Menopause Myth #8: The Antidepressant Myth: When Mood Symptoms Are Actually Hormonal

She’s been taking the antidepressant for eight weeks. It’s helped slightly — the panic attacks are less frequent — but she still doesn’t feel right. She still wakes at 3am with her mind racing. She still feels on edge. She still doesn’t recognize the anxious, irritable person she’s become.

“Maybe I need a higher dose?” she asks. “Or a different antidepressant?”

Then I ask a question no one else has asked: “Are your periods still regular, or have they changed?”

Her face shifts. “They’re all over the place. Sometimes 25 days, sometimes 45. Really heavy when they come. I didn’t think that mattered.”

It matters enormously.

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The Pattern I See Daily

In my practice as a registered nurse specializing in menopause care, I see this pattern constantly:

Women in their 40s develop anxiety or mood symptoms for the first time in their lives. Or women with previous mild anxiety find it suddenly intensifies to an unbearable degree.

They go to their GP seeking help. The GP — who may have received just 1-2 hours of menopause training in their entire medical education — sees: Woman. 40s. Anxiety. Depression.

Diagnosis: Anxiety disorder. Generalized anxiety disorder. Depression.

Treatment: Antidepressants.

But no one asks about periods. No one connects the dots. No one considers: Could this be perimenopausal?

The woman takes antidepressants. Sometimes they help a bit. Often they don’t help much at all. She’s told to increase the dose, or try a different SSRI, or add another medication.

Meanwhile, her hormones continue fluctuating wildly. Her sleep continues being disrupted. Her anxiety continues escalating. She continues not feeling like herself.

Because the root cause — hormonal chaos — isn’t being addressed.

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The Myth: Mental Health and Menopause Are Separate

The pervasive myth: If you’re experiencing anxiety or low mood during perimenopause, these are separate mental health issues unrelated to your hormones.

The reality: Fluctuating oestrogen directly affects neurotransmitters (serotonin, GABA, dopamine). Mood and anxiety symptoms during perimenopause are often HORMONALLY driven — not separate mental health disorders.

This doesn’t mean the symptoms aren’t “real.” They’re very real — with real causes rooted in brain chemistry changes triggered by hormonal fluctuations.

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The Science: How Hormones Affect Mood

Oestrogen has profound effects on brain function. It’s not just a “reproductive hormone” — it’s a neuroactive steroid that affects multiple neurotransmitter systems throughout the brain.

Oestrogen and Serotonin

Serotonin is the neurotransmitter most associated with mood regulation. Low serotonin is implicated in depression, anxiety, irritability.

Oestrogen influences serotonin in multiple ways:

• Increases the number of serotonin receptors in the brain
• Increases serotonin production
• Reduces the breakdown of serotonin (so it stays active longer)
• Enhances serotonin transmission between neurons

When oestrogen levels decline or fluctuate wildly (as in perimenopause), all of these effects diminish or become erratic.

Result: Lower serotonin availability and activity. This creates symptoms identical to depression and anxiety: low mood, irritability, anxiety, loss of pleasure, crying spells.

Oestrogen and GABA

GABA (gamma-aminobutyric acid) is the brain’s primary calming neurotransmitter. It inhibits neural activity, creating a sense of calm and reducing anxiety.

Oestrogen enhances GABA function. It makes GABA more effective at calming the nervous system.

When oestrogen fluctuates wildly during perimenopause, GABA function becomes erratic. This creates:

• Anxiety and panic (the nervous system can’t calm itself effectively)
• Feeling “wired” even when exhausted
• Difficulty relaxing
• Hypervigilance and being “on edge”

Oestrogen and Dopamine

Dopamine affects motivation, pleasure, reward, and goal-directed behavior.

Declining oestrogen impacts dopamine function. This contributes to:

• Low motivation (“I can’t be bothered”)
• Anhedonia (inability to feel pleasure in things you used to enjoy)
• Flat affect (feeling emotionally numb)
• Difficulty initiating tasks
• Loss of interest in activities

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Why Perimenopausal Mood Symptoms Feel Like Mental Illness

Here’s the critical point: When oestrogen fluctuations affect serotonin, GABA, and dopamine, the resulting symptoms are biochemically identical to depression and anxiety disorders.

The same neurotransmitter systems are affected. The same brain regions are impacted. The symptoms look the same clinically.

This is why perimenopausal mood and anxiety symptoms can feel — and be diagnosed as — depression, generalized anxiety disorder, panic disorder, or other mental health conditions.

But the underlying cause is different: hormonal fluctuations disrupting neurotransmitter systems.

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How to Distinguish Hormonal Mood Symptoms from Primary Mental Health Issues

This is challenging because symptoms overlap significantly. But there are patterns that suggest a hormonal component:

Suspect Hormonally-Driven Mood Symptoms If:

Timing:

• Symptoms began or significantly worsened in your 40s or early 50s
• Symptoms started or intensified around the time your periods became irregular
• No previous history of depression or anxiety (or only mild, well-controlled symptoms previously)

Cyclical Pattern:

• Symptoms fluctuate with your menstrual cycle (worse in certain phases)
• “Good weeks” and “terrible weeks” with no obvious external trigger
• Symptoms intensify in the 7-10 days before your period (if you still have periods)

Associated Perimenopausal Symptoms:

• Hot flushes, night sweats (even if mild)
• Sleep disruption (difficulty falling asleep, waking at 3-4am, waking unrefreshed)
• Brain fog, difficulty concentrating, memory problems
• Joint pain, muscle aches
• Changes in libido
• Physical symptoms suggest hormonal involvement

Response to Treatment:

• Antidepressants provide partial relief but don’t fully resolve symptoms
• You feel “better” but not “back to yourself”
• Antidepressants help with panic or crying but not with underlying mood, energy, or sense of self

Suspect Primary Mental Health Issue (or Co-Occurring) If:

History:

• Long history of depression or anxiety (since teens, 20s, 30s)
• Previous episodes of major depression requiring treatment
• Family history of severe mental illness

Pattern:

• Symptoms constant rather than fluctuating
• Symptoms began well before perimenopause age
• No relationship to menstrual cycle
• Symptoms progressively worsening over months/years rather than fluctuating

Severity:

• Suicidal ideation (always requires immediate psychiatric assessment)
• Psychotic symptoms (hallucinations, delusions)
• Severe functional impairment (can’t work, care for self, leave house)

Important: These aren’t mutually exclusive. You can have BOTH perimenopausal hormonal mood symptoms AND a co-occurring mental health condition. Both need addressing.

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The Problem with Treating Only Mental Health

When mood and anxiety symptoms during perimenopause are treated as only mental health issues — without considering or addressing the hormonal component — several problems arise:

1. Antidepressants May Not Work Well

SSRIs and SNRIs work by artificially increasing serotonin (or serotonin and norepinephrine) availability in the brain.

This can help somewhat if low serotonin is contributing to symptoms.

But if the root problem is wildly fluctuating oestrogen affecting multiple neurotransmitter systems (not just serotonin), antidepressants alone often provide only partial relief.

Women describe:

• “I feel less panicky, but I still don’t feel like myself”
• “The crying has stopped, but I still feel flat and unmotivated”
• “My anxiety is slightly better, but I still wake at 3am with my mind racing”
• “I’m coping better, but I still don’t have the energy or drive I used to have”

2. The Underlying Hormonal Chaos Continues

Antidepressants don’t address the hormonal fluctuations causing neurotransmitter disruption.

So while you might feel somewhat better (because serotonin is being artificially boosted), the hormonal chaos continues affecting:

• Sleep architecture (even without night sweats, hormonal changes disrupt sleep quality)
• Cognitive function (brain fog, memory problems)
• Energy levels
• Physical symptoms (hot flushes, joint pain, etc.)
• Overall sense of wellbeing

3. Long-Term Health Implications Are Missed

When perimenopause is misdiagnosed as “just” mental health issues, the long-term health implications of menopause aren’t addressed:

• Bone density isn’t monitored (osteoporosis risk increases post-menopause)
• Cardiovascular risk isn’t assessed (heart disease becomes leading cause of death in post-menopausal women)
• Genitourinary symptoms aren’t prevented or treated
• Metabolic health changes aren’t addressed

4. Women Blame Themselves

When women are told they have “anxiety disorder” or “depression” but antidepressants don’t fully help, they often blame themselves:

• “I must not be taking them right”
• “Maybe I need a higher dose”
• “Maybe I’m just weak”
• “Maybe this is just who I am now”

They don’t realize the treatment isn’t addressing the root cause.

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The Evidence: HRT for Mood Symptoms

Research consistently shows that oestrogen has antidepressant effects in perimenopausal women experiencing mood symptoms.

NICE Guidelines (2015)

NICE recognizes that HRT can effectively treat low mood that arises during perimenopause. The guidelines state that HRT should be considered for mood symptoms before or alongside antidepressants.

Research Evidence

Multiple studies show:

Oestrogen as antidepressant:

• Randomized controlled trials show oestrogen therapy improves mood in perimenopausal women with depressive symptoms
• Some studies suggest oestrogen is as effective as traditional antidepressants for perimenopausal depression
• Effect is specific to perimenopausal women (oestrogen doesn’t work as antidepressant in men or non-menopausal women)

HRT for anxiety:

• Women on HRT report lower anxiety scores than women not on HRT
• Stabilizing oestrogen levels reduces anxiety symptoms in many perimenopausal women
• Particularly effective for anxiety related to sleep disruption (HRT improves sleep, which improves anxiety)

Mechanism:

• HRT stabilizes oestrogen levels (or smooths fluctuations)
• This stabilizes serotonin, GABA, and dopamine function
• Neurotransmitter systems can function more normally
• Mood and anxiety improve

British Menopause Society Position

The British Menopause Society states that HRT should be first-line treatment for mood symptoms that emerge during perimenopause, with antidepressants considered if HRT alone is insufficient or contraindicated.

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When Do You Need Both HRT and Antidepressants?

For some women, the answer isn’t “HRT or antidepressants” — it’s both.

You may need both if:

1. Pre-existing mental health condition: If you have a history of major depression or severe anxiety disorder (before perimenopause), you may need ongoing psychiatric treatment alongside menopause care.

Perimenopause can trigger relapse or worsening of pre-existing conditions. Addressing hormones helps, but doesn’t replace psychiatric treatment.

2. Severe symptoms requiring immediate stabilization: If symptoms are severe — particularly if there’s any suicidal ideation — psychiatric intervention takes priority while HRT is initiated.

HRT can take weeks to months to reach full effect. Antidepressants may be needed for immediate symptom management.

3. HRT alone doesn’t fully resolve symptoms: Some women find that HRT dramatically improves mood and anxiety, but not completely. Adding a low dose of antidepressant alongside HRT provides full relief.

4. Contraindications to HRT: If you have genuine contraindications to HRT (though many “contraindications” are outdated or relative rather than absolute), antidepressants may be the primary treatment option.

Certain SSRIs (paroxetine, escitalopram) and SNRIs (venlafaxine) have evidence for treating menopausal hot flushes and mood symptoms when HRT can’t be used.

The key is: Address all contributing factors. Don’t assume it’s “just” mental health or “just” hormones. Comprehensive assessment and treatment of both leads to best outcomes.

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What You Should Do

If You’re Experiencing Mood or Anxiety Symptoms in Your 40s-50s:

1. Ask yourself these questions:

• Did these symptoms start or significantly worsen around the time my periods became irregular?
• Do I have other perimenopausal symptoms (hot flushes, night sweats, sleep issues, brain fog, joint pain)?
• Do symptoms fluctuate in a cyclical pattern (good weeks, terrible weeks)?
• Have I been on antidepressants but still don’t feel “back to normal”?

If you answered yes to several of these, hormones are likely involved.

2. Track your symptoms:

Keep a detailed symptom diary for at least one month (preferably two):

• Mood symptoms (anxiety, low mood, irritability, panic)
• Sleep quality
• Menstrual cycle (if still having periods — when they occur, how heavy, length)
• Physical symptoms (hot flushes, joint pain, headaches, etc.)
• Energy levels
• Cognitive symptoms (brain fog, concentration)

Look for patterns. Do symptoms worsen at certain times in your cycle? Do they fluctuate week to week?

3. Discuss the hormonal connection with your healthcare provider:

Bring your symptom diary. Say:

“I’m experiencing anxiety/low mood that started in my 40s around the time my periods became irregular. I’m wondering if hormones could be contributing. Can we discuss whether HRT might be appropriate to address the root cause?”

If your GP dismisses the hormonal connection without consideration, seek a second opinion from a menopause specialist.

4. If you’re already on antidepressants:

If you’re currently taking antidepressants but:

• They’re only partially effective
• You still don’t feel like yourself
• You have other perimenopausal symptoms
• Your periods have changed

Ask your GP: “Could hormones be contributing to my symptoms alongside mental health? Would it be worth trying HRT in addition to (not instead of) my antidepressant?”

Don’t stop antidepressants abruptly. If you and your provider decide to try HRT, it should be added alongside your current treatment. Once HRT has reached full effect (3-6 months), you can reassess whether the antidepressant is still needed.

5. If your GP won’t consider the hormonal connection:

See a menopause specialist. Many women get appropriate care only after seeing a provider who specializes in menopause and understands the connection between hormones and mood.

Options:

• NHS menopause clinic (ask your GP for referral)
• Private menopause specialist (gynecologist or nurse with menopause certification)
• British Menopause Society directory lists certified specialists

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Lifestyle Factors That Support Mood During Perimenopause

Whether you pursue HRT, antidepressants, both, or neither, lifestyle interventions are crucial for mood and anxiety during perimenopause:

Sleep (Non-Negotiable)

Sleep deprivation catastrophically worsens mood and anxiety. It’s nearly impossible to feel mentally well without adequate sleep.

If sleep is disrupted:

• Address night sweats (HRT often dramatically helps)
• Optimize sleep hygiene (cool room, dark, quiet, consistent schedule, no screens before bed)
• Limit caffeine and alcohol
• Consider magnesium supplementation
• Address underlying sleep disorders if present (sleep apnea)

Prioritize 7-9 hours of quality sleep above almost everything else.

Stress Management and Nervous System Regulation

Chronic stress amplifies every perimenopausal symptom, particularly mood and anxiety.

Daily practices that regulate your nervous system:

• Breathwork: Box breathing, physiological sighs, any practice with longer exhale than inhale
• Vagal tone exercises: Humming, singing, gargling (stimulates vagus nerve)
• Movement: Walking (especially in nature), gentle yoga, swimming
• Time in nature: Even 10-15 minutes reduces cortisol
• Social connection: Face-to-face interaction activates parasympathetic nervous system

Limit inputs that dysregulate:

• Excessive social media, news consumption
• Toxic relationships or environments
• Over-committing, saying yes to everything

Exercise

Regular physical activity is one of the most effective interventions for mood and anxiety — comparable to antidepressants for mild-moderate depression.

• Aerobic exercise: 150 minutes per week of moderate activity
• Strength training: 2-3x per week (also crucial for bone health, metabolic health)
• Consistency matters more than intensity: Daily walking is more beneficial than occasional intense workouts

Exercise increases:

• Serotonin, dopamine, endorphins (natural mood boosters)
• BDNF (brain-derived neurotrophic factor — supports brain health)
• Neuroplasticity (brain’s ability to adapt)

Nutrition

Blood sugar stability profoundly affects mood and anxiety.

• Eat regular meals: Don’t skip meals or go long periods without eating
• Adequate protein: At every meal (supports neurotransmitter production, stabilizes blood sugar)
• Reduce refined carbohydrates and sugar: Blood sugar spikes and crashes worsen anxiety and mood
• Anti-inflammatory diet: Mediterranean-style eating pattern associated with better mood
• Omega-3 fatty acids: Oily fish, flaxseed, walnuts (support brain health, reduce inflammation)
• Limit alcohol: Worsens sleep, anxiety, and mood (despite initial relaxing effect)
• Limit caffeine: If anxiety is significant, reduce or eliminate caffeine

Social Connection

Isolation worsens mood and anxiety. Connection improves it.

• Prioritize meaningful relationships
• Spend time with people who support and understand you
• Join communities (online or in-person) of women going through similar experiences
• Let go of relationships that drain or stress you

Even brief positive social interactions activate the parasympathetic nervous system and improve mood.

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The Bottom Line

Mood and anxiety symptoms during perimenopause are real, valid, and deserve treatment.

But that treatment should address what’s actually causing the symptoms.

For many women, the root cause is hormonal — fluctuating oestrogen affecting multiple neurotransmitter systems in the brain.

When hormones are the primary driver:

• Antidepressants alone may provide only partial relief
• HRT can be transformative (addressing the root cause rather than just managing symptoms)
• Best outcomes often occur when both medical treatment (HRT or antidepressants or both) AND lifestyle interventions are used together

You’re not “just depressed” or “just anxious.”

You’re experiencing genuine neurochemical changes triggered by hormonal fluctuations during a major life transition.

This doesn’t diminish the severity of your symptoms. It empowers you to seek treatment that addresses the actual cause.

You deserve comprehensive care that recognizes the profound connection between hormones and mood — not dismissal with “you’re just stressed” or automatic antidepressants without investigating hormonal factors.

If your healthcare provider won’t consider the hormonal component, find one who will.

Your mental health during perimenopause matters. The cause matters. Getting the right treatment matters.

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Need Support?

If you’re experiencing mood or anxiety symptoms during perimenopause and need help navigating whether hormones are involved, I can help.

As a registered nurse and prescriber specializing in menopause care, I provide comprehensive assessment that considers both mental health and hormonal factors.