Perimenopausal Depression – A Review of Diagnosis and Management
Perimenopause includes early and late phases of menopausal onset and early transitions during postmenopause.
The WHO defines perimenopause:
The term perimenopause should include the period immediately before the menopause (when the endocrinological, biological and clinical features of approaching menopause commence) and the first year after menopause. [WHO Scientific Group 1996]
The WHO uses menopausal transition to include only perimenopause before the final menstrual period.
Stages of Menopausal Transition: [Harlow et al.,2012]
- Early menopausal transition: persistent difference of 7 days or more in the length of consecutive cycles, or one more skipped cycles
- Late menopausal transition: longer periods of amenorrhea; when they last 60 days or longer, 1-3 years
- Postmenopause: 1 year of amenorrhea (also divided into early and late); Early menopause lasts approximately 5-8 yrs.
The diagnosis of perimenopausal depression is therefore often made retrospectively. There are no definitive endocrine markers of perimenopause as hormonal changes are highly variable. Low Estradiol levels, however, characterise Postmenopause.
To complicate matters, the physical symptoms of menopause often present much later (up to five years) than the psychological symptoms.
Symptoms may include night sweats, hot flushes, vaginal dryness, decreased libido, insomnia, anxiety, and joint pain. These can make women more vulnerable to different types of depression. [Dennerstein et al., 2000]
Problematic menopause affects approximately 1.5 million women every year, and symptoms often co-occur and overlap with psychiatric symptoms, making accurate diagnosis and treatment difficult. [Cohen et al., 2006], [Maki et al., 2018]
Recent literature suggests that perimenopausal depression is a unique subtype of depression, with characteristic symptoms, aetiology, and course distinct from other depression subtypes.
In 2015 the Board of Trustees for the North American Menopause Society (NAMS) and the Women and Mood Disorders Taskforce of the National Network of Depression Centres developed a new clinical practice guideline for assessing and managing perimenopausal depression. [Maki et al., 2018]
Harlow, S. D., Gass, M., Hall, J. E., Lobo, R., Maki, P., Rebar, R. W., Sherman, S., Sluss, P. M., de Villiers, T. J., & STRAW 10 Collaborative Group (2012). Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. Menopause (New York, N.Y.), 19(4), 387–395.
Maki, P. M., Kornstein, S. G., Joffe, H., Bromberger, J. T., Freeman, E. W., Athappilly, G., Bobo, W. V., Rubin, L. H., Koleva, H. K., Cohen, L. S., Soares, C. N., & Board of Trustees for The North American Menopause Society (NAMS) and the Women and Mood Disorders Task Force of the National Network of Depression Centers. (2018). Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. Menopause (New York, N.Y.), 25(10), 1069–1085.
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