About a quarter of women will develop depression as they approach menopause - even if they have never experienced it before - and they need to be ready, experts urge.
Depression is more common among women, and we have long known that times of hormonal fluctuation increase their risks for the mood disorder dramatically, reports the Daily Mail.
While postpartum depression is widely discussed and screened for, perimenopausal depression too often gets swept under the rug.
Even if they never have children, all women who live into middle age will experience menopause, and a panel of University of Illinois at Chicago-led scientists have finally read the first guidelines ever on perimenopausal depression.
An expert gave Daily Mail Online her own guide to why menopause may bring on depression and what women (and doctors) can do to be ready for the change.
Why does menopause increase depression risks? It's complicated
Between the ages of 45 and 55, women have their final period, marking the end of the reproductive period and the beginning of menopause.
Women experience unique periods of hormonal fluctuation during puberty, pregnancy and menopause.
Twice as many women as men develop depression at any age or life stage, and hormones play a role in this.
Of the 12 million women that experience depression at some point in their lives, nearly 60 per cent that develop it during younger years will have another episode in the perimenopausal period.
"There are both environmental and biological factors" that lend to depression, says lead study author Dr Pauline Maki of the University of Illinois at Chicago, and they both have to be addressed.
Biological shifts change the brain's chemical balance too
Menopause is an inevitable bodily change that upsets the previous balance of a woman's system.
As a woman ages, she begins to exhaust her store of eggs and the ovaries' functionality decline.
"We think of this as when the ovaries are shutting down - and that's true - but many think that comes with a steady decline in estradiol created by them, but, in reality, we see dramatic fluctuations in estrogen," says Dr Maki.
"It turns out that across different life events, it's the fluctuations in the estrogen levels that are tied to disruption in mood, not absolute levels."
Estrogen encourages the production of serotonin which in turn helps to regulate mood. So when estrogen levels are all over the place, serotonin and mood can get destabilised, too.
Knowing that this can help women prepare for the mood fluctuations that might be to come.
Though the new guidelines specify that hormone replacement therapy (HRT) will not treat depression itself, it may help to minimise this serotonin shift.
"There's a lot of misunderstanding about hormone therapy, but the benefits outweigh the risks," says Dr Maki.
"So, for women with co-occurring symptoms [of menopause and depression], I don't want to be a pill pusher, but hormone therapy is an option."
Antidepressants, too, are an option says Dr Maki, and women and their doctors can "discuss whether we prophylactically treat you or wait until symptoms occur."
Major life changes affect mood but talk therapy can help
Menopause is "a significant life event for women, on a personal level," says Dr Maki.
"Women are getting older, they are no longer fertile, many are at the peak of their careers, balancing the needs of ageing parents plus children and it can be a period of marital stress."
While the underlying causes of depression include genetic and hormonal factors, most research suggests that stressful life events are still the most significant risk factors for the mood disorder.
"Women kind of look at all of these big changes in their lives at a time when the brain is more vulnerable than in other times in life," Dr Maki says.
There is no getting around the stressors of menopause, but talk therapy can help women cope with these shifts and changes.
"Cognitive behavioral therapy is a nice alternative, because a pill's not going to help you come to terms with your ageing," says Dr Maki.
Beat the heat flashes and get some sleep
Hot flashes and especially night sweats are among the hallmark, dreaded symptoms of menopause, and feeling miserable does nothing for a woman's mood, or sleep.
"I would add that hot flashes disrupt sleep and you and I both know that multiple nights of disturbed sleep are not good for our mood and thinking," says Dr Maki.
Plus depression itself can lead to insomnia.
"You take a period of hormonal vulnerability and add to it sleep symptoms and the life events, and it's kind of a perfect storm," Dr Maki says.
Really the only way to get rid of the night sweats is to take estrogen to balance out the hormonal decline.
What women can do to beat menopausal blues
Unfortunately, Dr Maki says that women and practitioners alike seem to lack awareness of perimenopausal depression - as well as a willingness to discuss it.
"It's a time of vulnerability," she says.
"Women don't like to talk about menopause openly, there's still a stigma about it."
What's more, when it comes to post menopausal depression, "I don't know that the knowledge is there that, 'oh, this is a thing.'"
The guidelines aim to change that, but beyond keeping up a good diet and exercising, women and their doctors really must work together to deal with perimenopausal depression.
"As a vegetarian who loves yoga, we also reviewed alternative approaches. We tried botanicals and other things that we thought might work, but there wasn't the support for it unfortunately," says Dr Maki.
But exercise helps, and, "depending on the nature of the factors that contribute to depression, there are different ways that one can treat it."
This form of depression is "very complicated because it's biological, environmental, and particularly because it involves menopausal symptoms, but we do have solutions," Dr Maki says.
• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services: (06) 3555 906
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (available 24/7)
• Whatsup: 0800 942 8787 (1pm to 11pm)
• The Word • Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• CASPER Suicide Prevention
If it is an emergency and you feel like you or someone else is at risk, call 111.