Why doctors are misdiagnosing menopausal women with depression
Read any article listing the symptoms of menopause, and on there you will see either low mood, depression, or both. As you approach the menopause, in the period known as perimenopause, dips in mood and mood swings can affect some, along with a variety of other symptoms including memory loss, fatigue, hot flushes and vaginal dryness.
The same hormonal changes that cause your menstrual cycle to start becoming irregular during perimenopause can also cause symptoms that are more commonly associated with depression, including feeling tearful or low, a change in appetite, and losing interest in activities you previously enjoyed. These symptoms can actually lead to the development of depression in rare cases.
There have been some studies into depression and menopause, although none have reached any definitive answers on the how and the why, particularly on why it doesn’t seem to affect all women.
One study did reach the conclusion, however, that there is an increase in depressive symptoms among menopausal women compared to women who are premenopausal.
As you approach the menopause, your levels of oestrogen start to decline. Oestrogen is a hormone that is particularly linked to mood as it stimulates serotonin. There are also oestrogen receptors in the brain, so oestrogen affects your neural pathways.
The Harvard study of moods and cycles also found, in the first cohort of women analysed, that those without a history of depression were nearly twice as likely to experience depression during menopause compared with premenopausal women.
When this was adjusted for those with a history of adverse life events and vasomotor symptoms, risk of depressive symptoms increased to 2.5 times as likely in menopausal women.
Studies looking at the risk of clinical depression revealed more mixed results however, and while some concluded that the risk of depression was greater in the two years surrounding the final menstrual period than in the proceeding years, the second cohort in the Harvard study suggested rates of new-onset depression in menopausal women were extremely low.
What does seem to be the (fortunate) case from a systematic review of all the studies, is that only a minority of mid-life women experience what can be classified as clinical depression, and, while there is evidence to “support the role of the changing endocrine milieu in the development of depressed mood in the menopause transition” the role hormones play in this is classed as “small”.
So while doctors and scientists don’t currently know the exact science behind the link between menopause and depressive symptoms, and occasionally clinical depression, what is known is that HRT has been proven to help.
If this is the case then, why are doctors so quick to prescribe SSRIs to menopausal-aged women who come to their appointments complaining of low mood? Why aren’t they simply being offered HRT instead in the first instance, or being advised on lifestyle changes or coping mechanisms?
“I would say about 70% of my patients have been offered antidepressants by their GPs, which is shocking,” says Dr Louise Newson, a GP, who also runs a specialist menopause clinic. “But it’s not an issue with GPs, but rather a combination of factors.” According to her, the menopause training that GPs get at university is “scanty”, and very few people are given comprehensive training.
“In fact, a lot of doctors won’t even have full knowledge of the NICE guidelines,” adds Dr. Newson. “These guidelines do state that antidepressants don’t work for low mood related to menopause in the first instance.”
But it isn’t only the short amount of time given to training about the menopause that contributes to this lack of awareness. There is also a distinct misconception, amongst healthcare professionals and women alike, about what the symptoms of menopause actually are. For example, a lot of women know about hot flushes and night sweats, but they don’t realise that low mood and anxiety can also be related to hormone changes.
“So,” says Dr. Newson, “When they go to visit their GP, they talk about feeling tearful, feeling detached, and in a ten minute consultation, it’s really hard for your GP because they can only think about what their patient is telling them.”
As a GP herself, Dr. Newson adds that you only have time in that situation to deal with what you are presented with. “In that time, of course, women aren’t necessarily associating their mood with changes to their periods as they don’t see it relevant,” she says.
And, due to their lack of training, GPs aren’t asking the right questions either. Dr. Newson adds that with a lot of GPs, the problem is not that they are unwilling to prescribe HRT, it’s simply that they are not thinking about the menopause when a woman comes to them with low mood and doesn’t mention any other symptoms.
Another issue both women and doctors are face with is of course the question of whether they are, in fact, dealing with depression, and not low mood associated with menopause. “When it comes to signs that indicate that a menopausal woman might actually have developed depression that is not simply low mood solvable with HRT, there is a massive debate around it,” says Dr. Newson.
She continues, “I’ve lectured a lot about menopausal depression, and a lot of women do obviously fill the criteria for being depressed.” Personally, she says she will often prescribe HRT in the first line, and then review patients after a few weeks to see if they do, in fact, need antidepressants. Of course, any such patient would need to be monitored closely and reviewed regularly.
However, between menopause and depression it’s a very grey area, Dr. Newson adds. “Psychiatrists will think someone has depression, and menopause experts will think it’s the menopause; there isn’t a test you can do to tell which it is,” she says. The problem is that doctors, and women, just aren’t asking the right questions. And when a patient is offered SSRIs instead of HRT, it’s a missed opportunity, as the menopause needs to be seen as a consultation to educate women about their future health, too.
“On top of that, of course, there are other benefits to taking HRT, whereas SSRIs can actually cause problems such as lower libido and feeling numb,” adds Dr. Newson.
The most important thing, to ensure women are receiving adequate care, is to raise awareness, both among women and doctors. “If a woman thinks her symptoms could be related to menopause, it is important that she mentions this to her GP, and discusses her other menopausal symptoms too,” says Dr. Newson. “A lot of the work I do is about empowering women. If women can ask questions and help their GP understand what’s going on, they’ll get more out of it.”
It’s not ideal, of course, but, as with any problem about which you need to visit your doctor, the more knowledge you have, and the more prepared you are when you attend your appointment, the better.