Recommendations issued for diagnosing, managing depression during menopause

Women with past major depressive episodes and women with severe depressive symptoms and/or suicidal ideation should always be evaluated for a mood disorder, among other recommendations.

Two medical groups issued consensus recommendations on managing depression among women going through menopause.

The recommendations were issued on behalf of The North American Menopause Society and the Women and Mood Disorders Task Force of the National Network of Depression Centers. An expert panel systematically reviewed the published literature to develop guidelines on the evaluation and management of perimenopausal depression, including epidemiology, clinical presentation, antidepressants, hormone therapy, and alternative remedies.

The recommendations were published online Sept. 4 by Menopause and was co-published in the Journal of Women's Health.

“Overall, evidence generally suggests that most midlife women who experience a major depressive episode during the perimenopause have experienced a prior episode of depression,” the recommendations stated.

Depression during midlife presents with classic symptoms, commonly along with menopause symptoms, the recommendations stated. Vasomotor symptoms are associated with depressive symptoms but not major depressive episodes, except in women with first lifetime onset of a depressive episode during perimenopause.

Life stressors that are common for middle-aged women, such as caring for children and parents, career and relationship shifts, and other body changes, can affect mood but have little enduring effect, the recommendations stated. The groups recommended that evaluation include identifying the stage of menopause, assessing overlapping symptoms, disentangling symptoms, and distinguishing diagnoses.

Women with past major depressive episodes and women with severe depressive symptoms and/or suicidal ideation should always be evaluated for a mood disorder. “The differential diagnosis of depression during the perimenopause includes MDD [major depressive disorder], subsyndromal depression, adjustment disorder, psychological distress, bereavement, depressive episodes associated with bipolar disorder, and general medical causes of depression,” the recommendations stated.

Several general validated screening measures such as the Patient Health Questionnaire-9 may be used to make a mood disorder diagnoses. Validated menopause symptom and health-related quality-of-life scales include mood items and may be useful in clarifying the contribution of menopause-related symptoms, the recommendations said.

Proven therapeutic options for depression such as antidepressants and cognitive behavioral therapy are front-line treatments for major depressive episodes during perimenopause, the recommendations said. Selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors (citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, sertraline, and venlafaxine) have good efficacy and tolerability at usual doses, they noted. In women who have a history of major depressive disorder, a previous adequate response to a particular antidepressant should guide treatment selection when the condition recurs during midlife years, the recommendations said. Only desvenlafaxine has been studied and proven efficacious in large randomized placebo-controlled trials of well-defined peri- and postmenopausal depressed women, the recommendations stated.

Many antidepressants may also improve menopause-related symptoms such as pain, the recommendations said, and clinicians should also consider treating co-occurring sleep disturbance and night sweats as part of treatment for menopause-related depression.

There is some evidence that estrogen therapy may have antidepressant effects similar to those of classic antidepressant agents when administered to perimenopausal women with depression and with or without concomitant vasomotor symptoms, the recommendations stated. Estrogen therapy is ineffective as a treatment for depressive disorders in postmenopausal women; there is some evidence that estrogen therapy enhances mood and improves well-being in nondepressed perimenopausal women, the recommendations said. “Hormonal contraceptives—particularly when used continuously—have shown some benefits for mood regulation and may improve depressive symptoms in women approaching menopause,” the recommendations said. The recommendations also noted that estrogen is not FDA-approved for mood disturbance.

The recommendations also noted that exercise is a reasonable recommendation in peri- and postmenopausal women with depression, particularly when it is used in combination with recommended psychotherapies and pharmacotherapies.