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A low blow: depression in perimenopause

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It’s more common than you might think. And antidepressants may not necessarily be the solution. So what does help? 

By Dr Ornella Cappellari   

Menopause can be a daunting time in our lives. But the 24-hour period that is technically defined as menopause isn’t the trigger for the low mood that can affect women at this stage – the culprit is what comes before it. Perimenopause is all about change, and many of the 34 symptoms related to it can trigger depression and anxiety. What’s behind all the changes happening now? Hormones.  

In particular, it’s the continuous variation in hormone levels (the rollercoaster effect) that creates the problem. If it were simply a question of new, low levels, our bodies would struggle but eventually adjust. During perimenopause, hormone levels go up and down. They ultimately stabilise, but the process can take years. Rome wasn’t built in a day. 

So what are the changes that could potentially contribute to depression and anxiety? First, there’s sleep deprivation: there are few things more detrimental to the brain than lack of sleep. Then there are aesthetic concerns: metabolic changes can lead to weight gain (in particular, thickness round the middle), which in itself can become a problem, as well as causing self-esteem issues, which can lead to comfort eating and greater weight gain… It’s a vicious circle that can cause your mood to plummet.  

Depressive symptoms must be taken seriously. It is unusual for significant depression to appear for the first time after menopause, but in perimenopause, women can become more vulnerable to it. It has been shown that the risk for major depression around this time is greatest in women who have a history of depression or who have had an episode after childbirth (postpartum depression). Women experiencing problems with low mood around the time of their period (premenstrual dysphoric disorder) are also considered to be at greater risk for major depression in perimenopause. And some women can become depressed now for the first time in their lives. 

There are several theories that try to explain this increase in depression during perimenopause. One traditional psychological view is that “empty-nest syndrome” can lead to feelings of loss and sadness. More recently, scientists have focused on the biological effects of hormonal fluctuations on mood. This is the time when the ovaries begin to make less oestrogen. Oestrogen interacts with chemicals in the brain that can strongly affect mood. So in some women, the decrease in oestrogen in perimenopause can lead to depression. Hot flushes and insomnia can also contribute to emotional distress.  

What is depression? 

Depression is a disorder that affects a person’s ability to experience normal mood states. Mood disorders such as depression are believed to be caused by changes in brain chemistry; a tendency to depression can sometimes be inherited genetically. Physical or emotional stress (and menopause is quite a stress) can trigger the biological changes that occur in depression, especially in women who may be prone to it because of underlying brain chemistry or family history.  

The symptoms of major depression include: 

  • Depressed mood for large parts of the day, for a period of two weeks or longer  
  • Loss of interest in activities that you usually enjoy 

Other symptoms can include:  

  • Fatigue or lack of energy  
  • Restlessness or feeling slowed down  
  • Feelings of guilt or worthlessness  
  • Difficulty concentrating  
  • Trouble sleeping or sleeping too much  

What are the treatments for depression? 

Antidepressants are the most appropriate treatment for severe depression in perimenopausal women, but oestrogen may also be appropriate for mild to moderate symptoms, particularly if this is your first episode. In fact, many women experience some kind of low mood during the perimenopause transition and antidepressants are not appropriate first-line treatment for all of them.  

For most women, stabilising their hormones is enough to ameliorate mood symptoms. HRT can often be a solution. There are a number of other things you can do, too, in order to improve your mood. 

Tips to help you handle your fluctuating emotions: 

  • Exercise and eat healthily 
  • Find a self-soothing practice, such as yoga, meditation or breathwork 
  • Avoid alcohol or replace by a non-alcoholic spirits alternative
  • Engage in a creative outlet  
  • Stay connected with your family and community 
  • Nurture your friendships 

Remember, you are not alone. Low mood is very common during perimenopause: don’t hesitate to talk about it with someone you trust.  

Anyone can contact Samaritans FREE any time from any phone on 116 123, even a mobile without credit. This number won’t show up on your phone bill. Or you can email or visit 

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Meg's Quote

If you are depressed,
you are living in the past.
If you are anxious,
you are living in the future.
If you are at peace,
you are living in the present.
– Lao Tzu –

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