A case of perimenopausal depression

To The Editor

We report a case of perimenopausal depression encountered at our outpatient Women’s Mental Health Clinic. A highly functional 53-year-old woman with no psychiatric history presented with abrupt onset anxious and depressive symptoms, culminating in two high lethality suicide attempts. She had two public admissions before shifting to the private setting. Her depression stabilised somewhat on high dose venlafaxine 225 mg and olanzapine 5 mg. However, she improved significantly after her general physician (GP) prescribed tibolone hormone replacement therapy (HRT), in response to the emergence of physical menopausal symptoms of hot flushes and sweating.

This case highlights several features of perimenopausal depression (Worsley et al., 2012). Importantly, we wish to point out that women with no previous psychiatric history can present for the first time with new, unexpected and unexplained depressive symptoms, often accompanied by prominent anxiety. This can occur at any time over the decade of perimenopausal change, that is, from age 40 onwards. Recognition of menopausal influence can be difficult. Psychiatric symptoms can present before the physical symptoms of menopause; menopausal hormone fluctuations impact central nervous system neurotransmitters many years before peripheral serum assays detect hormonal changes.

Treatment of perimenopausal depression may require HRT, in addition to antidepressant and psychological interventions outlined in the College Clinical Practice Guidelines (Malhi et al., 2015). HRT can take the form of estrogen patches (with concomitant progestin by way of a Mirena IUD or oral medroxyprogesterone), or oral tibolone (a compound with properties similar to estrogen, progesterone and testosterone: Khan et al., 2016). These supplements externally regulate the patient’s fluctuating endogenous production of estrogen. If tolerated, HRT should continue over the longer term of 4–5 years, with regular routine health monitoring including pap smears and mammography. HRT may be contraindicated in some patients (such as those with a history of hormone-responsive breast cancer). The appropriate use and monitoring of hormonal therapies can be done in conjunction with another medical specialist such as a GP, endocrinologist or gynaecologist.

Prompt attention to the hormonal aspects of treatment is in the interests of a speedier recovery and prevention of further psychosocial damage. Notably, women who have suffered premenstrual dysphoric disorder or postnatal depression are at greater risk of a perimenopausal depression, suggesting that the mental state vulnerability to gonadal hormonal fluctuations is present over the life cycle. Ongoing psychosocial support is important in recovery, in view of the rich challenges women face over the mid life years.