Treating depression with HRT

This article by Professor John StuddHow should reproductive depression be treated? first appeared in Total Health

Depression in women commonly occurs at times of hormonal changes, most often in the days before menstruation. A peak of depression is also seen often in the months after childbirth, even following a pregnancy that has actually been characterised by a good mood with less depression.

Menopausal transition and "reproductive depression"

Later in life, depression occurs at its most severe in the two or three years before the periods cease, in what is called the menopausal transition. When taken together, these components, including: 

  • premenstrual depression,
  • postnatal depression and
  • menopausal depression

can be called “reproductive depression”. This term emphasises the fact that this is a hormone-related mood change that may well be most effectively and simply treated by correction of these hormonal changes. 

Antidepressants are not the answer for reproductive depression

The tragedy for women is that usually the association between hormonal fluctuations and depression is not recognised by their doctors who will instead treat them with antidepressants. As these are inappropriate for hormone responsive depression they often do not work and the dose will then be increased. Often, a second or third antidepressant will be prescribed and sometimes even mood-stabilising and anti-epileptic drugs. Sometimes the condition will be dangerously diagnosed as bipolar disorder.

These peaks of depression often occur in the same woman. The typical story is one of a woman who had mild to moderate pre-menstrual syndrome (PMS) as a teenager that may have become worse with age, with fewer good days per month. When pregnancy occurs she will normally experience a good mood throughout the pregnancy in spite of other common problems that may occur, such as nausea, pre-eclampsia or other obstetric complications. However, after her baby is born she then develops postnatal depression that may go on for many months. It is at this point that women often have their first ‘nervous breakdown’. They are treated with various antidepressants, which are barely effective. When the periods return, the depression becomes cyclical and more severe but improves with subsequent pregnancies. These women still have cyclical depression in their forties and the depression becomes worse in the two or three years of the menopause transition. If they develop symptoms of hot flushes and sweats they may be given oestrogens, which will cure these symptoms and usually help the depression. 

Why “normal” hormone levels do not tell the full story of reproductive depression

With this history in mind, it is important to realise that hormone responsive depression cannot be diagnosed by any blood test. Too frequently, women who believe that their depression is related to their hormones will have their hormone levels measured and the results will be normal. Any association with hormonal changes are then simply dismissed. However, these women are all pre-menopausal and their follicle stimulating hormone (FSH) and oestradiol levels will be within the normal range, even though they may not be optimal for the individual woman. It is therefore a huge mistake to exclude hormone responsive depression because of seemingly normal hormonal levels. The clue to the diagnosis is in each woman’s medical history but even then, doctors will often regard the association of depression with periods and childbirth as irrelevant.