The menopause transition can be a challenging time for women, bringing about changes in physical wellbeing, including vasomotor symptoms, sleep disturbance and vaginal dryness. Women may experience significant psychosocial change, including loss of identity associated with family, employment and reproductive changes. This article provides an overview of the mental health implications of the menopause transition and outlines important points for clinical practice in providing comprehensive care in the menopause setting.

Symptoms

Mood disturbance associated with the menopause transition may present with a variety of symptoms. Studies in this setting often use screening tools such as the Center for Epidemiologic Studies Depression Scale Revised (CESD-R) to classify symptoms, which may include low mood, sleep disturbance, loss of appetite, low libido, feelings of worthlessness and loss of interest in usual activities.

Depressive symptoms may be of significant severity to amount to a depressive disorder. However, some depressive symptoms, including sleep disturbance and low libido, are common experiences of menopause independent of mood disturbance. This distinction is clinically significant for the provision of patient-focused care, guiding management decisions and monitoring response to treatment. Furthermore, it highlights the broad nature of menopausal symptoms and the potential clinical value in creating menopause-specific tools for mental health.

Potential causes

There is extensive evidence of the connection between the menopause transition and depressive symptoms. Several longitudinal studies have shown that women in the menopause transition are up to twice as likely to experience a depressive disorder, compared to the premenopausal period, independent of a history of depression, with an overall prevalence that may be as high 40 per cent.1, 2, 3, 4

Data regarding the postmenopausal period is conflicting. Bromberger et al and Mulhall et al have demonstrated increased risk of having a depressive disorder during the postmenopausal period.5, 6 However, observational data from Freeman et al showed that this was only the case for women with a history of depression, who were eight times more likely to have postmenopausal depression. In contrast, women with no prior history of depression who experienced a perimenopausal depressive disorder had no higher risk of postmenopausal depression than women who had not had any depressive symptoms associated with the menopause transition.7

There is no high-level evidence demonstrating a clear relationship between basal hormone levels and symptom onset. However, there are several factors clearly suggesting a hormonal basis to the disorder. Depressive symptoms in the menopause transition remain prevalent in the absence of a history of mental illness. There is extensive data from both animal and human studies demonstrating the involvement of ovarian steroids in neuroregulatory pathways, particularly those involving serotonin and noradrenaline, known to be implicated in depression.8 There are also randomised controlled data demonstrating significant improvement in depressive symptoms with the use of hormonal replacement therapy9, 10 and, moreover, recurrence of depressive symptoms in women with perimenopausal depression following withdrawal of hormone treatment.11

There are several other aspects to the menopause transition involved in the development of depressive symptoms. Worsley et al undertook a systematic review that demonstrated the relationship between depressive and vasomotor symptoms during the menopause transition. The presence of vasomotor symptoms increased the risk of developing depressive symptoms and depressive symptoms increased the prevalence of vasomotor symptoms.12

Poor sleep quality during the menopause transition has also been implicated. Vasomotor symptoms may predispose to depression by reducing sleep quality. However, evidence has been conflicting and reduced sleep quality occurs during this time independent of vasomotor symptoms.13, 14, 15, 16

Management

Depressive symptoms during the menopause transition are multifactorial and treatment should address the individual history and clinical experience. Antidepressants remain first-line pharmacological treatment in the management of perimenopausal mood disturbance. Oestrogen hormonal therapy has been shown to be effective in improving depressive symptoms in perimenopausal women.17, 18, 19 However, a clinical consideration is the need for concomitant progesterone therapy for women with an intact uterus, which has been shown to potentially worsen depressive symptoms.20While hormonal therapy may offer additional benefit to mood disturbance when used for the treatment of vasomotor symptoms, current guidelines advise against the use of hormonal therapy for the primary treatment of perimenopausal depressive symptoms.21

Consideration should also be given to the use of psychological management to address the biopsychosocial issues arising during the menopause transition. Cognitive-behavioural therapy has been shown to be effective in improving both physical and psychological symptoms of menopause and is an important alternative or adjunct to pharmacological treatment.22

Conclusion

The menopause transition involves a challenging period of physical and psychological change for many women. Clinicians should be mindful of predisposing factors for developing perimenopausal mood disturbance, such as a history of depressive disorders, including postnatal depression and premenstrual mood disturbance. Comprehensive, patient-focused care requires an understanding of the symptoms of menopause and depression and a targeted approach to managing the individual experience of both.