Are antidepressants the right treatment for perimenopause and menopause symptoms?

A BBC Panorama investigation broadcast in 2023 revealed that 23% of the total UK adult population are currently taking antidepressants¹. Breaking this figure down the UK Office of National Statistics (ONS) shows that of those in the 40-64 age bracket 69% are women – significant because many of them will be of perimenopause and menopausal age.

The National Institute for Clinical Excellence (NICE) guidelines, however, are clear that prescribing antidepressants for perimenopause and menopause symptoms like low mood should not be a first line of treatment². Despite the NICE recommendation, however, many women appear to have been inappropriately prescribed them (including Joan Graham, who describes her story below) - ONS figures also reveal that between 2021 and 2022 the most common group on antidepressants were women aged between 50 and 59³ – perhaps indicative of the fact that some may have been diagnosed with clinical depression at perimenopausal/menopausal age when maybe their symptoms were hormonal. The question is why exactly might antidepressants be the wrong course of treatment for women presenting with sadness and low mood during perimenopause?

Cognitive changes during perimenopause

To understand why antidepressants might not be the right treatment for perimenopause and menopause symptoms we need to be aware of how the hormonal shifts that occur during these transitional times typically affect women’s brain function. Decreasing oestrogen during perimenopause (a transitional stage most women will go through between the ages of 45-55)⁴ can lead to mild cognitive changes like changes to processing speed (the slowing down of your abilities like finding a word or recovering a memory or fact and frequently losing your train of thought). In short, many women experience brain fog and the inability to think clearly which can, understandably, lead to low mood and a feeling of generally ‘losing their faculties’ and not being able to cope. It is these cognitive symptoms which tend to floor women more than the physical ones like hot flushes, as they appear to come from nowhere, and lead many to feel they are experiencing symptoms of early onset dementia.

Cognitive symptom changes are largely due to the dysregulation of the hormone cortisol which occurs due to the fluctuation and decrease of oestrogen. The effects of this are that women are likely to experience a high level of anxiety and become tearful, snappy and intolerant. This can lead to them presenting with anxiety and what can appear to be low mood and depression. Yet when you actually speak with women who are perimenopausal or menopausal their mood changes are not fully on par with the symptoms presented by someone with classical clinical depression but more of a sadness and overwhelm-edness. As it is not the ‘depression receptors’ that are causing these mood changes then antidepressants are unlikely to work. In fact, there is no evidence to show antidepressants help with psychological perimenopausal and menopausal symptoms and could actually exacerbate

them by ignoring the underlying cause of hormone imbalance and cause unwanted side effects such as a flattening of mood and loss of libido.

Antidepressants prescribed for perimenopausal symptoms

A survey from 2019 reveals that over a third of women who went to their GP with symptoms of menopause were offered antidepressants however,⁵ it is only more recently that the cluster of symptoms that we recognise as perimenopause have become more widely understood. In fact, the perimenopause was not a subject really discussed in my medical training. Previously each symptom a woman presented with would be taken in isolation. If these symptoms were not ’classically hormonal’ then the perimenopause would unlikely even be considered as a cause for this. Subsequently, this would lead to women being put on medications, sent for investigations or to specialists to try and determine a cause. When these medications inevitably did not work and/or the investigations proved normal she was advised to ‘just manage’ her symptoms. It was only when a woman presented with ‘classical’ menopausal symptoms (period changes, hot flushes and night sweats) that the idea of HRT would even be considered and, amazingly, patients would see a resolution and improvement in the other perimenopausal symptoms they had been experiencing.

Potential side effects of antidepressants

Common antidepressants include Sertraline, Citalopram, Fluoxetine, Mirtazapine and Venlafaxine. Side effects are often flatness of mood, gastrointestinal symptoms including nausea, and loss of libido. Significantly, these medication ‘side-effects’ can also be common symptoms of perimenopause and menopause. The Panorama investigation also included people talking about their experience of ‘genital numbing’ and ‘enduring sexual dysfunction’ or PSDD, a condition that persists in some people even after they have stopped taking antidepressants. Personally, I have not had anyone on antidepressants coming to me presenting with these rare genital symptoms, but mood changes and loss of libido are very commonly seen.

HRT vs antidepressants

I would always trial HRT first as I feel it is a treatment option that manages the root cause of the symptoms. A three-to-six-month trial of HRT will give you enough information to know what symptoms are hormonal and then you can look to manage any remaining symptoms using other treatment or lifestyle options. I very rarely initiate antidepressants for perimenopausal/menopausal women first unless there is a reason why a woman is unable or does not want to take HRT. Most women when on the right dose and type of HRT find their depressive symptoms improve.

Can you take HRT and antidepressants?

Yes, they don’t negatively impact each other, and you can safely take both. A meta-analysis from 2020 provides evidence that antidepressants are effective for the treatment of depressive disorders during, and after, menopause⁶.

What else can help?

Whether you are on antidepressants or HRT - or both or neither - there are practical things you can do to help improve your perimenopausal and menopausal journey including:

Document your symptoms. Do this either on paper or use an app. Download the free Health & Her tracker and log not only the frequency of your periods (marking the days when they start and when they end) but also chart your moods, potential food cravings and pick up on any potential triggers (like caffeine or stress) that exacerbate your symptoms (these are some of the most common perimenopause and menopause triggers). This will not only give you the information you need to make changes yourself but also will provide a good record of information when, or if, you need to talk to your GP or menopause specialist about your symptoms.

Diet. A healthy, balanced diet will help keep you generally healthier but there are certain foods that appear to be particularly helpful in reducing symptoms of perimenopause. These include ones high in omega 3 like oily fish (salmon, mackerel, sardines), nuts and seeds for selenium and magnesium (like pumpkin and linseed), pulses and extra virgin olive oil which may improve the severity of some menopausal symptoms and are linked to improved mood⁷. For more healthy food suggestions read Diet and recipes to help balance hormones in menopause.

Exercise. Regular exercise can help reduce anxiety and low mood as well as improving bone and heart health and it should also lead to better quality sleep⁸,⁹.

Manage stress. Exercise is also one of the most well-documented ways to manage stress. Getting enough sleep will help too. Find more helpful suggestions in Coping with stress and anxiety during menopause.

Cut down on alcohol. Drinking alcohol can contribute to feelings of anxiety and these can be magnified when you are perimenopausal. In recent research carried out by Health & Her, alcohol is one of the most common triggers for exacerbating symptoms, with four out of 10 women reporting becoming increasingly intolerant to its effects.

Try CBT – (Cognitive behavioural therapy) The British Menopause Society say this talking therapy can be helpful for managing stress and anxiety during perimenopause¹⁰. Our CBT expert gives insight into CBT for menopause.

Joan's story

‘Anti-depressants made my (already bad) symptoms even worse…We have to prevent any more women from dying or being locked away in a psychiatric unit like I was…’

Joan Graham, 61, from Renfrewshire near Glasgow was prescribed antidepressants for her severe menopause symptoms. Here she explains what happened and her fight to be heard and get the treatment she knew she needed.

‘My story began five years ago, in 2018, when I went for a routine smear test and started bleeding after the procedure. It had never happened before and I waited a few days but things got progressively worse so I rang my GP who referred me to an on-call gynaecologist at Paisley Hospital. One of the questions the gynaecologist asked was whether I was on the pill. I told him I was taking the combined pill to which he immediately replied I shouldn’t as I was over 50 – I was 56 at the time. I had always been told it was safe because I was a non-smoker and wasn’t overweight and my GP just kept on giving me a repeat prescription. I explained to the gynaecologist I had been on it for over 35 years and asked if I could expect any side effects if I stopped abruptly but he told me to just wait and see and if I had any problems to go and see my GP. I was given no information about how coming off it might affect me.

I know now the hormones in the combined pill can mask and control menopause symptoms, and without it, mine were immediately life affecting and debilitating. The worst was the crippling insomnia – I’d never been a great sleeper but now I couldn’t sleep at all and this went on for months and months. I recognised that what was happening was almost certainly hormonal because there was no gradual decline in my condition - it was so immediate after coming of the pill. Plus, I knew I was around the right age to be going through the menopause and there was no real stress going on in my life at that point to make me think anything else was the catalyst. On the contrary, I had recently got married to a marvellous man, Michael, and had my amazing children and grandchildren around me – life on the surface was great. But my symptoms were catastrophic – besides the insomnia over the next few months I lost my appetite, my hair started falling out, I lost four stone, my joints ached, my confidence was rock bottom, I had panic attacks and suffered brain fog and memory problems. I literally could not function.

When I went to my GP I asked if I could be prescribed HRT but she refused because I said I hadn’t experienced hot flushes. Instead, she diagnosed me with clinical depression and gave me antidepressants and sleeping pills. I had never suffered with depression in my life – not post-natal depression when I had my two children, nothing. Long story short: the antidepressants just made my (already bad) symptoms even worse. I physically could not get up off the couch. The symptoms became so severe I convinced myself I was going through the early stages of dementia and was so concerned I actually paid to see a neurologist at a private clinic. He diagnosed my problems as being hormonal and wrote to my GP to say as much but again my GP said no to HRT.

By Christmas 2018 I was literally pleading with my GP for help. She prescribed me Diazepam for anxiety and Temazepam for insomnia and told me I was on a waiting list for CBT. But by January 2019 I couldn’t see a way forward. I attempted suicide by overdosing - and was found by my husband Michael a matter of hours later. After being admitted to hospital I was referred to a psychiatric unit and was kept there until the middle of June. In the unit I was given the drug Quetiapine, a powerful antipsychotic. At the same I was also on the antidepressants Venlafaxine, Nortriptyline and Diazepam plus the tranquilliser Triazolam– I wasn’t offered counselling I was just medicated. With all this going on I lost my job as a special needs classroom assistant – a job I absolutely adored - and my relationship with my daughter became increasingly strained as she couldn’t understand why I could even contemplate taking my own life.

What helped my recovery hugely was when I was researching my symptoms online I came across a woman called Diane Danzebrink. Diane was plunged into a sudden early menopause after surgery and couldn’t find the information or resources she needed to make sense of what was happening to her. I read her account and thought, ‘This is me’. She has since set up a hugely successful support group for women (menopausesupport.co.uk) and I now volunteer for her and another support group. Having a support network around you is so vital for women going through menopause along with having access to relevant and up to date information. I have made so many good friends in these groups – nobody can truly understand truly if they haven’t suffered such severe effects. I also know that GPs should be following NICE guidelines which say antidepressants should not be the first line of treatment for menopausal symptoms – HRT should be - although I was told by NHS Scotland these are not mandatory. The guidelines also state patient choice should be taken into account when clearly they are not. Diane Danzebrink is organising a petition to present to government to help change all this and get women the treatment they need. We have to prevent any more women from dying or suffering debilitating symptoms and being locked away in psychiatric hospitals like me.

My recovery has been long and slow but when I was eventually prescribed HRT within a matter of weeks my joint pain had stopped, I started to have the confidence to go out again and my brain fog and memory improved slightly. I have had to fight to get testosterone included as part of my HRT regimen but that has helped with my brain fog along with making lifestyle changes like following a Mediterranean-style diet and doing Reiki. Throughout this whole nightmare scenario I am so lucky that Michael has been an unbelievable support. He is now as passionate about women getting help for their menopause symptoms as I am. All I know is if this has happened to me, it is surely happening to a lot of other women so if sharing my story helps just one other something positive has come out of my experience.’

Resources

If you are feeling low, are worried about your mental health and/or having thoughts of suicide there are a range of crisis helplines and online resources to help including:

Samaritans – open 24 hours a day, all year. Call 116 123 (free from any phone), email jo@samaritans.org or visit some branches in person.

National Suicide Prevention Helpline UK – call 0800 689 5652 (6pm to midnight daily).

SANEline – if you, or someone you know, is having mental health problems call 0300 304 7000 (4.30pm to 10.30pm daily)