Menopause transition does not increase risk for depressive symptoms for all women
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Key takeaways:
- Studies are inconclusive as to whether women have a higher risk for depressive symptoms during menopause transition.
- Providers should be aware of risk factors that may increase depression risk during menopause.
Women are not universally at risk for depressive symptoms during menopause transition, but providers should be aware of risk factors and treat mental health disorders promptly, according to a review published in The Lancet.
Researchers conducted a review of prospective studies that assessed changes in mental health symptoms and disorders from before menopause until after menopause. Not all women are at risk for depressive symptoms during menopause transition, but researchers were able to identify several psychosocial and menopause-related factors that may lead to an increased risk.
“Clinicians should not automatically assume that psychological symptoms at midlife are attributable to menopause, and instead investigate symptoms as they would at any other life stage,” Lydia Brown, PhD, MPsych, senior lecturer in the School of Psychological Sciences at the University of Melbourne in Australia, told Healio.
Brown and colleagues reviewed studies assessing menopause and depressive disorders published from 1990 to July 1, 2023. Studies were obtained from the MEDLINE, Embase and PsycINFO databases.
There were 12 studies that investigated associations between menopause transition and depression. An association between menopause and depression tends to be widely promoted, but some self-reported symptoms that are defined as depressive may be related to other causes, the researchers wrote. Of the 12 studies, only two defined depression as major depressive disorder. One study found menopause increased risk for major depressive disorders for women who had a previous episode of major depressive disorder, but no increased risk was observed for first lifetime episode of major depressive disorder. The second study found no association between major depressive disorder for perimenopausal or postmenopausal people.
“Women with a history of major depressive disorder may be at risk of recurrence during the menopause transition,” Brown said. “Clinicians should be cautious about discontinuing active treatments for depression at this time.”
Findings on depressive symptoms during menopausal transition were mixed. Of the 12 prospective studies, two reported an increased risk for depressive symptoms during menopause, three found no association, and seven found mixed results. Researchers also found no evidence supporting increased anxiety during menopause transition. No prospective studies have assessed other mental health disorders such as bipolar disorder or schizophrenia during menopause transition.
The authors wrote that there is no substantive evidence of an association between attempted or completed suicide and menopause transition. However, one longitudinal study found women using menopausal hormone therapy have a higher risk for attempted and completed suicide.
Risk factors for depression
The authors identified risk factors for depressive symptoms during menopause transition. Some psychosocial stressors that increase the risk for depressive symptoms include financial problems, unemployment, poor social support and stressful life events. Other risk factors include adverse childhood experiences, being from a racial-ethnic minority group, higher BMI, neuroticism and lifestyle behaviors such as smoking and lack of physical activity.
Some menopause-related factors may also be associated with an increased risk for depressive symptoms, according to the authors. Some studies found surgical menopause is linked to a higher risk for depressive symptoms than hysterectomy alone. Women with premature or early menopause may also have a higher risk for depressive symptoms.
The presence and frequency of vasomotor symptoms is bidirectionally associated with depressive symptoms, according to a systematic review of 33 studies. Some studies found estradiol variability, low progesterone levels and changes in testosterone-to-estradiol ratio are linked to an increased risk for depressive symptoms, but the associations have not been consistently replicated, according to the authors. Women with more negative attitudes toward menopause and aging may also be more likely to experience depressive symptoms.
Treating mental health during menopause
The authors outlined several recommendations for diagnosing and treating depressive symptoms during menopause. For diagnosis, Brown said providers should not immediately attribute depressive symptoms to menopause itself and investigate it as they would during any other life stage.
“Clinicians can wrongly assume that depressive disorders are caused by menopause without doing a full assessment,” Brown said. “They may prescribe HT instead of gold standard evidence-based treatments for depression. This can lead to delays in treatment for depression, and therefore an unnecessary burden on women.”
Providers should be aware of risk factors that may increases one’s risk for depression during menopause, Brown said.
“Some risk factors relate specifically to the menopause and others are unrelated to the menopause,” Brown said. “Clinicians should consider treating modifiable risk factors, such as severe hot flashes, with evidence-based treatments.”
Brown acknowledged that research on mental health during menopause is still lagging behind and more studies are needed to build stronger evidence.
“We need more high-quality prospective studies that track changes in mental health symptoms and disorders from pre- to post-menopause to improve our understanding of the relationship between menopause and mental health,” Brown said. “These studies need to use validated measures of mental health symptoms and disorders, not just yes or no checklists. More research on the mental health experience of transgender men and gender-diverse people is also needed, as well as studies from low- and middle-income countries.”
For more information:
Lydia Brown, PhD, MPsych, can be reached at lydia.brown@unimelb.edu.au.
Perspective
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The authors provide an excellent summary of prospective studies on menopause and depressive symptoms and mood disorders. They help clarify that the rate of depressive symptoms may be increased during the menopause transition, but that it is not universally experienced. They also provide reassuring evidence that other more serious psychiatric disorders, such as bipolar disorder and suicide risk, are not found to be increased. Furthermore, the authors nicely outline risk factors for depression at menopause, including a surgical menopause (the sudden and complete loss of ovarian hormones and the psychological consequences of early menopause), a prior history of major depression and numerous psychosocial stressors (poor social support, stressful life events, being from a minority ethnic group, adverse childhood events, higher BMI and lifestyle behaviors), most of which have been found to increase risk throughout life.
However, I disagree with their take-home messages. I believe it is paternalistic to express concern that to highlight a potential increased risk for depressive symptoms will “negatively influence expectations and experiences of women.” Instead, I believe it is important to validate the experience of women who are having depressive symptoms and, hopefully, encourage them to seek treatment for their condition. Being made aware of the possible reasons (windows of hormonal vulnerability, sleep disturbances impacting mood, and vasomotor symptoms negatively impacting mood) may help them feel less stigmatized or ashamed by these symptoms and less likely to suffer in silence.
Midlife women’s health concerns already often go unassessed and undertreated. I believe the authors’ fear is misplaced. We as practitioners should not fear that midlife women who present with symptoms of depression will be sent away with a prescription for hormone therapy, which is already underutilized in almost all medical settings. Many menopausal women are prescribed antidepressants regardless of whether they even have mood symptoms for vasomotor symptoms when, in fact, they are good candidates for HT.
While some perimenopausal (not postmenopausal) women may experience improvement in depressive symptoms with estrogen therapy, depression is not an FDA-approved treatment for that indication. Moreover, with reproductive-related depressive episodes, such as premenstrual dysphoric disorder and postpartum depression, even when hormone variations are implicated as a likely etiologic factor, first-line treatment is not HT, but rather evidence-based treatments for depression, including psychotherapy, antidepressants or a combination, treating sleep disturbance and recognizing the many psychosocial risk factors for depression.
In my opinion, the key take-home message should be that asking about symptoms of menopause, including depressive symptoms, opens the door for a dialogue about menopause. This would be one step forward to providing women with the necessary tools to be educated self-advocates.
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