Perimenopause or depression?

If you are struggling right now

If you have thoughts of harming yourself or feel you cannot keep yourself safe, call 999 or go to A&E now. The NHS page on urgent mental health help says a mental health emergency should be taken as seriously as a physical one. For urgent help that is not an emergency, call 111 and choose the mental health option, or ask for an urgent GP appointment. In the UK and Ireland you can call Samaritans free on 116 123. In the US, the 988 Suicide & Crisis Lifeline takes calls, texts and chats around the clock, free and confidential. Elsewhere, your local emergency number is the place to start.

Why mood changes in perimenopause

The NHS perimenopause symptom page lists mood swings, low mood and depression alongside memory and concentration problems, and says they can feel worse with poor sleep and tiredness. It also says broken sleep on its own can leave you irritable, stressed and anxious, and that night sweats make sleep worse. The NICE menopause guideline (NG23) names effects on mood, such as depressive symptoms, among the changes doctors should explain.

Timing is part of the picture. The NHS notes that symptoms usually last 7 to 9 years and change along the way: hot flushes and night sweats may settle and be followed by low mood and anxiety. So a woman whose flushes eased last year can still be in the middle of this.

What research says about depression risk

The best long-running evidence comes from SWAN, the Study of Women's Health Across the Nation, which enrolled 3,302 US women aged 42 to 52 and checked on them every year. A ten-year summary of its mood findings reports that 20.9% of premenopausal women scored high on a depression screening scale at the start, against 27.8% of those in early perimenopause. Over eight years of yearly checks, the odds of a high score climbed from early perimenopause to late perimenopause to postmenopause, even after allowing for education, stress and support.

Several other things pushed the odds up too. Hot flushes and night sweats did, and so did smoking, financial strain and low social support. The strongest single factor was two or more upsetting life events in the past year, which raised the odds more than fivefold. Hormone levels in the blood did not explain the link between menopausal stage and mood, which is one reason a hormone test cannot answer this question for you.

Screening scores are one thing and diagnosed depression is another. A SWAN study of 221 women in Pittsburgh, interviewed every year by trained assessors, found that a major depressive episode was two to four times more likely while they were perimenopausal or early postmenopausal than before. A history of major depression was a strong predictor throughout. The group was small and all from one US city, but the SWAN authors note that other long-term studies point the same way.

Where the two look alike

Read the NHS list of depression symptoms next to the perimenopause one and much of it repeats. Low mood, feeling anxious, irritability, poor sleep, lack of energy, low sex drive, unexplained aches and finding decisions hard appear on both. Waking very early, which the NHS gives as a sign of depression, is also what happens when night sweats wake you at 4am.

Hot flushes add a layer of their own. The NHS says a flush can bring on anxiety or palpitations, so a racing heart and a wave of dread at 3am may be one event. If palpitations are part of it, our page on palpitations in perimenopause sets out when they need checking.

Signs that point towards depression

No list settles it, and both can be true at once. These are the questions I would ask myself before the appointment.

Low mood that fits perimenopause more often:

• comes and goes, with worse days after bad nights or around a period
• arrived with other changes, such as shifting cycles, hot flushes or night sweats
• leaves room for good days when you still enjoy things

Signs the NHS and the diagnostic criteria tie to depression itself:

• low mood or sadness most of the day, nearly every day, for more than 2 weeks
• losing interest or enjoyment in things you used to like
• feeling hopeless, helpless or weighed down by guilt
• avoiding friends and dropping hobbies
• thoughts of death or self-harm, which need help that day

A past episode of depression matters too. SWAN found it was one of the strongest predictors of another one in midlife, so if you have been depressed before, say so early in the appointment. If your worst days fall in the week or two before each period, our page on PMDD or perimenopause explains how to tell a premenstrual pattern from a month-long one.

Perimenopause anxiety and rage

Many women describe sudden anger in their 40s rather than sadness, and search for it as perimenopause rage. That is not a diagnosis, but irritability runs through the evidence. SWAN measured how many women felt blue, irritable and tense: 20.9% of premenopausal women and 28.9% of those in early perimenopause. The NHS lists "feeling irritable and intolerant of others" as a sign of depression and links irritability and anxiety to poor sleep.

Anger that is new, out of proportion and hard to explain is worth raising in the same way as low mood. It can come from broken sleep, from depression, or from both, and a doctor can only sort that out with the whole picture.

How a GP assesses low mood

The NHS says you will usually be asked a set of questions to judge how severe depression is. One widely used set is the PHQ-9: nine questions about the past 2 weeks, each scored from 0 (not at all) to 3 (nearly every day), for a total of 0 to 27. In the study that validated it, scores of 5, 10, 15 and 20 marked mild, moderate, moderately severe and severe depression. A score of 10 or more picked up 88% of people with major depression. The question about thoughts of being better off dead or hurting yourself counts if it is there at all, however rarely.

A score does not make the diagnosis on its own. The same paper says a clinician should rule out physical causes first, and in your 40s that usually means a blood test for anaemia and thyroid problems. Our guides to perimenopause or thyroid and heavy periods cover those two. Over 45, NICE says perimenopause itself is identified from symptoms and cycle changes without hormone tests, so what you describe carries most of the weight.

Treatment is a decision to make with your doctor, and NICE says it should come with the benefits and risks of each option explained. Its 2024 update found that cognitive behavioural therapy (CBT) could be an option for some people with depressive symptoms around menopause, and asks doctors to explain what it involves.

What to note before the appointment

Two to four weeks of short daily notes make the conversation easier, because low mood tends to blur the days together. Write down:

• your mood each day as mild, moderate or severe, and whether you enjoyed anything
• how you slept, and whether night sweats or hot flushes woke you
• the first day of each period and anything unusual about it
• outbursts of anger or anxiety, and what was happening at the time
• big events of the past year, past episodes of depression, and any medicines or supplements

The diary in our printable symptom diary and appointment checklist has rows for mood, sleep and bleeding, and the cycle length calculator turns period dates into cycle lengths you can show the GP.

My take

I'd start by dropping the question of which one it is, and I'd judge the next step by two things: how many weeks the low mood has lasted and whether you still enjoy anything. The research shows the two often turn up together in these years, and a doctor needs the same notes either way, plus your sleep and your cycle. If the low mood has been there most days for more than two weeks, I would book now with a week or two of notes, and I would mention any past depression in the first minute. If it comes and goes with bad nights and you still have good days, keeping a month of notes before a routine appointment is reasonable. Any thought of hurting yourself means getting help the same day.

Related reading

This page sits with the other look-alike guides in Is it perimenopause?, including perimenopause or ADHD. If poor concentration is part of it, see brain fog in perimenopause, and perimenopause symptoms and how to track them covers the full list.