Lately you’ve been feeling bummed out. Sometimes you even get teary-eyed for no reason. You drag yourself through the day, exhausted, and minor things feel like major frustrations. It’s perplexing because you’ve always considered yourself to be an upbeat person.
But being sad is wearing you down, and you don’t know how to fix it. Is this just the way life is when you hit middle age?
The “middle age” blues
It’s normal to feel gloomy now and then, especially during difficult times. But if you feel down much of the time, you may be experiencing depression.
Women are at a higher risk for mental health issues like depression during the perimenopause and menopause years. In fact, perimenopausal women are three times more likely to experience a major depressive event compared to premenopausal women. (1,2)
This is partly because the estrogen receptors in mood-regulating areas of the brain can be affected by fluctuating estrogen levels. The ups and downs of estrogen, progesterone, and DHEA during perimenopause may lead to mood dysregulation and symptoms of anxiety or depression. (3,4,5) And depression is more common in women with symptoms that affect their sleep, like hot flashes and night sweats. (6)
While perimenopause typically begins in your 40s, it may show up as early as your 30s. The tricky thing about having mood-related symptoms of perimenopause is that they can lead to misdiagnosis. You’re at risk of being diagnosed and treated for depression, without addressing the underlying hormonal issues at play. (2)
Getting the right diagnosis
At many doctor visits, a screening test of several questions is used for mental health issues. A nurse may ask questions like, “Have you felt hopeless or anxious lately? Do you often feel frustrated or irritable? Do you have frequent aches and pains?”
If a woman in her 30s or 40s answers “yes” to those questions or says she feels sad often, the provider may not even consider perimenopause as a root cause. Instead, they may skip directly to a diagnosis of depression, anxiety, fibromyalgia, or another condition. (2)
Depression vs perimenopause
In perimenopause, a diagnosis of depression may be especially likely. Why? Because depression and perimenopause have so many overlapping symptoms, like:
- mood changes
- sleep disturbances
- body changes
- memory problems
- difficulty concentrating
If you think you may be perimenopausal, but your provider wants to address your depression or anxiety with antidepressants, you may need to advocate for yourself for a more holistic approach to discovering the root causes of your concerns. (2)
Remind your practitioner that depression and anxiety can be symptoms of high or low levels of many hormones, including cortisol, thyroid hormones, and sex hormones like estrogen, progesterone, testosterone, and DHEA. To dig deeper and get to the root cause or your symptoms, ask for hormone testing as part of your wellness workup. (2)
Hormonal support for better mental health
Considering bioidentical hormone replacement therapy (BHRT) as early as perimenopause may have a positive effect on mental health. Studies show how responsive perimenopausal women can be to BHRT. For example, starting estrogen therapy when hormonal fluctuations are at their greatest can provide an antidepressive effect by minimizing the ups and downs that lead to perimenopausal mood swings. (2)
Progesterone and testosterone may also benefit some women. In one study, women reported that they felt less irritable and less emotional while on bioidentical progesterone. (2,7) In another study, adding a testosterone cream to BHRT improved women’s mood symptoms. (2,8)
If you feel like something is off with your overall mental wellness, and you’re anywhere from your late 30s to your 50s, consider that perimenopause may be a factor. When you talk with your provider, be honest about your symptoms. But don’t settle for a depression diagnosis without doing some detective work. Advocate for some lab tests and discuss all your symptoms with your medical provider, so you can work together to find the root cause of your symptoms.
References:
1. Borozan S. Kamul-Hasan ABM, Pappachan JM. Hormone replacement therapy for menopausal mood swings and sleep quality: The current evidence. World J Psychiatry. 2024
2. DeRosa A, Noonan RG, Crane A. The meaning of mental health, hormones, and happiness in midlife. Belmar Pharma Solutions webinar.
Link: Hormones & Mood Disorders – Belmar Pharma Solutions
3. Mental Health. The Menopause Society.
Link: Mental Health | The Menopause Society
4. Herson M, Kulkarni J. Hormonal Agents for the Treatment of Depression Associated with the Menopause. Drugs Aging. 2022 Aug;39(8):607-618. doi: 10.1007/s40266-022-00962-x.
Link: Hormonal Agents for the Treatment of Depression Associated with the Menopause – PMC
5. Cybulska AM, Szkup M, Schneider-Matyka D, Skonieczna-Żydecka K, Kaczmarczyk M, Jurczak A, Wieder-Huszla S, Karakiewicz B, Grochans E. Depressive Symptoms among Middle-Aged Women-Understanding the Cause. Brain Sci. 2020 Dec 28;11(1):26. doi: 10.3390/brainsci11010026
Link: Depressive Symptoms among Middle-Aged Women—Understanding the Cause – PMC
6. Llaneza P., García-Portilla M.P., Llaneza-Suárez D., Armott B., Pérez-López F.R. Depressive disorders and the menopause transition. Maturitas. 2012;71:120–130. doi: 10.1016/j.maturitas.2011.11.017
Link: Depressive disorders and the menopause transition – PubMed
7. Ruiz AD, Daniels KR, Barner JC, Carson JJ, Frei CR. Effectiveness of compounded bioidentical hormone replacement therapy: an observational cohort study. BMC Womens Health. 2011 Jun 8;11:27. doi: 10.1186/1472-6874-11-27. PMID: 21651797
Link: Effectiveness of Compounded Bioidentical Hormone Replacement Therapy: An Observational Cohort Study | BMC Women’s Health | Full Text
8. Glynne S, Kamal AM, Reisel D, Newson L. Effect of transdermal testosterone therapy on mood and cognitive symptoms in peri- and postmenopausal women: A pilot study. Arch Womens Ment Health. 2025;28(3):541-550.
