Guidelines for Managing Perimenopausal Depression Now Available

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The panel notes that estrogen is not approved by the Food and Drug Administration to treat mood disturbance.
The panel notes that estrogen is not approved by the Food and Drug Administration to treat mood disturbance.

The first-ever guidelines for the evaluation and treatment of perimenopausal depression have been published by The North American Menopause Society in collaboration with the National Network on Depression Centers for Women and Mood Disorders Task Group. The new guidelines have been endorsed by the International Menopause Society and are currently available for review in the journal Menopause and the Journal of Women's Health.

The 5 topics addressed by the 11-member expert panel include epidemiology, clinical presentation, therapeutic effects of antidepressants, effects of hormone therapy, and the effectiveness of other therapies (eg, psychotherapy, exercise, natural health products). "The reason these guidelines are needed is because depression during the perimenopausal phase can occur along with menopausal symptoms, and these 2 sets of symptoms are hard to tease apart, which makes it difficult for clinicians to appropriately treat these women," said Dr Pauline Maki, professor of psychology and psychiatry in the University of Illinois at Chicago College of Medicine and co-lead author of the new guidelines. "Many women experience a new onset of depressive symptoms. If there is underlying low-level depression to begin with, perimenopause can increase the intensity of depressive symptoms."

Regarding treatment, the panel recommends proven therapeutic options such as antidepressants, cognitive-behavioral therapy, and other psychotherapies as first-line therapies for major depressive episodes. When selecting an antidepressant, clinicians should consider the patient's prior experience with these agents, as well as the possibility of adverse events and safety issues such as drug-drug interactions.

At usual doses, selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been shown to be effective and may also improve menopause-related issues such as vasomotor symptoms and pain. Desvenlafaxine, in particular, has proven efficacy based on large, placebo-controlled trials involving peri- and postmenopausal depressed women. In addition, sleep disturbance and night sweats should be factored into the treatment of menopause-related depression. 

With regard to estrogen therapy, the guidelines state that the treatment is ineffective for depressive disorders in postmenopausal women, although there is some evidence to suggest that estrogen has antidepressant effects similar to that seen with antidepressant agents in depressed perimenopausal women. In women approaching menopause, hormonal contraceptives, used continuously, may improve depressive symptoms. The panel notes that estrogen is not approved by the Food and Drug Administration to treat mood disturbance and that most studies of hormone therapy as a treatment for depression examined the effects of unopposed estrogen; data on combined hormone therapy or for progestogens is inconclusive.

As for botanical and alternative approaches, there is insufficient evidence to recommend these treatments for depression related to perimenopause.

"There has been a need for expert consensus as well as clear clinical guidance regarding how to evaluate and treat depression in women during perimenopause," said Dr Susan Kornstein, professor of psychiatry and obstetrics & gynecology at Virginia Commonwealth University and co-lead author of the guidelines. "These new clinical recommendations address this gap and offer much-needed information and guidance to healthcare practitioners so that they can provide optimal care and treatment for midlife women."

For more information visit journals.lww.com.

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