We talk a lot about changes in the hormonal levels of estrogen, progesterone, and testosterone with menopause, and the symptoms that these hormonal changes can cause. While hormone replacement therapy (HRT) can help with a wide variety of physical and mental symptoms, we should also include a conversation about antidepressants for menopause and perimenopause. There’s a lot you should know.
The drop in the hormones estrogen, progesterone, and testosterone at perimenopause and menopause can directly impact a woman’s mood and feelings of stress, anxiety, and depression. Additionally, the combined effects of decreased estrogen, progesterone, and testosterone hormones can lead to lowered libido, weight gain, aging skin, vaginal changes, sleepless nights, hot flashes, low energy, poor self-image, and so much more…
What Should You Know About Antidepressants for Women in Their Middle Life (Menopause)?
You should know that the hormones that control your menstrual and menopause cycles also influence the levels of brain chemicals that promote feelings of calm, well-being, and happiness. With all the hormonal changes that happen at menopause, the change in brain chemicals can lead to increased irritability, anxiety, and depression.1
During perimenopause, falling hormone levels can trigger mood swings that make a woman less able to cope with events that she would normally let roll off her back. If left untreated, these hormonal dips can set off deep mood disorders and lead to depression. Unfortunately, many women do not recognize that anxiety, mood swings, and depression are all likely symptoms of peri- and menopause.
HRT for menopause and antidepressants can help reduce peri- and menopause sleep disorders, stress, anxiety, and depression. By treating the underlying source of these problems, which are menopausal hormone changes, you can start to feel rested, happier, and healthier.2,3,4
All women are used to dealing with hormonal changes. Whether it is puberty, your monthly cycle, postpartum (after giving birth), perimenopause, or menopause, women deal with the ups and downs of hormones for most of their lives. Because of these fluctuations, women are at a higher risk for depression than men. These hormone changes make women twice as likely as men to develop depression.5,6
While menopause is not a disease that has to be cured, it does have some pretty terrible symptoms. These symptoms can be alleviated with hormone replacement therapy. With a doctor’s consultation, HRT can also be combined with antidepressants. Untreated anxiety and mood disorders can lead to depression and can have profound consequences.
Benefits of Antidepressants With Menopause
Troublesome vasomotor symptoms, aka ‘hot flashes and night sweats,’ can interfere with your quality of life. While hormone replacement therapy is the mainstay treatment for hot flashes and night sweats, it might not be enough, or it might not be the right fit for you.4
While HRT is more effective than antidepressants for women who are experiencing hot flashes during their perimenopausal or early postmenopausal period, some may also benefit from antidepressants. For those who cannot take hormone replacement therapy because of medical concerns (contraindications to HRT), antidepressants can serve as an alternative to hormone therapy. Antidepressants are widely used and have a good safety record.
Many studies have shown the relationships between poor sleep, hot flashes, anxiety, sexual disorders, depression, and lowered hormone levels with menopause.7-11 Although the exact mechanism of how antidepressants improve these menopause symptoms is unclear, many have demonstrated their effectiveness. By normalizing the levels of hormones and treating depression, women can feel the benefits rather quickly after starting both HRT and antidepressants.
Transitioning from perimenopause to menopause is a complex physiological process that typically begins when a woman is in her mid to late 30s and lasts 5-6 years. It is during this time that there is an increased risk of developing depression and depressive disorder.8 Women frequently report symptoms of rapid mood changes or swings, irritability, stress, and nervousness during perimenopause.
It is also common for women to experience insomnia during perimenopause; partly because of nighttime hot flashes but also because of stress, anxiety, or mood changes. Poor sleep can make you up to 10 times more likely to become depressed.3 Both HRT and antidepressants are highly effective at treating sleep disorders that can lead to depression.
In addition to anxiety, poor sleep, and hot flashes, sexual dysfunction can increase during the menopausal transition. Commonly reported sexual problems include pain with intercourse (dyspareunia), reduced libido, and difficulty achieving arousal and orgasm.8
Menopause and Mood Disorders
Menopausal hormone fluctuations are problematic. Add into the mix a woman’s life stresses, interrupted sleep, weight gain, and signs of aging and you have created a perfect situation for emotional distress, which can lead to anxiety, mood swings, and depression. Menopausal women often report symptoms of depressed mood, stress, anxiety, and a decreased general happiness. Those are not feelings that should be ignored or that you should have to endure.
This phase of a woman’s life often marks significant life changes that can adversely impact their mental health too.3 Children leaving for college, helping aging/ailing parents, facing increased career demands, and now Covid-19.4 This combination of physical and environmental changes poses an increased risk of suicidality.3
Anxiety, moodiness, and depression are some of the most commonly reported issues in women aged 42-52. But there is a recognition gap between these symptoms and their relationship to menopause. This confusion may be due to a stigma surrounding menopausal transition, loss of youth, or vitality. Additionally, when the words “moody,” “anxious,” and “depressed” are used, it sounds like an insult. Who would even want to admit to feeling this way?
To add to the confusion, the psychological symptoms of perimenopause often start to occur about five years before the more obvious physical symptoms of menopause. The lack of obvious physical symptoms for women in their late 30’s and into their 40’s often leads them to say, “Oh, I’m not in menopause!” and they will not seek treatment for the mental changes associated with perimenopause.
At its most extreme, when hormone levels are off, depression can set in, and suicide can follow. Many of the depressive disorders that lead to suicide are often overlooked or misunderstood. There is a significantly higher rate of mental illness and suicide when women experience perimenopause and menopause.1 The seriousness of mental health issues during perimenopause cannot be ignored. Suicide rates among menopausal women have increased by 45% over the past 15 years.2 The risk for depressive symptoms is elevated even in women with no prior history of depression.2
Perimenopausal women may still experience regular monthly periods and then move to an occasional period. This delay in recognizing the mental symptoms, and waiting for the more obvious physical symptoms (hot flashes or end of menses), often makes the diagnosis of perimenopausal depression retrospective. In other words, women-only realize they were suffering unnecessarily after the fact. Women that don’t recognize perimenopause for what it is being left to suffer unnecessarily for years and years!
Perimenopause impacts both a woman’s mind and her body. It is critically important for women who are experiencing anxiety and depression in their late 30s and early 40s to recognize that they may be in perimenopause and that treatment is available.
The good news is that there are effective treatments if a woman’s medical history allows. Anxiety and depression can be abated with HRT, antidepressants, or both.1 It is common for women with perimenopausal symptoms to experience depressive symptoms that do not meet the ‘clinical criteria’ for depression, and antidepressants may not be warranted. However, their low-level depressive symptoms can be treated with hormone replacement therapy, and anxiety and mood can definitely be improved.5
Most women with perimenopausal depression respond to appropriate HRT treatment, and they should not fear trying it. It is no longer acceptable to deem this type of perimenopausal depression as minor or presume it will improve with time. The process of going through perimenopause and menopause can take well over a decade to complete. And unlike hot flashes that tend to improve over time, untreated depression often does not.
Perimenopause is a very vulnerable time for women. There is no need for a woman or their families, and colleagues to suffer unnecessarily with these perimenopausal and menopausal symptoms. If left untreated, depression can significantly impact a woman’s quality of life and that of her family.4 This phenomenon is one that has been ignored for far too long. If it is continued to be neglected, the mental health, physical health, and general well-being of women and their families alike will continue to suffer. Suicide in middle-aged women is becoming a more common occurrence. It can be prevented with increased awareness of the root causes and the availability of all of the options for treatment.
What is an Antidepressant? What is The Best Antidepressant for Menopause Depression?
Beyond hormone replacement therapy to treat menopausal mood changes, anxiety and depression, there is also the option to choose non-hormonal drug therapies which have been shown to reduce some of the more frustrating symptoms of menopause.8 The most commonly talked about non-hormonal drugs used as antidepressants include gabapentin, pregabalin, and clonidine which can also help to reduce hot flashes, night sweats, and insomnia.
There are several classes of antidepressants, but the most often used are serotonin and noradrenaline reuptake inhibitors (SNRIs), and selective serotonin reuptake inhibitors (SSRIs). They are the most well-investigated group of non-hormonal antidepressants for the treatment of hot flashes. SSRI antidepressants work by increasing levels of serotonin within the brain. Serotonin is a neurotransmitter that is often referred to as the “feel-good hormone.” SNRIs are effective at treating depression, anxiety disorders, and long-term (chronic) pain.
How Antidepressants Work
The exact mechanism of how SSRIs and SNRIs decrease menopausal symptoms is unclear, but women taking them often swear by their effectiveness.8 Some studies of SSRIs and SNRIs have demonstrated that 50-60% of women taking them have noticed benefits in reducing hot flashes and night sweats.8
While we don’t know the specific physiological reason for antidepressant effectiveness, we do know that when estrogen drops, like during menopause, there is a decrease in the level of endorphins. Endorphins are chemical messengers that can reduce stress and regulate feelings of happiness, and even euphoria.
When there is a reduction in estrogen, there is also a reduction in endorphin production. If endorphin levels are very low, the body temperature increases. If the endorphins are very high, then there is a decreased body temperature.4 As hormone levels go up and down (mostly down) with menopause, your body may reset its thermostat set point - which can lead to your body thinking it is hot or cold when it actually isn’t. The result is an overreaction, a hot flash or night sweat, to an internal thermostat that is out of whack.8
In women with underlying depression, hot flashes, and night sweats taking antidepressants can reduce the number of hot flashes and improve their ability to cope with their overall mood and depression.8
Side Effects of Antidepressants
Gabapentin and pregabalin can cause dizziness. Clonidine can have some side effects including hypotension, dizziness, and rebound hypertension.8 SNRIs can potentially elevate blood pressure and regular monitoring of blood pressure is needed. Because of the variable adverse effects and efficacy of SSRIs and SNRI drugs, if any one of these drugs is not effective or well-tolerated, another drug can be prescribed.8
Sexual Side Effects of Antidepressant Drugs
While women in peri- and menopause may already be suffering from sexual dysfunction symptoms due to reduced hormones, the addition of SSRIs may have some sexual side effects that include diminished sexual desire, trouble achieving and maintaining arousal, and difficulty achieving orgasm. Depression can be both a cause and a result of sexual problems.12 About 50% of people taking SSRIs report some sexual dysfunction, but some SSRIs cause less sexual dysfunction than others. Some SSRIs actually increase sexual drive and arousal in women. Ask your doctor about which medication is best for you.
SSRIs (and other antidepressants) can also cause drug interactions that should not be taken lightly. Always consult a physician before taking prescription medications, changing dosages, or considering stopping. This is a delicate balancing act. Any changes in antidepressant therapy or dosing should be done only in consultation with your healthcare provider. Be sure to ask your healthcare provider about which SSRI might be best for you.
SUMMARY
There are several effective types of antidepressants for menopause. The first way to treat depression is with hormone replacement therapy. When hormones are in balance, neither too high nor too low, women can look and feel their best. But when hormones are not balanced, a range of symptoms can occur including fatigue, trouble sleeping, anxiety, irritability, and depression. This can be just the beginning of a cascade of menopausal symptoms.
Here at Winona, menopausal symptoms can be prevented, treated, and reversed, with a proactive HRT approach that deals with the natural decreases in the hormones estrogen, progesterone, and testosterone. Lifestyle adjustments can also help reduce perimenopause symptoms and promote good postmenopausal health.
Paying attention to healthy eating habits and leading an active lifestyle is important to feelings of wellness and be effective antidepressants for menopause. Healthy habits include eating a nutritious diet and limiting caffeine and alcohol consumption.
Beyond hormone replacement therapy to treat depression, there is also the option to choose non-hormonal drug therapies, the most often used are SNRIs and SSRIs.
For many women, reaching menopause is a relief, and once the hormones settle down, the mood fluctuations and anxiety will too.
