In this Q&A, Hadine Joffe, M.D., M.Sc., a Mass General Brigham psychiatrist and women’s mental health specialist, answers patients’ most commonly searched questions about perimenopause and perimenopausal depression. Dr. Joffe is executive director of the Mary Horrigan Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital. Her clinical and research work focuses on the course, mechanisms, and treatment of menopausal symptoms in healthy women and in breast cancer patients.

Q: What is perimenopause?

Joffe: Perimenopause is a period of time where women have changes in their menstrual cycle patterns. On average, perimenopause lasts four years; and on average, it starts in the mid-to-late forties. So somebody who has predictable monthly menstrual cycles will start to have shorter cycles or longer cycles. They may vary and be unpredictable. Eventually they slow down. They become less frequent. Once a woman has had 12 months without a menstrual period, she’s officially postmenopausal. This means she has reached menopause.

All women go through menopause, and for most women, they go through it without major impact on their well-being. It’s not a disease; it’s not a condition. It’s a reproductive transition in the same way that puberty is a natural stage of life. When a woman goes through perimenopause, her experience reflects changes in the body: The ovaries are aging and hormonal changes in the brain indicate that this reproductive aging is occurring. The ovaries have fewer and fewer follicles that release eggs as women age.

Q: What are the symptoms of perimenopause?

Joffe: The most common symptoms are:

• Changes in menstrual cycle patterns
• Changes in sleep, interrupted sleep, or insomnia
• Hot flashes
• Low daytime energy and fatigue during the day
• Mood changes
• Night sweats
• Vaginal dryness

For most women who have a uterus, they have a menstrual marker of what’s happening in their body. But for those women who don’t have a uterus because it was removed for a hysterectomy, or they had some other kind of medical treatment, we don’t always have that menstrual marker. We can do a blood test to help understand whether they are in the perimenopause.

Q: What is perimenopausal depression?

Joffe: Depression occurs when people, in this case women, have sadness that they can’t escape or they are not interested in their usual activities. In its milder form, this depressive condition is common during perimenopause and can last for a long period of time. It comes and it goes. It’s really linked to the hormone changes that we know are occurring in their brain and their body.

Q: What are signs and symptoms of major depression during perimenopause?

Joffe: Major depression during perimenopause is a more severe and impairing form of perimenopausal depression. It’s less common than the milder condition. These women typically have had depression in the past, but they may not have had it. This goes together with a number of other symptoms, like trouble sleeping or sleeping too much, lack of motivation, lack of energy problems, concentration problems, appetite changes (eating too much, eating too little), and sometimes more disturbing, hopeless thoughts.

Depression is hard because it can consume people. You know, people feel like it’s like this veil over their whole head and body and they can’t see it as easily. It’s nebulous. And so if somebody notices that they’re just not themselves, it’s important to try and connect with somebody else. If you think you may have perimenopausal depression, talk to your primary care doctor. They know their patients well and they’re usually very experienced at treating depression.

Q: What is the difference between milder mood changes and clinical or major depression?

Joffe: Major depression can interfere with daytime function and relationships. Women may feel hopeless, or have very serious thoughts of not wanting to be alive (also called suicidal ideation or suicidal thinking). The more severe depression, perimenopause-related major depression, is not as common. But perimenopause is a period of risk. It’s a period of vulnerability, like the postpartum period or the premenstrual phase of the menstrual cycle, to having these mood changes.

It is a vulnerable period of time that can continue over a few years because perimenopause can last for a number of years. So for women who have a history of depression, for those who seem to be hormonally sensitive in particular, we do want to be vigilant with them. We do want to monitor them through perimenopause. When they get to postmenopause, it looks like the risk goes down as their hormones settle. Depression can happen at any stage of life. And it is important to remember that it can happen when a woman happens to be perimenopausal, but it may not necessarily be related to perimenopause. This is a key part of the clinical evaluation of depression in perimenopausal women.

Q: How is perimenopausal depression treated?

Joffe: Perimenopausal depression is very treatable. The most common treatment is an antidepressant and almost always, it’s serotonin-based (SSRIs or SNRIs). For some women, therapy is most important. This talk therapy can be cognitive behavioral therapy (CBT) or other supportive approaches. It’s really valuable for women to understand their symptoms and to manage their symptoms. If they’re not concentrating, if they’re avoiding their social life, the behavioral strategies and the lifestyle modifications that come with therapy are very effective.

Other aspects of managing or treating clinical depression may include exercise, limiting or eliminating alcohol use, getting out of the house, light exposure, socializing, and mood monitoring. These are simple things they can track on a calendar and in their phone to check on mood changes. How often are they low? Are there triggers? This kind of information can be really helpful to bring to their therapist or their doctor when they’re getting treatment for the depression.