antidepressants during peri?

Mood changes are common during perimenopause but MHT doesn’t always solve them!

Menopause is a significant life transition, and for many women, it brings about noticeable mood changes. These mood disturbances primarily occur during perimenopause when hormonal fluctuations are at their peak. While hormonal shifts play a role in mood changes, not all mood disturbances in midlife women are hormonal. Psychological, social, and lifestyle factors also contribute, meaning that treatment needs to be personalised and comprehensive.

Who is most at risk of mood changes during perimenopause?

Not all women experience mood disturbances during perimenopause, but some are more vulnerable than others. Women with a past or current history of depression, anxiety, or hormone related mood changes such as premenstrual dysphoric disorder (PMDD), postnatal depression or mood changes on some contraceptive pills are at a higher risk. Other risk factors include high stress levels, poor sleep, significant life changes (such as divorce or loss of a loved one), and lack of social support. Additionally, women who experience severe physical symptoms of menopause—like hot flushes and insomnia—may find that these symptoms exacerbate their mood issues.

If depression or anxiety present for the first time after the last menstrual period, it is unlikely that hormonal influences are directly responsible. After the last period, sex hormone levels may be low, but they are also stable. Other causes need to be explored although MHT may still benefit symptoms aggravating mood such as insomnia and flushes.

Perimenopause describes the lead up to the menopause, and is defined by an irregular cycle. If your menstrual cycle is regular but your flow has changed and your age is around 40 yrs+, then you may still be experiencing hormone related mood changes. These tend to be cyclic, occurring in the week or 2 before your period. MHT in this scenario may not help as research tells us that oestrogen levels are normal to high during this stage (also known as Late Reproductive Stage) and may be unsupported by progesterone during the luteal phase (2 weeks before the period starts). Hormonal strategies can still be helpful but would include overriding the cycle using a contraception pill or a trial of supporting the luteal phase with added progesterone.

Defining anxiety and depression: normal mood variations vs. pathology

Anxiety and depression are clinical conditions that go beyond normal fluctuations in mood. It is natural for individuals to experience temporary sadness, worry, or stress in response to life’s challenges. However, when these feelings become persistent, overwhelming, and interfere with daily life, they may indicate a clinical disorder. Depression is characterised by prolonged low mood, loss of interest or pleasure, fatigue, sleep disturbances, and feelings of worthlessness. Anxiety disorders involve excessive and persistent worry, restlessness, irritability, and physical symptoms such as increased heart rate or muscle tension. The distinction between normal mood changes and pathology lies in duration, intensity, and impact on functioning.

The DSM-V-TR is the diagnostic manual determining mental health diagnoses.

There are several validated survey tools to help you understand your level of symptoms. The DASS-21 is a great start.

The role of MHT

MHT is often used to manage the physical symptoms of menopause, such as hot flushes and night sweats. However, it also has a role in mood regulation. Oestrogen, particularly when combined with progesterone if needed, has been shown to have mood-enhancing effects, particularly for women experiencing perimenopausal depression rather than major depressive disorder. Oestrogen influences neurotransmitters like serotonin and dopamine, which play key roles in mood stability.

Recent evidence suggests that perimenopausal mood swings and irritability—common features of menopausal transition—respond well to MHT rather than antidepressants. While some social media discussions suggest that antidepressants are never appropriate for perimenopausal women, the reality is more nuanced. MHT is highly effective for hormone-related mood disturbances, but antidepressants remain a valid treatment for women experiencing clinical depression or anxiety that is independent of hormonal fluctuations or who are not responding to or not able to use MHT.

The role of antidepressants

Antidepressants are another option for managing mood changes during menopause, especially for women experiencing significant depression or anxiety. However, their use should be carefully considered. The most commonly prescribed antidepressants for midlife mood disorders include:

• Selective Serotonin Re-uptake Inhibitors (SSRIs) – such as fluoxetine, citalopram, sertraline, paroxetine, and escitalopram, which increase serotonin levels in the brain and help stabilise mood.
• Serotonin-Norepinephrine Re-uptake Inhibitors (SNRIs) – such as venlafaxine and duloxetine, which target both serotonin and norepinephrine to alleviate depression and anxiety.
• Tricyclic Antidepressants (TCAs) and Other Classes – sometimes used when first-line options are not effective. Agomelatine is an atypical antidepressant derived from the hormone melatonin. It has reduced negative impact on libido and may improve sleep when compared to other antidepressants.

Interestingly, some SSRIs and SNRIs (such as venlafaxine) can also help reduce hot flushes, providing a dual benefit for menopausal women. On the other hand, some women experience facial flushing as a side effect.

When both MHT and antidepressants are needed

For some women, a combination of MHT and antidepressants is the most effective approach. This is particularly the case for women with underlying clinical depression that is exacerbated by perimenopause. In such cases, MHT can help stabilise hormone-related mood fluctuations, while antidepressants address underlying depression and anxiety disorders.

Psychological support

Psychological support plays a crucial role in managing mood disturbances during menopause. Cognitive behavioural therapy (CBT), mindfulness, and other psychological therapies have been shown to improve mood and resilience. Psychologists can help women address underlying stressors, negative thought patterns, and lifestyle factors that may contribute to mood changes.

Lifestyle measures still matter

Regardless of whether a woman uses MHT, antidepressants, or both, lifestyle factors remain essential. Regular exercise, a healthy diet, limiting alcohol and caffeine, good sleep hygiene, stress reduction techniques (such as yoga or meditation), and social support all contribute to emotional well-being during menopause.

 

Mood changes during menopause can be complex, with both hormonal and non-hormonal factors playing a role. While MHT is the most effective treatment for mood disturbances directly related to hormonal fluctuations, antidepressants still play an important role in managing clinical depression and anxiety disorders. A balanced approach considers both hormonal and non-hormonal causes of mood changes, ensuring that women receive the right treatment for their specific situation. In some cases, both treatments may be necessary, along with psychological support. Understanding the nuances of these treatments allows women to make informed decisions about their mental health during this transitional phase of life.

 

Make sure to speak with your doctor and consider all available and suitable interventions for your own personal mental health.

 

References:

• Australasian Menopause Society. (2024). Perimenopausal Mood Disturbances and Treatment Options. Retrieved from [https://www.menopause.org.au]
• Kulkarni, J. (2023). Hormonal Treatments for Menopausal Mood Changes: A Shift in Understanding. The Medical Journal of Australia, 218(2), 72-75.