Depression
Depression is defined as persistent negative emotions that affect one’s ability to feel, think, or act. An increase in depressive feelings may result in extreme tiredness; lack of energy; loss of interest in normal activities; sadness or an “empty” feeling; a sense of helplessness or hopelessness; feelings of guilt; or, difficulty in decision-making. In severe cases, symptoms may result in chronic insomnia or persistent thoughts about death. To be clinical in nature, depression will cause emotional or physical problems affecting daily life functions for a sustained period of time.
During menopause, up to 20% of women experience periodic depression.
The onset of depression tends to be more common during peri-menopause than post-menopause, and women who have a previous history of mental health troubles or clinical depression are at higher risk to developing depression during peri-menopause. The good news is that, as estrogen levels stabilize in post-menopause, mood related disorders experienced during the peri-menopausal stage normally recede in the absence of an underlying major depressive disorder. It is important to recognize that peri-menopause is a time of vulnerability to depression for many women and it is important to seek help if you are suffering from any of these feelings.
Why is this happening?
Depression and the mood-regulating aspects of a woman’s physiology is affected by hormonal fluctuations. A woman’s endocrine system (the system that regulates biological processes through hormone releasing glands) works with her nervous system (hypothalamic-pituitary system) to create physiological wellness. Any imbalance can result in physical and mental effects, and we know that peri-menopause alters the levels of estrogen, progesterone, and serotonin in a woman’s body.
Additional hormones affected by menopause that may cause troubles regarding neurotransmission, resulting in mood-based dysfunction, are progesterone and GABA. During peri-menopause, progesterone levels are declining and can lead to changes in a woman’s sense of emotional stability. When progesterone is metabolized, it produces GABA (a receptor agonist called Gamma-Aminobutyric acid) in order to regulate emotions, moods, and sleep. During times of lowered progesterone and GABA, anxiety, depression, and sleep disorders may increase.
Depression is linked to an increased risk of self-harm and social isolation
That’s why it is important that early indicators are assessed for an accurate diagnosis. If behavioral symptoms are interfering with normal daily activities, cognitive functions, or are disrupting relationships, it is important to seek a healthcare evaluation.Particularly if you are having suicidal thoughts or persistent thoughts about death, you may be experiencing the effects of depression and will benefit from early and accurate diagnosis and possible treatment alternatives. Depression is a common by-product of hormonal fluctuations and should not be associated with negative feelings of shame or deficiency. With compassionate medical treatment, clinical depression is manageable.
Other impacted areas
There are a few behavioral changes that may be triggered by, or positively correlated with, depression: Changes in appetite, slowed movements or speech, feelings of lack of worth or guilt. This is in addition to other general menopausal symptoms that are often inter-related with depression are:
- Mood swings
- Anxiety
- Irritability
- Fatigue and/or lack of energy
- Sleep disturbance, particularly difficulty falling asleep and oversleeping
- “Brain fog” & difficulty concentrating
- Decreased libido
Diagnosis
Medical professionals have accurate diagnostic tests to evaluate self-reported symptoms. Doctors and therapists use a scale-of-severity testing method to determine if symptoms are chronic or temporary.
Clinical diagnosis of depression, prior to or during menopause, involves the assessment of key characteristics. The DSM-V diagnostic assessment involves a series of self-reported answers to standardized questions. If a woman reports more than a threshold number of affirmative answers for a duration of longer than two weeks, she may be diagnosed with clinical depression requiring treatment. The existence of occasional depressive thoughts or cyclical (hormonal related) depressive episodes is not sufficient evidence to prove clinical depression, but you can still receive treatment.
Possible triggers or risk factors
The strongest predictor for depression during menopause is a prior depressive episode or period, particularly if it was related to your hormonal cycle. However, any women with a history of mental health diagnoses is at higher risk for developing menopausal depression. Vasomotor symptoms and anxiety are also known to modulate the risk for menopausal depression.
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Treatments & remedies
Menopause can feel like an upside-down time of life, but it’s important to understand you are not alone, you are not going crazy and a variety of excellent treatment alternatives is available. In addition to the supplement and pharmaceutical alternatives described below, there are other therapies that have excellent efficacy rates, either in isolation or combination. Cognitive Behavior Therapy (CBT) and other forms of counseling, intentional reduction of life stressors, and engaging proactively in self-care activities are among the important alternatives to consider.
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Nutrition
General guidelines for an optimal diet, whether experiencing menopause, clinical depression, or both, includes:
- Adequate hydration at all times
- Balanced foods, ideally focused on a Mediterranean diet (whole grains, fruits, vegetables, seafood, beans, nuts)
- Elimination of tobacco products
- Reduction or elimination of caffeine and alcohol
Exercise
Throughout menopause, a woman’s goal should be to lead a healthy and activate lifestyle to minimise the impact of menopausal symptoms. Regular aerobic exercise is a key component of this and necessary to maintain best-possible hormonal balances, body weight, muscle mass, bone density, and cardiovascular health. Exercise and a positive sense of mental wellbeing are closely related. Mood improvement has been shown to accompany even mild exercise routines such as daily walking.
During menopause, light-exercise (such as stretching, yoga, walking) was found to be positively correlated with a reduction in self-reporting of depression symptoms. Although moderate-to-intensive exercise may be associated with an increase in other menopausal symptoms, such as hot flashes, light-exercise did not lead to additional negative effects.
Mindset
-
Supplements
There are many foods and nutrients that are felt to relieve feelings of depression, however they have not been adequately studied for women suffering from clinical menopausal depression. Some of these options include:
- Ginseng (tea, powder, extract)
- Maca root
- Red clover (isoflavones)
- Black cohosh
There is limited clinical evidence that St. John’s wort (hypericum perforatum) is effective in treating mild and moderate depression. However, if you decide to take this it is imperative that you tell your doctor as St. John’s wort can interact in dangerous, sometimes life-threatening ways with a variety of medicines.
OTC Products
Currently there are no scientifically proven effective over-the-counter products for the relief of depression.
Prescription
For hormone related depressive symptoms, antidepressant medication in combination with lifestyle improvements, alternative therapies, and/or hormonal treatments can be effective. When speaking to your physician you should make sure s/he is fully informed regarding all prescription and non-prescription drugs being taken before an accurate and safe antidepressant regime can be prescribed.
- The most commonly prescribed medication for anxiety and depression are SSRIs and SNRIs. Both are frequently referred to as antidepressant medication, even though they’re effective and therefore prescribed to help manage a range of mental health related symptoms. Please note that these medications take time to reach effectiveness and it is important to work closely with your doctor to establish optimal dosage. For more in depth information on how this type of medication works, the difference between SSRIs and SNRIs and side effects please refer to this article.
Hormone Treatment
It is unclear how HRT improves mood and relieves depression, but estrogen levels are related to the neurotransmitters in the brain which control everything from body temperature to sleep regulation. There are three types of hormonal treatment options that have been clinically proven to help women suffering from hormone related depressive feelings:
- Oral contraceptive pills - frequently prescribed to women in pre and early peri-menopause.
- Hormonal Replacement Therapy (HRT) - is prescribed to women that are peri-menopause or post menopausal.
Holistic Treatment
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FAQ
What are the symptoms of Menopause?
There are roughly 34 symptoms of Menopause with the most commonly experienced being:
- Irregular periods
- Vaginal dryness
- Hot flashes
- Night sweats
- Fatigue
- Sleep problems
- Mood changes and irritability
- Weight gain
- Thinning hair and dry skin
Medically reviewed and detailed symptom fact sheets can be found here, and a general overview of what (peri) menopause is and entails can be found here.
What is the average age of Menopause?
The average age for menopause in Asian women (including women in Singapore) is 50 - 52. The onset of peri-menopause is usually in a women's mid 40s, with 3.7% of women experiencing it before the age of 30.
What are the symptoms of Menopause?
There are 34 different symptoms associated with the Menopause transition impacting women on a mental, emotional and physical level. Symptoms range from the well known Hot Flashes & Night sweats, to depression, anxiety and a dry itchy skin. For and overview of all symptoms and detailed symptoms fact sheets please click here.
Do men get Menopause?
The short answer is No. “Male Menopause” or “andropause” are terms that are being used by the media, but have no medical basis. Testosterone levels in men do decline as they age, but this is a very gradual process at less than 2% per year starting from their 30s/40s. There is no sudden drop in Testosterone around midlife causing severe symptoms as is the case with Menopause. In many cases the symptoms that are claimed to be part of “male menopause” have nothing to do with (a change in) hormones.
References
Freeman, E. W. (2015). Depression in the menopause transition: risks in the changing hormone milieu as observed in the general population. Women’s Midlife Health, 1(1).
Gordon JL, Girdler SS. Hormone replacement therapy in the treatment of perimenopausal depression. Curr Psychiatry Rep. 2014 Dec;16(12):517. doi: 10.1007/s11920-014-0517-1. PMID: 25308388.
Graziottin A, Serafini A. Depression and the menopause: why antidepressants are not enough? Menopause Int. 2009 Jun;15(2):76-81. doi: 10.1258/mi.2009.009021. PMID: 19465674.
Joffe H, de Wit A, Coborn J, Crawford S, Freeman M, Wiley A, Athappilly G, Kim S, Sullivan KA, Cohen LS, Hall JE. Impact of Estradiol Variability and Progesterone on Mood in Perimenopausal Women With Depressive Symptoms. J Clin Endocrinol Metab. 2020 Mar 1;105(3):e642–50. doi: 10.1210/clinem/dgz181. PMID: 31693131; PMCID: PMC7075107.
Kai Y, Nagamatsu T, Kitabatake Y, Sensui H. Effects of stretching on menopausal and depressive symptoms in middle-aged women: a randomized controlled trial. Menopause. 2016;23(8):827-832. doi:10.1097/GME.0000000000000651
Maki PM, Kornstein SG, Joffe H, Bromberger JT, Freeman EW, Athappilly G, Bobo WV, Rubin LH, Koleva HK, Cohen LS, Soares CN; 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. Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. Menopause. 2018 Oct;25(10):1069-1085. doi: 10.1097/GME.0000000000001174. PMID: 30179986.
Soares CN. Depression and Menopause: An Update on Current Knowledge and Clinical Management for this Critical Window. Med Clin North Am. 2019 Jul;103(4):651-667. doi: 10.1016/j.mcna.2019.03.001. PMID: 31078198.
Soares CN. Depression and Menopause: Current Knowledge and Clinical Recommendations for a Critical Window. Psychiatr Clin North Am. 2017 Jun;40(2):239-254. doi: 10.1016/j.psc.2017.01.007. Epub 2017 Mar 6. PMID: 28477650.
Soares CN. Mood disorders in midlife women: understanding the critical window and its clinical implications. Menopause. 2014 Feb;21(2):198-206. doi: 10.1097/GME.0000000000000193. PMID: 24448106.19465674.
As Menopause Nears, Be Aware It Can Trigger Depression And Anxiety, Too. (2020, January 16). NPR.
Depression in the menopause transition: risks in the changing hormone milieu as observed in the general population. Women’s Midlife Health, 1(1).
https://psychiatry.org/patients-families/depression/what-is-depression
http://www.menopause.org/docs/default-source/agm/roussos-ross-k-2017-slides.pdf
https://www.aafp.org/afp/2018/1015/p508.html
https://www.menopause.org/for-women/menopauseflashes/mental-health-at-menopause/depression-menopause
Depression
Depression is defined as persistent negative emotions that affect one’s ability to feel, think, or act. An increase in depressive feelings may result in extreme tiredness; lack of energy; loss of interest in normal activities; sadness or an “empty” feeling; a sense of helplessness or hopelessness; feelings of guilt; or, difficulty in decision-making. In severe cases, symptoms may result in chronic insomnia or persistent thoughts about death. To be clinical in nature, depression will cause emotional or physical problems affecting daily life functions for a sustained period of time.
During menopause, up to 20% of women experience periodic depression.
The onset of depression tends to be more common during peri-menopause than post-menopause, and women who have a previous history of mental health troubles or clinical depression are at higher risk to developing depression during peri-menopause. The good news is that, as estrogen levels stabilize in post-menopause, mood related disorders experienced during the peri-menopausal stage normally recede in the absence of an underlying major depressive disorder. It is important to recognize that peri-menopause is a time of vulnerability to depression for many women and it is important to seek help if you are suffering from any of these feelings.
Dr. June Tan Sheren
Why this is happening
Depression and the mood-regulating aspects of a woman’s physiology is affected by hormonal fluctuations. A woman’s endocrine system (the system that regulates biological processes through hormone releasing glands) works with her nervous system (hypothalamic-pituitary system) to create physiological wellness. Any imbalance can result in physical and mental effects, and we know that peri-menopause alters the levels of estrogen, progesterone, and serotonin in a woman’s body.
Additional hormones affected by menopause that may cause troubles regarding neurotransmission, resulting in mood-based dysfunction, are progesterone and GABA. During peri-menopause, progesterone levels are declining and can lead to changes in a woman’s sense of emotional stability. When progesterone is metabolized, it produces GABA (a receptor agonist called Gamma-Aminobutyric acid) in order to regulate emotions, moods, and sleep. During times of lowered progesterone and GABA, anxiety, depression, and sleep disorders may increase.
Depression is linked to an increased risk of self-harm and social isolation
That’s why it is important that early indicators are assessed for an accurate diagnosis. If behavioral symptoms are interfering with normal daily activities, cognitive functions, or are disrupting relationships, it is important to seek a healthcare evaluation.Particularly if you are having suicidal thoughts or persistent thoughts about death, you may be experiencing the effects of depression and will benefit from early and accurate diagnosis and possible treatment alternatives. Depression is a common by-product of hormonal fluctuations and should not be associated with negative feelings of shame or deficiency. With compassionate medical treatment, clinical depression is manageable.
Other impacted areas
There are a few behavioral changes that may be triggered by, or positively correlated with, depression: Changes in appetite, slowed movements or speech, feelings of lack of worth or guilt. This is in addition to other general menopausal symptoms that are often inter-related with depression are:
- Mood swings
- Anxiety
- Irritability
- Fatigue and/or lack of energy
- Sleep disturbance, particularly difficulty falling asleep and oversleeping
- “Brain fog” & difficulty concentrating
- Decreased libido
Diagnosis
Medical professionals have accurate diagnostic tests to evaluate self-reported symptoms. Doctors and therapists use a scale-of-severity testing method to determine if symptoms are chronic or temporary.
Clinical diagnosis of depression, prior to or during menopause, involves the assessment of key characteristics. The DSM-V diagnostic assessment involves a series of self-reported answers to standardized questions. If a woman reports more than a threshold number of affirmative answers for a duration of longer than two weeks, she may be diagnosed with clinical depression requiring treatment. The existence of occasional depressive thoughts or cyclical (hormonal related) depressive episodes is not sufficient evidence to prove clinical depression, but you can still receive treatment.
Possible triggers or risk factors
The strongest predictor for depression during menopause is a prior depressive episode or period, particularly if it was related to your hormonal cycle. However, any women with a history of mental health diagnoses is at higher risk for developing menopausal depression. Vasomotor symptoms and anxiety are also known to modulate the risk for menopausal depression.
Treatments & Remedies
Menopause can feel like an upside-down time of life, but it’s important to understand you are not alone, you are not going crazy and a variety of excellent treatment alternatives is available. In addition to the supplement and pharmaceutical alternatives described below, there are other therapies that have excellent efficacy rates, either in isolation or combination. Cognitive Behavior Therapy (CBT) and other forms of counseling, intentional reduction of life stressors, and engaging proactively in self-care activities are among the important alternatives to consider.
Products
There are many foods and nutrients that are felt to relieve feelings of depression, however they have not been adequately studied for women suffering from clinical menopausal depression. Some of these options include:
- Ginseng (tea, powder, extract)
- Maca root
- Red clover (isoflavones)
- Black cohosh
There is limited clinical evidence that St. John’s wort (hypericum perforatum) is effective in treating mild and moderate depression. However, if you decide to take this it is imperative that you tell your doctor as St. John’s wort can interact in dangerous, sometimes life-threatening ways with a variety of medicines.
Currently there are no scientifically proven effective over-the-counter products for the relief of depression.
For hormone related depressive symptoms, antidepressant medication in combination with lifestyle improvements, alternative therapies, and/or hormonal treatments can be effective. When speaking to your physician you should make sure s/he is fully informed regarding all prescription and non-prescription drugs being taken before an accurate and safe antidepressant regime can be prescribed.
- The most commonly prescribed medication for anxiety and depression are SSRIs and SNRIs. Both are frequently referred to as antidepressant medication, even though they’re effective and therefore prescribed to help manage a range of mental health related symptoms. Please note that these medications take time to reach effectiveness and it is important to work closely with your doctor to establish optimal dosage. For more in depth information on how this type of medication works, the difference between SSRIs and SNRIs and side effects please refer to this article.
Lifestyle
General guidelines for an optimal diet, whether experiencing menopause, clinical depression, or both, includes:
- Adequate hydration at all times
- Balanced foods, ideally focused on a Mediterranean diet (whole grains, fruits, vegetables, seafood, beans, nuts)
- Elimination of tobacco products
- Reduction or elimination of caffeine and alcohol
Throughout menopause, a woman’s goal should be to lead a healthy and activate lifestyle to minimise the impact of menopausal symptoms. Regular aerobic exercise is a key component of this and necessary to maintain best-possible hormonal balances, body weight, muscle mass, bone density, and cardiovascular health. Exercise and a positive sense of mental wellbeing are closely related. Mood improvement has been shown to accompany even mild exercise routines such as daily walking.
During menopause, light-exercise (such as stretching, yoga, walking) was found to be positively correlated with a reduction in self-reporting of depression symptoms. Although moderate-to-intensive exercise may be associated with an increase in other menopausal symptoms, such as hot flashes, light-exercise did not lead to additional negative effects.
-
Holistic
TCM
Focus on acupuncture for kidney deficiency and heart-kidney imbalance.
Ayurveda
Predominant dosha is vatika and treatment can include sodhanam, samanam, rasayanam, and pathya apathya. Yoga, counseling, and music therapy are advisable.
Acupuncture
Recommended for Peri-menopausal Depressive Disorder (PDD) and the strengthening of estrogen receptors.
Mindfulness
Meditation, yoga, and fostering self-awareness.
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