The menopause transition is a window of higher risk for depression, even for people who’ve never been depressed before. Expert guidelines describe perimenopause as a window of vulnerability. Talking therapies and antidepressants remain first-line, and HRT may help in perimenopause. If you have thoughts of harming yourself, get help now.
How is depression different from menopausal low mood?
Low mood around menopause often comes and goes and may be linked to your cycle, sleep or hot flashes. Depression is more persistent and affects daily life. Signs of depression include, for most of the day, nearly every day, for at least two weeks:
- Feeling sad, empty or hopeless
- Losing interest or pleasure in things you usually enjoy
- Changes in sleep or appetite
- Tiredness or loss of energy
- Difficulty concentrating or making decisions
- Feeling worthless or excessively guilty
- Moving or speaking more slowly, or feeling restless
- Thoughts of death or suicide
In midlife, depression can also show up as irritability, anxiety or feeling numb rather than sad.
Why is the menopause transition a risk period?
The 2018 guidelines on perimenopausal depression were developed by The Menopause Society (then NAMS) and the National Network of Depression Centers’ Women and Mood Disorders Task Group, and endorsed by the International Menopause Society. They highlight:
- Hormone fluctuations. Research suggests the erratic swings of estrogen and progesterone in perimenopause make some people more vulnerable.
- Overlapping symptoms. Hot flashes, night sweats, sleep and sexual problems, weight and energy changes, and brain fog can complicate and worsen depression. See sleep problems and hot flashes.
- Life stressors. Caring for children and parents, career and relationship changes, aging and body changes, and illness can all affect mood.
A large study published in 2024 also found that perimenopause was associated with an increased risk of developing major depression.
Who is at higher risk?
Risk factors commonly discussed include:
- A previous episode of depression
- A history of severe premenstrual symptoms (PMDD) or postnatal depression
- Frequent or severe hot flashes and poor sleep
- Stressful life events and limited support
- Early or surgical menopause. See early menopause and surgical menopause.
The ObG Project’s summary of the 2018 guidelines notes data suggesting increased risk after hysterectomy, with or without removal of the ovaries.
How is depression diagnosed?
A clinician will usually:
- Ask about your mood, interest, sleep, appetite, energy and concentration, and how long symptoms have lasted
- Ask about menopause symptoms and your periods, to understand where you are in the transition
- Ask about previous depression, anxiety, PMDD or postnatal depression
- Ask about alcohol, medicines and life stressors
- Ask directly about thoughts of self-harm or suicide, to keep you safe
- Use a short questionnaire to measure symptoms
- Consider blood tests, such as thyroid function and a blood count, to rule out other causes
What treatments work?
Front-line treatments
The 2018 guidelines state that proven treatments for depression, meaning antidepressants and psychotherapies such as CBT, should remain the front-line treatments for major depression during perimenopause.
- Talking therapies, such as CBT, can be delivered individually, in groups or online.
- Antidepressants, such as SSRIs and SNRIs, can help depression and may also reduce hot flashes. Some SSRIs shouldn’t be taken with tamoxifen.
The role of hormone therapy
- In perimenopause: the 2018 guidelines note that, although estrogen isn’t approved to treat depression, there’s evidence it has antidepressant effects in perimenopausal women, particularly those with hot flashes.
- After menopause: the guidelines state estrogen therapy is ineffective as a treatment for depressive disorders in postmenopausal women.
- NICE guidance: NICE recommends considering HRT for depressive symptoms that don’t meet the criteria for depression and that start around the same time as other menopause symptoms. If depression is suspected or diagnosed, NICE recommends following depression guidance alongside menopause care.
Treating sleep and hot flashes
The 2018 guidelines advise clinicians to consider treating co-occurring sleep problems and night sweats as part of treatment for menopause-related depression.
Lifestyle support
Regular exercise, social connection, a healthy routine and limiting alcohol support recovery alongside treatment.
What to expect from treatment
- Talking therapies usually involve weekly or fortnightly sessions for several months. Online and group options can reduce waiting times.
- Antidepressants typically take a few weeks to start helping, and are usually continued for several months after you feel better to reduce the risk of relapse. Don’t stop suddenly; your clinician will advise on reducing the dose when the time comes.
- Regular reviews check progress, side effects and whether menopause treatment should be adjusted.
- Combined approaches, such as therapy plus medicine, plus treating sleep and hot flashes, often work best.
Why depression matters for your heart
The American Heart Association notes that depression during the menopause transition is strongly linked with higher cardiovascular risk. That’s another reason not to wait. See heart health after menopause.
Supporting someone with depression
- Notice changes, such as withdrawal, tearfulness, irritability or loss of interest, and gently ask how they are.
- Listen without judging or rushing to fix.
- Encourage them to see a clinician, and offer practical help, such as going with them.
- Know the warning signs of suicide, and act if you’re worried.
When should you get help?
Book an appointment if you’ve felt low, hopeless or lost interest in things for more than two weeks, or if your mood is affecting daily life.
Get help immediately if you:
- Have thoughts of harming yourself or ending your life
- Have made plans, or feel unable to keep yourself safe
Contact emergency services or a crisis line in your country straight away, or go to your nearest emergency department. If you’re worried about someone else, don’t leave them alone and seek help.
Questions to ask at your appointment
- Do I have depression, or menopause-related low mood?
- Which treatment do you recommend: talking therapy, an antidepressant or both?
- Could HRT help my mood, given my stage of menopause?
- Would treating my hot flashes and sleep help?
- How soon should I expect to feel better, and when will we review?
See your first menopause appointment.
Low mood · Anxiety · Mood swings · Irritability · Sleep problems · Fatigue
Frequently asked questions
Can menopause cause depression?
The menopause transition is associated with a higher risk of depression, even in people with no previous history. Hormone fluctuations, symptoms and life stressors all contribute.
Is HRT a treatment for depression?
Not on its own. Estrogen may have antidepressant effects in perimenopause, particularly with hot flashes, but antidepressants and psychotherapy remain the front-line treatments for major depression.
Do antidepressants help hot flashes too?
Some antidepressants can reduce hot flashes, which can be helpful if you have both. They’re not usually recommended as first-line treatment for hot flashes alone.
Will depression go away after menopause?
Depression needs treatment, whatever its timing. With the right support, most people recover.
Can I take HRT and antidepressants together?
They can be used together when appropriate. NICE recommends that, if depression is suspected or diagnosed, menopause care and depression treatment are planned together. Your clinician will check for interactions.
Is depression more likely after early or surgical menopause?
Guideline summaries note data suggesting increased risk after hysterectomy, with or without removal of the ovaries. NICE recommends offering psychological support to people distressed by early menopause.
References
- Maki PM et al. Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. Menopause, 2018
- Journal of Women’s Health: Perimenopausal depression guidelines (summary)
- ScienceDaily: First-ever guidelines for detecting, treating perimenopausal depression
- The ObG Project: Perimenopausal depression guidelines summary
- International Menopause Society: Review of the perimenopausal depression guidelines
- First onsets of major depressive disorder in perimenopause, 2024
- NICE guideline NG23: Menopause, identification and management (2024 update: depressive symptoms and depression)
- American Heart Association: The connection between menopause and cardiovascular disease risks
- NICE NG23 recommendations (SSRIs, tamoxifen)
Editorial status: evidence-based educational article; not individually medically reviewed. Last evidence check: September 10, 2026.
