In this article
Maybe you snap at people you love and then wonder where that came from. Maybe a low hum of worry follows you all day, or you wake at 4 a.m. with your heart racing. Mood changes in midlife are real, and they are not a character flaw. Here is what we know about hormones and mood, and where hormone therapy fits.
If you are thinking about harming yourself, call or text the 988 Suicide & Crisis Lifeline at 988, or chat at 988lifeline.org. In a life-threatening situation, call 911 [8].
Why mood can shift around menopause
Mood swings, including irritability, depression, and anxiety, are listed among menopause symptoms [9]. The Menopause Society says mood symptoms may be related to big swings in estrogen during perimenopause, though the exact mechanism is unknown [1]. Stress and other symptoms, like hot flashes and sleep changes, may also play a role [1].
Hot flashes and mood seem tightly linked. Hot flashes raise the risk of depressive symptoms, partly by interrupting sleep, and on a day-to-day basis they show up alongside low mood and predict low mood the next day [3]. They may also make anxiety worse, because they are unpredictable and can be embarrassing [1].
Who is most at risk
Women appear especially vulnerable to depression during the perimenopause years [1]. An expert guideline from The Menopause Society and the National Network of Depression Centers calls this time a window of vulnerability for both depressive symptoms and major depressive episodes [2]. Most women who have a major depressive episode in perimenopause have had one before [2], and a history of depressed mood earlier in life marks the highest risk [1].
Anxiety disorders are common in women across the lifespan [1]. Midlife depression often shows up alongside hot flashes and poor sleep, and the symptoms overlap, which can make them hard to tell apart [2].
What estrogen trials found
Most of the research tested estrogen in women who were already depressed, and most of it used estrogen without a progestogen [3]. Trials were small. Here is what they measured:
| Study | Who took part | What they took | What happened |
|---|---|---|---|
| Schmidt, 2000 | 34 perimenopausal women with depression [4] | Estradiol or placebo for 3 weeks [4] | Full or partial response in 80% on estradiol vs 22% on placebo, with or without hot flashes [4] |
| Soares, 2001 | 50 perimenopausal women aged 40 to 55 with a depressive disorder [5] | Estradiol patch (100 mcg) or placebo for 12 weeks [5] | Remission in 68% on estradiol vs 20% on placebo [5] |
| Gordon, 2018 | 172 perimenopausal and early postmenopausal women without depression [6] | Estradiol patch plus intermittent micronized progesterone, or placebo, for 12 months [6] | Reached the range of clinically significant depressive symptoms at least once: 17.3% vs 32.3% on placebo [6] |
| KEEPS, 2015 | 693 healthy women, average age 52.6, about 1.4 years past their last period [7] | Oral conjugated estrogens or an estradiol patch, each with micronized progesterone, or placebo, up to 4 years [7] | Oral conjugated estrogens improved depression and anxiety scores; the patch group was similar to placebo [7] |
In the Gordon trial, the benefit showed up in women in the early menopause transition, not in the late transition or after menopause [6]. That matches a wider pattern: The Menopause Society says estrogen does not appear to treat depressive disorders in postmenopausal women, suggesting a window of opportunity in perimenopause [3].
What the guidelines say
The expert guideline on perimenopausal depression is clear about the order of treatment [2]:
- Front-line treatment: proven depression treatments, meaning antidepressants and psychotherapy, come first [2].
- Estrogen's place: estrogen therapy is not approved to treat perimenopausal depression, but there is evidence it has antidepressant effects in perimenopausal women, especially those who also have hot flashes [2].
- Combined hormones: data on estrogen plus a progestogen are sparse and inconclusive [2].
The Menopause Society's 2022 position statement adds a few points [3]:
- In depressed perimenopausal women, estrogen's antidepressant effect has been similar in size to antidepressants, with or without hot flashes [3].
- In women who are not depressed, there is some evidence estrogen improves mood and well-being [3].
- Estrogen may help prevent depressive symptoms in perimenopause, but the evidence is not strong enough to recommend it for prevention [3].
- Estrogen may boost the response to antidepressants, preferably when it is also needed for symptoms like hot flashes [3].
- Estrogen is not government-approved to treat mood disturbance [3].
For women with a history of depression, the position statement says clinicians should screen for depression and use antidepressants or proven therapies, such as cognitive behavioral therapy, as the primary treatment for a recurrent major depressive episode [3]. It adds that hormone therapy for menopause symptoms like hot flashes should be considered in midlife women with depression [3].
What about anxiety?
Here the honest answer is that we know less. Most hormone trials were built around depression, not anxiety. In KEEPS, women on oral conjugated estrogens had lower anxiety scores over four years than women on placebo, while the estradiol patch group looked like placebo [7]. The authors described the mood benefits as small to medium [7].
Because hot flashes may make anxiety worse [1], they are worth raising with your clinician if you have both. Hormone therapy is the most effective treatment for hot flashes [3]. Read more in HRT for hot flashes.
When to get help
The Menopause Society says that if low mood and related symptoms last at least 2 weeks, they may be signs of major depression [1]. Any obvious changes should be brought to a healthcare professional [1].
- Notice how long low mood or worry has lasted
- Track hot flashes and sleep alongside mood
- Tell someone you trust how you feel
- Call or text 988 in a crisis
- Screen for depression and anxiety
- Ask about past episodes of depression
- Discuss therapy and antidepressants
- Weigh hormone therapy for menopause symptoms
Please do not wait if you have thoughts of suicide. Call or text 988, or chat at 988lifeline.org, and call 911 in a life-threatening situation [8].
Mood, menopause, and WarriorBabe Health
WarriorBabe Health clinicians focus on menopause symptoms. If hot flashes, night sweats, and broken sleep are part of what you are feeling, they can review your history and discuss whether hormone therapy fits. Options include oral estradiol, an estradiol patch, and a progesterone capsule for women with a uterus. See all options on our hormone therapy page.
Hormone therapy is not a substitute for depression care. If you think you may be depressed, please also talk with your primary care clinician or a mental health professional. Our hormone products are compounded by a licensed pharmacy and are not FDA-approved.
Day to dayWhat to do day to day, from the WarriorBabe Show:How stress affects your hormones, metabolism and mood →Frequently asked questions
Can HRT help with menopause anxiety?
The evidence is limited. In the KEEPS trial, oral conjugated estrogens lowered anxiety scores compared with placebo, but an estradiol patch did not [7]. Hot flashes may worsen anxiety [1], and hormone therapy is the most effective treatment for hot flashes [3]. Talk with your clinician about all your options.
Is HRT a treatment for depression?
No. Estrogen is not approved to treat depression or mood disturbance [2, 3]. Antidepressants and psychotherapy are the front-line treatments for perimenopausal depression [2]. Some trials found estrogen had antidepressant effects in perimenopausal women [4, 5].
Does HRT help mood after menopause?
For depressive disorders, estrogen does not appear to work after menopause, according to The Menopause Society [3]. There is some evidence it improves mood and well-being in women who are not depressed [3].
References
- The Menopause Society. Mental health. Menopause topics, patient education. menopause.org/patient-education/menopause-topics/mental-health
- Maki PM, Kornstein SG, Joffe H, et al. Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. Menopause. 2018;25(10):1069-1085. pubmed.ncbi.nlm.nih.gov/30179986/
- The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. menopause.org/wp-content/uploads/professional/nams-2022-hormone-therapy-position-statement.pdf
- Schmidt PJ, Nieman L, Danaceau MA, et al. Estrogen replacement in perimenopause-related depression: a preliminary report. Am J Obstet Gynecol. 2000;183(2):414-420. pubmed.ncbi.nlm.nih.gov/10942479/
- Soares CN, Almeida OP, Joffe H, Cohen LS. Efficacy of estradiol for the treatment of depressive disorders in perimenopausal women: a double-blind, randomized, placebo-controlled trial. Arch Gen Psychiatry. 2001;58(6):529-534. pubmed.ncbi.nlm.nih.gov/11386980/
- Gordon JL, Rubinow DR, Eisenlohr-Moul TA, et al. Efficacy of transdermal estradiol and micronized progesterone in the prevention of depressive symptoms in the menopause transition: a randomized clinical trial. JAMA Psychiatry. 2018;75(2):149-157. pubmed.ncbi.nlm.nih.gov/29322164/
- Gleason CE, Dowling NM, Wharton W, et al. Effects of hormone therapy on cognition and mood in recently postmenopausal women: findings from the randomized, controlled KEEPS-Cognitive and Affective Study. PLoS Med. 2015;12(6):e1001833. pubmed.ncbi.nlm.nih.gov/26035291/
- National Institute of Mental Health. Suicide prevention. Health topics. www.nimh.nih.gov/health/topics/suicide-prevention
- MedlinePlus. Menopause. Medical Encyclopedia. US National Library of Medicine. medlineplus.gov/ency/article/000894.htm
This article is for general information. It is not medical advice and does not replace a visit with a licensed clinician who knows your history. Do not start, stop or change a medication without talking to your clinician. If you think you are having a medical emergency, call 911.
