimenopausal or menopausal symptoms, over a third of respondents (39%) said they were offered antidepressants instead of HRT as the first course of treatment [1].

While 26% of these women were offered one type of antidepressant, 8% were offered two types and 5% said they were offered more than two types [1].

Antidepressants are not effective for the low mood and anxiety associated with perimenopause and menopause as they are not treating or addressing the underlying cause of low hormone levels.

RELATED: HRT or antidepressants for low mood?

How should hormonal low mood be treated?

Because mood changes during perimenopause and menopause are caused by altered hormones, the most effective treatment is to stabilise hormone levels with HRT, often with testosterone too. A Newson Health study of 510 women – who had already been using HRT (transdermal oestrogen with or without a progestogen) – who were treated with transdermal body-identical testosterone for four months, found significant improvements in cognition and mood. Among symptoms most likely to improve were ‘loss of interest in most things’ (56% of women reported an improvement) and ‘crying spells’ (55%) [4]. 

Many women find that they feel calmer, their motivation and interest in things returns, along with a greater sense of energy, and they are generally much happier after a few months of being on HRT. There will usually be an improvement in other menopausal symptoms as well, such as hot flushes and night sweats, insomnia, vaginal dryness and many other symptoms.

Research has shown that if women are given HRT when they are perimenopausal, this can reduce the incidence of clinical depression developing [5].

Many women who start HRT and have been incorrectly given antidepressants in the past, find that their depressive symptoms improve on the right dose and type of HRT, to the extent that they can reduce and often stop taking their antidepressants.

This is something Jaany experienced when she was 44, and was prescribed for her perimenopausal symptoms of rage, aching joints, brain fog, social anxiety, changes in periods and lack of energy. But after she researched perimenopause, Jaany requested and received HRT. She says ‘Everything changed after this. I emerged from a very unfamiliar place where I didn’t recognise myself, to one of familiarity. I slowly realised that with the necessary hormones flowing through my veins again, I had actually regained myself. Now, a year down the line, my symptoms have all lessened considerably.’ You can read more of Jaany’s experience: My story: Losing and regaining my sense of self

Can HRT and antidepressants be used together?

For women who have been diagnosed with clinical depression, and who are also experiencing perimenopause or menopause symptoms, both HRT and antidepressants can be prescribed and taken safely together.

There is some evidence that oestradiol can enhance the effectiveness of a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI), such as citalopram, fluoxetine, sertraline [6]. Ensuring you have optimal levels of oestrogen is therefore helpful in dealing with symptoms of low mood.

RELATED: Menopause and antidepressants: Kim Goulding & Dr Louise Newson

What else can I do for menopausal low mood?

For most women experiencing low mood, anxiety, irritability, or mood swings, combining appropriate treatment with lifestyle adjustments is key.

A healthy diet with lots of fruit and vegetables and limiting overly processed foods, excess salt and sugar and white refined carbohydrates, can be beneficial. Foods high in essential fats such as omega 3 oils, and those rich in B vitamins, calcium and vitamin D can help improve your mood.

There is evidence that the bacteria that live in our guts can be helpful for mood and anxiety [7].  Eating fermented and high fibre foods help to ensure we have lots of different healthy bacteria. Find out more about looking after your gut in Dr Louise Newson’s podcast Irritable bowel, bloating and digestive health with the gut experts.

Regular exercise boosts endorphins – hormones that relieve pain and reduce stress.

RELATED: How walking can ease your mind 

Talking therapy such as cognitive behavioural therapy (CBT) has been shown to help with menopausal low mood and anxiety, and interestingly, even physical symptoms such as hot flushes.
Remember, individualisation of treatment is key. ‘If you have not had episodes of depression in the past and have now been prescribed antidepressants for your low mood or anxiety associated with your menopause or perimenopause, consider whether this is the right treatment for you,’ says Dr Louisa.

‘If you have had depression in the past but this feels different or your usual treatment has been ineffective, it is worth considering whether hormone deficiency may be hampering your recovery,’ Dr Louisa adds. ‘Also think HRT first if you have a history of mood changes related to periods, fertility treatment or pregnancy.’

Dr Louisa suggests tracking symptoms using the balance app to start a conversation about perimenopause, and seeing a doctor who specialises in the menopause for individualised advice.

References

1. Newson Health, Experiences of Perimenopause and Menopause, 2022
2. Albert KM, Newhouse PA. Estrogen, Stress, and Depression: Cognitive and Biological Interactions. Annu Rev Clin Psychol. 2019 May 7;15:399-423. doi: 10.1146/annurev-clinpsy-050718-095557
3. Musial N, Ali Z, Grbevski J, Veerakumar A, Sharma P. Perimenopause and First-Onset Mood Disorders: A Closer Look. Focus (Am Psychiatr Publ). 2021 Jul;19(3):330-337. doi: 10.1176/appi.focus.20200041.
4. Glynne S., Kamal A., Kamel A.M. et al. (2024), ‘Effect of transdermal testosterone therapy on mood and cognitive symptoms in peri- and postmenopausal women: a pilot study‘, Arch Womens Ment Health. https://doi.org/10.1007/s00737-024-01513-6
5. Gordon JL, Rubinow DR, Eisenlohr-Moul TA, Xia K, Schmidt PJ, Girdler SS. (2018), ‘Efficacy of Transdermal Estradiol and Micronized Progesterone in the Prevention of Depressive Symptoms in the Menopause Transition: A Randomized Clinical Trial. JAMA Psychiatry. ;75(2):149–157. doi:10.1001/jamapsychiatry.2017.3998
6. Estrada-Camarena E., López-Rubalcava C., Vega-Rivera N., Récamier-Carballo S., Fernández-Guasti A. (2010), ‘Antidepressant effects of estrogens: a basic approximation’, Behavioural Pharmacology 21(5-6) pp451-464. DOI: 10.1097/FBP.0b013e32833db7e9
7. Kumar A, Pramanik J, Goyal N, Chauhan D, Sivamaruthi BS, Prajapati BG, Chaiyasut C. Gut Microbiota in Anxiety and Depression: Unveiling the Relationships and Management Options. Pharmaceuticals (Basel). 2023 Apr 9;16(4):565. doi: 10.3390/ph16040565.