Treatments for perimenopausal depression usually include antidepressants and gonadal hormones. Often, the order in which they are used depends on the clinician’s particular expertise or medical specialty.
Hormone therapy alone may be appropriate for recent onset depression, without suicidality, in otherwise healthy women experiencing other perimenopausal symptoms. The hormone therapy chosen must be tailored for each patient. Recommendations by the International Menopause Society, updated in 2016,5 are a useful, comprehensive set of evidence-based practice guidelines.
Tibolone is a synthetic steroid with a mixed hormonal profile which has shown benefit in treating perimenopausal depression.6 Tibolone can cause minor intermenstrual bleeding, but does not cause increased breast density.6
Bioidentical hormones are compounds synthesised to resemble ovarian hormones. There are limited safety and dosing data on these compounds which are not recommended by the International Menopause Society.5
Antidepressant treatment for perimenopausal depression usually begins with a selective serotonin reuptake inhibitor. If this approach is not effective, serotonin noradrenaline reuptake inhibitors are often second-line drugs. However, both classes can have agitating adverse effects and a woman with prominent perimenopausal insomnia, irritability and anxiety may experience exacerbation of these symptoms with drugs such as fluoxetine. Agomelatine is a newer antidepressant with positive sedative impact and fewer adverse effects in women with perimenopausal depression.7
Combining hormone therapy and antidepressant therapy may be required for perimenopausal women with depressive symptoms that do not respond to either treatment alone. In such cases, the adverse effects of combined treatment need to be monitored carefully.