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Endorsement by the IMS

Professor Wendy Wolfman

IMS Education Committee and Education Committee Members, Department of Obstetrics and Gynaecology, University of Toronto, Canada

The North American Menopause Society has developed an important guideline for the evaluation and treatment of perimenopausal depression [1]. This document, co-authored by an 11-member panel of experts and opinion leaders, who systematically reviewed the literature between 1980 and 2015 on depression and depressive symptoms, focuses on issues related specifically to perimenopause and postmenopausal women. The document reviews five relevant areas: epidemiology, clinical presentation, therapeutic effects of antidepressants and hormonal therapies as well as the efficacy of other therapies including psychotherapy, exercise and natural health products.

The IMS endorses this well-written comprehensive document that provides a summary and recommendations for improving the mental health of perimenopausal and menopausal women. Depressive symptoms are highly prevalent in at least 45% of perimenopausal women around the world. The paper confirms that the perimenopause is a time of vulnerability for the development of depression in women, particularly those who have had a prior episode of depression. The presentation may be complicated by perimenopausal symptomatology such as hot flushes, night sweats, sleep and sexual disturbances, weight changes and cognitive shifts. Evaluation involves identifying the menopausal stage and assessing psychiatric symptoms via validated screening tools. Proven therapeutic options include antidepressants such as SSRI and SNRI antidepressants, cognitive behavior therapy and other psychotherapies. For perimenopausal women, there is some evidence that estrogen therapy has antidepressant effects similar to antidepressant agents. However, estrogen alone is ineffective for depressive disorders in postmenopausal women. Estrogen may enhance the clinical response to antidepressants. This synergy needs to be evaluated in further research trials.

Some of the limitations of the document identified by the IMS reviewers included little mention of effects of other hormones on depression such as thyroid and adrenal hormones, and only a small mention of testosterone [2,3]. A section on directions for future research would have been useful in the document. For instance, comment could have been made about very important recent genetic research and its impact on depression, as noted in the recent review on gene polymorphisms and the risk of depression in menopausal women [4]. Also, there is currently a deficiency in the literature comparing doses, types, vehicles and timing of hormone therapies with regard to outcomes of depression. More research is needed to address the etiology and management of premature ovarian insufficiency-related depression as well as the synergistic effects of psychoactive medication with hormone therapies. These areas may prove to be relevant to address in future research recommendations.

In conclusion, we endorse this excellent guideline. We believe it validates the alterations in mental well-being that occur during the menopause transition, with the goal of improving the health of women around the globe.



  1. Maki PM, Kornstein SG, Joffe H, et al. on behalf of the 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;25. Epub ahead of print September 5
  2. Montgomery JC, Appleby L Brincat M, et al. Effect of oestrogen and testosterone implants on psychological disorders in the climacteric. Lancet 1987;1:297-9
  3. Studd J, Nappi RE. Reproductive depression. Gynecol Endocrinol 2012;28(Suppl 1):42-5
  4. Rozycka A, Slopien R, Slopien A, et al. The MAOA, COMT, MTHFR and ESR1 gene polymorphisms are associated with the risk of depression in menopausal women. Maturitas 2016;84:42-54
  5. Clayton AH, Kornstein SG, Dunlop BW, et al. Efficacy and safety of desvenlafaxine 50 mg/d in a randomized, placebo-controlled study of perimenopausal and postmenopausal women with major depressive disorder. J Clin Psychiatry 2013;74:1010-17
  6. Soares CN, Arsenio H, Joffe H, et al. Escitalopram versus ethinyl estradiol and norethindrone acetate for symptomatic peri- and postmenopausal women: Impact on depression, vasomotor symptoms, sleep, and quality of life. Menopause 2006;13:780-6
  7. Soares CN, Almeida OP, Joffe H, Cohen LS. Efficacy of estradiol for the treatment of depressive disorders in perimenopausal women: A double-blind, randomized, placebo-controlled trial. Arch Gen Psychiatry 2001;58:529-34
  8. Gordon JL, Rubinow DR, Eisenlohr-Moul TA, Xia K, Schmidt PJ, Girdler SS. Efficacy of transdermal estradiol and micronized progesterone in the prevention of depressive symptoms in the menopause transition: A randomized clinical trial. JAMA Psychiatry 2018;75:149-57
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