It is well established that women are at increased risk for developing depression compared to men.  It has been hypothesized that this vulnerability to depression may be hormonally mediated, and several longitudinal studies have documented an increased risk of depressive symptoms during perimenopause or the menopausal transition.  Based on the results of two prospective cohort studies, approximately one-third of women will develop their first episode of depression during the menopausal transition.  (Cohen LS et al 2006, Freeman EW et al 2006).

Studies investigating the relationship between hot flashes, a hallmark vasomotor symptom of the menopause transition, and depression have indicated that hot flushes and night sweats are associated with depression in perimenopausal womenA recent large cross-sectional population-based survey of midlife women has attempted to better understand the impact of depression on menopausal symptoms.

This study included a sample of women (ages 45-70), who were obtained randomly from two large health plans, one in Washington State and the other in Massachusetts.  The majority of the 2530 eligible women had previously taken hormone replacement therapy and had since discontinued it.  Women who were taking SSRI or SNRI antidepressants were included.  Of the 2530 eligible women, 1358 women completed the telephone survey examining depressive symptoms using the Patient Health Questionnaire (PHQ-8) and the Wiklund Menopause Symptom Checklist. 580 of these women were taking hormone replacement therapy and were excluded from the analysis, as were another 8 women with unknown menopausal status.

A total of 770 women were included in the analysis, and it was observed that 98 (12.7%) of the women reported moderate to severe depressive symptoms.  After adjusting for age and body mass index, those women with moderate to severe depressive symptoms were almost twice as likely to report recent vasomotor symptoms (hot flashes or night sweats) than the women with no or mild depressive symptoms.

Women with severe depression were also more likely to report their vasomotor symptoms as severe, despite the fact that 20% of those women were also taking either an SSRI or SNRI, agents which have been shown to improve vasomotor symptoms.  The women who experienced moderate to severe depression were also more likely to experience feeling anxious at least 50% of the time.

This study is the first to demonstrate a correlation between the severity of depressive symptoms and the intensity of menopausal symptoms. The authors concluded that depressive symptoms “amplified” or were associated with more severe vasomotor symptoms, but they also noted that this study could not rule out the possibility that more severe vasomotor symptoms were in fact worsening the depressive symptoms.

This study has a few limitations including the fact that all the information was based on self report and some women were taking SSRI or SNRI antidepressants.  (The brands and dosages were not included in the results).  Also because women who were on hormone therapy were excluded, it is not known what impact hormonal replacement therapy may have on depressive symptoms.  Longitudinal studies comparing depressed and non-depressed women as they transition into menopause may help to further delineate the relationship between menopausal symptoms and depression.

While some questions remain, these findings underscore the importance of screening for depressive symptoms in perimenopausal women.  Depression is a relatively common problem in this population, particularly in those with more severe vasomotor symptoms.  The authors point out that recognition and treatment of depression in women during the menopause transition may reduce the burden of menopausal or vasomotor symptoms.

April Hirschberg, MD

Cohen LS, Soares CN, Vitonis AF et al. Risk for new onset of depression during the menopausal transition: the Harvard study of moods and cycles. Arch Gen Psychiatry 2006; 63: 385-90.

Freeman EW, Sammel MD, Lin H et al. Associations of hormones and menopausal status with depressed mood in women with no history of depression. Arch Gen Psychiatry 2006; 63:375-82.

Reed SR, Ludman EJ, Newton KM et al. Depressive symptoms and menopausal burden in the midlife. Maturitas 2009; 62: 306-310.