Benefits, Harms, and Costs
- 1The perimenopausal period is a window of vulnerability for the development of depressive symptoms and major depressive episodes, even in women with no history of depression (high).
- 2Factors related and unrelated to menopause contribute to the occurrence and severity of mood symptoms in mid-life. Factors related to menopause are those that are context-related or timing-related, such as vasomotor symptoms, sleep disturbances, and health problems, whereas those unrelated to menopause represent a continuum of risk that precedes menopause, or longitudinal risk factors, such as unemployment, smoking, and lifetime history of anxiety (high).
- 3Recent large-scale studies show an elevated risk of depression in women following hysterectomy, with or without oophorectomy. A history of primary ovarian insufficiency, which occurs in 1% of women, is also associated with an increased risk of depression (high).
- 4Poor sleep quality, as measured both subjectively and objectively, is common among women in the perimenopausal and postmenopausal periods (high).
- 5Cognitive symptoms, such as worsening memory and slower cognitive speed, are often reported among newly menopausal women, and these symptoms have been demonstrated in prospective, longitudinal studies (moderate).
- 1Proven therapeutic options for depression at any life stage (i.e., antidepressants, cognitive behavioural therapy, and other behaviour-based psychotherapies) should remain the first-line treatment options for depressive symptoms and episodes during the menopausal transition and postmenopausal years (strong, high).
- 2For women experiencing recurrent episodes of depression during the perimenopausal period, selection of antidepressants should consider the patient's response to and toleration of previous trials of antidepressants (strong, moderate).
- 3For women experiencing new-onset depression, both adverse effects (e.g., sexual dysfunction, weight changes) and drug–drug interactions (e.g., between specific selective serotonin reuptake inhibitors and tamoxifen) specific to this population should be considered (strong, moderate).
- 4There is some evidence that hormone therapy has antidepressant effects similar in magnitude to those observed with classic antidepressant agents in perimenopausal women with depression, with or without concomitant vasomotor symptoms (strong, high). However, hormone therapy is ineffective in treating depressive disorders in postmenopausal women, suggesting a possible window of opportunity for the antidepressant benefits of hormone therapy in perimenopause (strong, moderate).
- 5The approach to poor sleep during the menopausal transition should initially include education about sleep hygiene, and primary sleep disorders should be ruled out (strong, high).
- 6Vasomotor symptoms are a significant contributor to sleep disruption and should be addressed; hormone therapy may improve sleep when vasomotor symptoms are present (strong, high).
- 7Several other therapies for sleep have shown benefit, including cognitive behavioural therapy–insomnia (strong, high), aerobic exercise, eszopiclone, venlafaxine, black cohosh, and valerian root (strong, moderate).
- 8For women with cognitive complaints, lifestyle modifications are recommended to decrease the risk of cognitive decline. These include increasing aerobic exercise and including vegetables in the diet more often, as well as limiting the potential influence of hypertension, diabetes, and atherosclerotic disease (strong, high).
- 9Menopausal hormone therapy has not been shown to significantly improve measures of cognitive function over several years of use (strong, moderate).
ABBREVIATIONS:CBT (cognitive behavioural therapy), CBT-I (cognitive behavioural therapy for insomnia), HT (hormone therapy), MDD (major depressive disorder), PSQI (Pittsburgh Sleep Quality Index), SSRI (selective serotonin reuptake inhibitor), SNRI (serotonin-norepinephrine reuptake inhibitor), VMS (vasomotor symptoms)
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This document reflects emerging clinical and scientific advances as of the publication date and is subject to change. The information is not meant to dictate an exclusive course of treatment or procedure. Institutions are free to amend the recommendations. The SOGC suggests, however, that they adequately document any such amendments.
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Language and inclusivity: The SOGC recognizes the importance to be fully inclusive and when context is appropriate, gender-neutral language will be used. In other circumstances, we continue to use gendered language because of our mission to advance women's health. The SOGC recognizes and respects the rights of all people for whom the information in this document may apply, including but not limited to transgender, non-binary, and intersex people. The SOGC encourages health care providers to engage in respectful conversation with their patients about their gender identity and preferred gender pronouns and to apply these guidelines in a way that is sensitive to each person's needs.