Depression or perimenopause

Perimenopause, which comes near the end of a woman's childbearing years but before the actual menopause, is the time in a woman's life when the levels of key hormones that control the reproductive system begin to change.

Perimenopause has recently gotten more attention than ever before. A growing body of research strongly suggests that the hormonal shifts that produce the physical and psychological symptoms commonly associated with menopause — such as hot flashes and mood swings — actually start (and can be more troublesome) during perimenopause. And for some women symptoms can develop at a relatively young age.

Menopause begins on the last day of a woman's final menstruation and is clinically confirmed after a year without periods. But the absence of menstruation, which is the most obvious sign of menopause, is only one aspect of the transition. Perimenopause, in fact, spans a few or many years leading up to menopause.

"The constant change of hormone levels during perimenopause can have a troubling effect on emotions," reports the American College of Obstetricians and Gynecologists. "Some women have mood swings, memory lapses and poor concentration. Some say they cry for no reason. Some feel irritable or are depressed."

More than 50 percent of women experience some perimenopausal symptoms before reaching the menopause, including depression.

During the perimenopausal phase of a woman's life the body's reproductive physiology is going through a tremendous series of changes and adjustments. Women, as a whole, are more vulnerable to physical and emotional problems during this time.

Studies illustrate this point. Of the 101 women studied, nearly one-third suffer from a depressive disorder. Of those, half are experiencing major depression, while the other half are experiencing a milder condition called dysthymia.

Theoretically, any increased risk of depression would result from "abrupt fluctuations" — surges and ebbs — of estrogen and progesterone levels in the bloodstream of perimenopausal women, Dr. Soares says. "It's like having high levels of progesterone and low levels of estrogen one day, and the next day, significantly higher levels of estrogen and lower levels of progesterone."

The links between hormonal fluctuations and physical symptoms during perimenopause are becoming clearer. Take hot flashes, for example. The temperature-regulating center in the hypothalamus [of the brain] appears to be influenced by estrogen and progesterone. Researchers speculate that during perimenopause the fluctuations of these hormones can cause the hypothalamus to regulate body heat less efficiently, he says.

Fluctuations in reproductive hormones are associated with depression at other points in the reproductive cycle. For instance, women may experience depressed or irritable mood in the premenstrual part of their cycle — which, depending on severity may be called either premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). In addition, some new mothers develop symptoms of depression in the days, weeks or months following the birth of their baby (the postpartum period).

Antidepressant medication and psychotherapy continue to be the treatments of choice for depression occurring during the perimenopausal period. Estrogen-replacement therapy can reduce symptoms of mild-to-moderate depression in some perimenopausal women, but this option is less attractive given the additional concerns about estrogen-replacement.

Doctors might consider estrogen for short-term treatment of depressive symptoms in some perimenopausal women, especially those who also are experiencing other symptoms, such as hot flashes.

But doctors warn that while estrogen may offer some women a two-for-one benefit — reducing physical and emotional symptoms — it's not the treatment of choice for every perimenopausal woman suffering from depression. Estrogen-replacement therapy comes with drawbacks, such as increased risk of breast and uterine cancer. Women who are severely depressed, should seek comprehensive psychiatric treatment, including an evaluation for traditional antidepressant therapy.

Each woman must carefully weigh the benefits and risks of even short-term estrogen-replacement therapy for the depression that occurs during perimenopause. Many women will want to consider consulting their primary-care physician, their gynecologist and a psychiatrist to help them make the best decision. Such factors as the specific symptoms, the medical and psychiatric history, and the family's medical history are very important.