Chirinos DA, Yin Z, Schreiner PJ, Appiah D, Wellons MF, Lewis CE, et al. Trajectories of depressive symptoms in a population-based cohort of Black and White women from late reproductive age through the menopause transition: a 30-year analysis. Menopause. 2024;31(12).
The menopause transition, or perimenopause (PMP) is often framed as an important period for women’s mental health, with fluctuating hormones blamed for mood swings and depressive symptoms. A recent study published in Menopause: The Journal of The Menopause Society tried to shed more light on this, by examining the long-term trajectories of depressive symptoms across a 30-year period in women. The findings offered some further insights into the role of oestrogen and hormonal contraception in shaping mental health outcomes during midlife.
The study used data from the Coronary Artery Risk Development in Young Adults (CARDIA) project, a large population-based cohort that tracked 2,160 women aged 23–60. The researchers assessed depressive symptoms every five years using the Center for Epidemiologic Studies Depression Scale (CES-D), a validated tool for measuring depressive symptoms. The participants were classified into three distinct trajectories:
1. Minimal Symptoms (61%): Most women showed consistently low levels of depressive symptoms.
2. Intermediate Symptoms (31%): This group experienced moderate depressive symptoms over time.
3.Persistent Symptoms (7%): A small but significant proportion faced ongoing, high levels of depressive symptoms.
By identifying these patterns, the study demonstrated that depressive symptoms are not random but follow stable trajectories influenced by sociodemographic, behavioural, and hormonal factors.
The Role of Hormones: Oestrogen and Contraception
Hormonal changes during menopause are often implicated in mood disturbances, but the findings challenge the oversimplified view of hormones as mere culprits of midlife depression. Women who used oestrogen therapy to manage vasomotor symptoms (VMS) like hot flushes were more likely to experience persistent depressive symptoms. The odds ratio (OR) of 1.71 indicates a higher likelihood of depressive symptoms among oestrogen users compared to non-users. While this might suggest a negative impact of oestrogen, the researchers proposed a different explanation that women with severe VMS—often treated with oestrogen—may have been more prone to depressive symptoms in the first place. Conversely, hormonal contraceptive use was linked to a protective effect, with lower odds (OR 0.69) of persistent depressive symptoms. This finding is similar to previous research showing that hormonal contraception can stabilise mood by maintaining consistent hormone levels. These results reiterate the complexity of hormone therapy, suggesting that its effects on mental health may depend on individual circumstances, including the presence of VMS and pre-existing mood disorders.
Sociodemographic and Behavioural Factors
Beyond hormones, the study highlights the influence of sociodemographic and lifestyle factors on mental health. Women in the persistent depressive symptoms group were more likely to be black, have lower income and education levels, and engage in unhealthy behaviours, like smoking and excessive alcohol consumption. Body mass index (BMI) also emerged as a significant predictor, with higher BMI associated with persistent depressive symptoms. This reinforces the interconnectedness of physical and mental health, suggesting that obesity and depression are linked, possibly through shared biological pathways. This is probably somewhat generalisable to the UK population although the number of black women was proportionally much higher in this cohort. There is also no mention of other ethnic groups which again limits how the results might apply to a UK population.
Menopause: A Myth-Busting Moment
One of the study’s most intriguing findings is that the menopause transition itself did not appear to exacerbate depressive symptoms. Depressive trajectories remained stable before, during, and after menopause, suggesting that midlife mental health is shaped by other factors, such as early-life influences, than by the hormonal fluctuations of menopause. This challenges the narrative that menopause is inherently a time of heightened vulnerability to mood disorders. Instead, the study calls for a broader view of women’s mental health, one that considers lifelong influences rather than focusing solely on menopause. I would argue this may represent a limitation of the study. While the 30 year timeframe is a good period for a longitudinal study, it is observational and relied on self-reporting measures every 5 years (with a 71% response rate). I had not come across the CES-D before. It seems to be a reliable tool, but the 20 items are depression related, with no questions about anxiety. These 2 areas, self-reporting and not asking about anxiety, would suggest the study may have under reported some of the cognitive issues women I see with perimenopausal symptoms really struggle with, but may not volunteer freely. Additionally, the use of the CES-D at five-year intervals may have missed shorter-term fluctuations in depressive symptoms, particularly around menopause.
Implications for Practice
This had some interesting findings, but for me, the take home is (once again) having a holistic approach to women presenting with cognitive symptoms during the PMP. Lower socioeconomic status or higher deprivation are perhaps beyond the scope of primary care, but addressing lifestyle factors (high BMI, lifestyle, strength training versus extreme cardiovascular exercise) can help alongside any pharmacological intervention. Enquiring about previous mental health presentations is also important. Is this the first time or is this an exacerbation of an underlying common mental health disorder? I have also had a few women questioning undiagnosed neurodiversity which has been made worse by the PMP. I think offering a pragmatic approach to medication can be helpful. Hormone Replacement Therapy is recommended as first line treatment for VMS of the PMP but crippling anxiety can be helped by anti-depressant medication, especially when there are few other symptoms. And while this study is interesting, it won’t really change my practice in this area. One area that I might raise in a consultation is the effect of combined contraception on mood. This does provide some evidence of a positive impact, and could be discussed where a woman has a concern about this effect.
