Depression in women can occur at various times of life where there are hormonal changes
• PMS, PMDD and postnatal depression are types of hormonal depression
• Low mood and depression can occur during perimenopause and menopause
• Learn how to identify and treat reproductive depression
Reproductive depression is a hormonally based depression that can come and go over the course of your reproductive life. Premenstrual depression (you might think of it as PMS or PMDD), postnatal depression and depression during perimenopause and menopause are all forms of reproductive depression.
It is important to realise that reproductive or hormone responsive depression cannot usually be diagnosed by any blood tests. You may realise that your depression is related to your hormones, but when your hormone levels are checked, especially oestradiol (oestrogen) and FSH, they may be normal and hormone levels can fluctuate. Testosterone levels may be low.
The underlying explanation for reproductive depression is that some women’s brains are much more sensitive to the hormonal fluctuations of the menstrual cycle, after pregnancy and during perimenopause and to the low levels during menopause.
The female brain relies on mechanisms to adapt to the hormonal flux that happens every month and around pregnancy. When these adaptive mechanisms are not working as they should, it can leave you vulnerable to a hormonal depression, particularly when levels of oestradiol, progesterone and testosterone decline.
Most women find that when they’re pregnant and not having monthly cycles, their mood is more stable and often good. Conversely, during perimenopause when hormones are fluctuating, women can find symptoms of depression are at their worst and these symptoms may last for several years.
RELATED: PMS, PMDD and menopause
How do hormones influence my menstrual cycle?
Hormones are your body’s chemical messengers. They travel in your bloodstream to your cells, tissues and organs then attach to a receptor in each cell to bring about a reaction. Hormones are involved in many different processes, including growth, metabolism, sexual function, reproduction and mood. There are certain hormones important to your menstrual cycle:
Follicle-stimulating hormone (FSH) is released from the pituitary gland in your brain, and it stimulates your ovarian follicles.
Luteinising hormone (LH) is also released from the pituitary gland in your brain at ovulation, causing rupture of a mature ovarian follicle, thus releasing the egg.
Oestradiol (oestrogen) is a female sex steroid hormone, responsible for thickening your womb lining and maturing an egg before you ovulate. Oestradiol is produced by your ovaries and by your adrenal glands, muscle, heart, bones, brain and fat cells. Oestradiol plays important roles in your mood, cognition and memory, bone health, cardiovascular health, and is anti-inflammatory. Inflammation can lead to an increased risk of numerous conditions, including cardiovascular disease, osteoporosis and cancer. Learn more by watching Understanding hormones: oestrogen, progesterone & testosterone explained.
Progesterone is another female sex steroid hormone. It is often referred to as the relaxing hormone. Levels of progesterone increase after ovulation and then levels decline very quickly in the second half of the cycle (luteal phase). Progesterone’s main role is to control the build-up of the endometrium (womb lining) and help maintain and mature the endometrium if there is a pregnancy. Like oestradiol, progesterone works throughout your body reducing inflammation. It is also known as the relaxing hormone - it has anti-anxiety (anxiolytic) properties so can be prescribed to relieve perimenopausal and menopausal symptoms such as sleeping problems, low mood and anxiety.
Testosterone is an important sex hormone for both men and women, although women have much lower levels. It is produced by your ovaries, adrenal glands and brain, as well as your muscles and other tissues. Testosterone often helps you maintain muscle and bone strength, enhances your sex drive and helps with your overall sense of wellbeing and zest for life.
Hormone fluctuations during the menstrual cycle
Premenstrual syndrome
Premenstrual syndrome, also known as PMS, is when you experience symptoms in the days or weeks leading up to the start of your period. These can be physical symptoms such as palpitations, breast tenderness, bloating, dry skin, cystitis and joint pains and also symptoms affecting your mental health such as low mood, anxiety, irritability, loss of confidence and mood swings.
It is the timing of symptoms that supports a diagnosis of PMS, rather than merely the nature of the symptoms themselves.
It is often worth keeping a symptom diary which can be the most reliable way to diagnose PMD and discuss possible treatments. You can use the Balance app to log your symptoms and periods.
Premenstrual dysphoric disorder
Premenstrual dysphoric disorder (PMDD) is more severe form of premenstrual disorder. The symptoms occur in the luteal phase and are severe enough to disrupt daily functioning. If you have PMDD, your mood changes each month can have a serious impact on your life. Experiencing PMDD can make it difficult to work, socialise and have healthy relationships. In some women with PMDD, it can also lead to suicidal thoughts.
Postnatal depression
Around 15%-20% of women experience depression and anxiety in the first year after birth, known as postnatal depression (PND) [1]. PND is a combination of both physical and mental symptoms, including low and depressed mood, anxiety, insomnia, poor concentration, lack of interest or enjoyment, low libido, fatigue and sometimes thoughts about harming yourself or the baby.
PND frequently goes unrecognised because many women regard depression and exhaustion as a normal consequence of looking after a new baby. Many women who are experiencing upsetting thoughts, especially those of harm, do not tell other people about this. It is very likely that the underlying cause of postnatal depression is the sudden decrease of hormones, particularly oestradiol and progesterone, that occurs after delivery. PND can be more severe and more prolonged in women who breastfeed as this can suppress levels of hormones further and for longer.
RELATED: Postnatal depression, PMDD and menopause: Wendy’s hormone journey
Perimenopausal depression
Perimenopause and menopause symptoms such as frequent hot flushes and night sweats, poor sleep, headaches, joint aches and genital discomfort can contribute to low mood. During perimenopause, hormone levels fluctuate, which can affect brain function, and it is often during this time (which can last for a decade) that mood symptoms are worse than during menopause.
There can be an overlap of symptoms between menopausal low mood and clinical depression, and it is also possible to be menopausal and suffer from depression at the same time.
RELATED: Am I depressed or menopausal?
How to treat reproductive depression
Oestrogen, progesterone and testosterone
HRT and testosterone should usually be considered the first-choice treatment for reproductive depression as the underlying cause is low and changing hormone levels [2].
The use of transdermal oestradiol (taken through the skin in a patch, gel or spray) is often recommended to replace the low levels of this hormone that occur. Higher doses are sometimes prescribed to suppress ovulation in women with PMS and PMDD so there is less variation of oestradiol levels throughout your menstrual cycle. Some women are only prescribed oestradiol on the days when they are experiencing symptoms – so the days before their periods.
Often women will be prescribed oestrogen or progesterone separately, and some women’s symptoms will improve with (body identical) progesterone alone. For most women progesterone can have a calming anti-anxiety (anxiolytic) effect on the GABA receptors in the brain and can often improve many symptoms related to PMS, PMDD and PND. (However, some women are particularly sensitive to progesterone, known as progesterone intolerance, and the hormone can have a paradoxical effect of worsening mood and anxiety.)
In the last week of your cycle, known as the late luteal phase, progesterone levels drop off rapidly and this fall in progesterone may well be one of the underlying causes of PMS and PMDD. Using high doses of body identical progesterone in the form of Cyclogest 400mg vaginal pessaries twice (or sometimes more) daily may improve symptoms more than oral progesterone for some women.
RELATED: All about progesterone: PMS, PMDD, postnatal depression and menopause
You may also be prescribed testosterone, which can often further improve your mood, energy levels and libido. A Newson Health study of 510 women – who had already been using HRT (transdermal oestrogen with or without a progestogen) – and were treated with transdermal body-identical testosterone for four months, found significant improvements in mood [3]. For instance, 56% of women reported an improvement in the symptom ‘loss of interest in most things’ and 55% reported improvement in ‘crying spells’.
Newson Research also looked at the effect of taking HRT on 1,081 perimenopausal and menopausal women who were already receiving antidepressants. After three months of taking HRT, the study found that 39% of patients had either reduced or discontinued their antidepressant/anxiolytic medication [4]. Discontinuation rates were almost double among women using testosterone with their HRT.
In severe cases of reproductive depression, GnRH analogues are sometimes used (usually when other treatments have been unsuccessful). These are synthetic hormones that ‘switch off’ your ovaries, suppressing the production of oestradiol, progesterone and testosterone. They are usually given as injections or a nasal spray – however, hormone levels will then be very low. ‘Add back’ HRT and testosterone are also usually prescribed to prevent the associated risks from a lack of hormones and to improve your future health. This is also likely to improve your symptoms as then hormone levels will be constant each day.
In the most severe cases, if symptoms still persist, the surgical removal of your womb and/or your ovaries may be an option, but only after all other options have been unsuccessful. This will lead to a surgical menopause, so HRT and testosterone is usually prescribed after the operation.
Other medications
Many women with PMS and PMDD are prescribed the contraceptive pill. However, it contains synthetic types of oestrogen and progestogen, which have different effects in your body than natural (body identical) hormones, and can lead to low mood, anxiety, reduced libido and low energy.
Even though reproductive illness is hormonal in origin, you may still be prescribed psychiatric medication. For instance, it is possible to have more than one diagnosis – ie, you can have hormonal low mood and clinical depression. Antidepressants can be taken alongside HRT and can be helpful if HRT alone is not bringing the desired effects.
There is some evidence that oestradiol can enhance the effectiveness of a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI) [5]. Ensuring you have optimal levels of oestrogen is therefore helpful in dealing with symptoms of low mood.
RELATED: Antidepressants and menopause
Diet
Eating regular meals with healthy whole foods can help to balance blood sugar levels and avoid dips (hypoglycaemia), which may exacerbate your symptoms. Try to include plenty of vegetables, fruits and legumes to provide fibre into your diet as well as vitamins and minerals, such as magnesium, calcium and B vitamins, and omega 3s from oily fish (or algae sources or supplements if you’re a vegetarian/vegan). Try to cut down, or cut out, caffeine and alcohol as these can make symptoms worse in the long run.
Exercise
Exercise helps to improve your mood by boosting endorphins, which help combat low mood and irritability. This can be both aerobic exercise in the form of walking, running, swimming and cycling or more low impact and restorative exercise such as yoga and Pilates. Exercise also helps maintain your heart and bone health as well as improve your immunity.
Stress
As soon as you begin to feel stressed, your body is flooded with the stress hormones cortisol and adrenaline. These are designed to put you into ‘fight or flight’ mode. If you have reproductive depression, persistent or chronic stress can worsen your symptoms as high cortisol (one of your stress hormones) levels can further lower progesterone levels. Know your triggers for feeling stressed and discover ways to help you cope with these and make time to relax and unwind. A quick five-minute breathing exercise can be very beneficial at times when you’re feeling overwhelmed.
Sleep
Make sure you prioritise your sleep and try to go to sleep at the same time every night. This can help to regulate your hormones and your body’s internal clock.
Counselling and therapy
Counselling, psychotherapy and Cognitive Behavioural Therapy (CBT) are immensely powerful when dealing with any form of depression and anxiety, whatever the underlying cause. Talking therapies can help you come to terms with what is happening to you and teach you techniques to manage the spiral of negative thought processes which can often occur.
Resources
NAPS (National Association for Premenstrual Syndromes)
Association for Post Natal Illness
