Depression is a serious issue for middle-aged women. The suicide of fashion designer Kate Spade at age 55 is but one example of how the hormonal changes that develop in late middle age can leave a woman vulnerable as her body moves toward menopause. Researchers have unfortunately paid little attention to the risk of depression during mid-life and perimenopause, when levels of female hormones are declining.

“There has been a need for expert consensus and clear guidelines about how to evaluate and treat depression in women during the perimenopause,” Susan Kornstein, one of the lead authors of a new set guidelines to help doctors and nurses screen for and treat perimenopausal depression, said in a statement.

Even women with no history of depression can develop depressive symptoms during perimenopause.

The new guidelines, put together by a panel from the North American Menopause Society (NAMS) and National Network of Depression Centers Women and Mood Disorders Task Group, and endorsed by the International Menopause Society, are meant to raise awareness of the much higher risk of mood disorders, particularly depression, as women transition into menopause.

Women should understand that the transition to menopause is a state of vulnerability, and that mood shifts are very common.

When it reviewed the findings of studies on depressive symptoms and disorders in perimenopausal women, the panel found that not only can perimenopause make women vulnerable to depressive symptoms, they are also more likely to be diagnosed with major depressive disorder (MDD). Even women with no history of depression can develop depressive symptoms during perimenopause. It is estimated that 58 percent of women with a history of depression will have a recurrence of major depression during that time, Pauline Maki, also a lead author of the guidelines, told TheDoctor.

The Overlapping Symptoms of Menopause and Depression

Common symptoms of perimenopause such as hot flashes and night sweats can complicate and overlap with symptoms of depression. “It can be difficult to distinguish between the symptoms of menopause and the symptoms of depression, making it difficult for clinicians to diagnose and treat these women,” said Maki.

About 80 to 90 percent of women experience hot flashes and night sweats during perimenopause. These symptoms disrupt sleep for many nights in a row, which would make anyone irritable. Treating these symptoms with hormone replacement therapy may be the best option for women whose depression is caused by sleep disturbance.

Stressful life events that occur during perimenopause, such as career and marital shifts, children leaving home and caring for aging parents, can trigger a more profound mood change when hormone levels are changing.

In addition to the hormonal changes that accompany it, the perimenopausal period is often also a time when stressful life events such as career and marital shifts, children leaving home and caring for aging parents can have negative affect on mood. For these women, psychotherapy, specifically cognitive behavioral therapy, may be appropriate. All the antidepressants in the world are not going to help women come to terms with the idea they are getting older, Maki said.

Depression during perimenopause can be attributed to a bit of all of the above. “We need a targeted research approach to better understand the subtypes of depression that emerge when women transition through menopause,” said Maki, a professor of psychology and psychiatry at the University of Illinois at Chicago College of Medicine.

What Women Should Know

Women looking for ways to deal with depression and mood swings that don't involve medication should know that botanical and complementary and alternative medicine approaches for treating depression during menopause are not yet supported by research, Maki said. Aerobic exercise is the only thing that consistently helps lift mood.

Women should understand that the transition to menopause is a state of vulnerability, Maki says, and that mood shifts are very common. The same kinds of stressors present when hormones aren’t shifting will trigger a more profound mood change when there is hormonal upheaval.

Women can download handouts about menopausal symptoms, such as depression, hot flashes and sleep problems, from the NAMS web site. “These handouts can help women have a better understanding of menopausal symptoms, so they can have a more informed conversation with their doctor,” said Maki.

The guidelines were published simultaneously in the Journal of Women’s Health and Menopause.