Assessing the suitability of antidepressant use during perimenopause

Perimenopause typically occurs during the decade leading up to menopause (with the average age of menopause in the UK being 51 years) and is associated with a range of physical and mental health symptoms. These symptoms are primarily caused by fluctuating hormone levels but are frequently misdiagnosed as primary mental health disorders. As a result, many women are prescribed antidepressants — a treatment that does not address the underlying hormonal cause.

This mismanagement can worsen mood and cognitive symptoms and, in more severe cases, lead to the inappropriate prescribing of antipsychotics. Research has shown that approximately 40% of perimenopausal women report increased depressive symptoms during this transitional period^​1​. However, many clinicians fail to recognise the link between these symptoms and hormonal changes, especially since mental health symptoms can appear early in the perimenopausal phase. This lack of awareness often leads to the prescribing of antidepressants instead of HRT, a more targeted and effective treatment. 

At the menopause clinic at Richford Gate Medical Practice, we have observed that many women referred for perimenopausal symptoms had already been prescribed antidepressants prior to their initial menopause review. Often, HRT was either introduced much later or not considered at all. 

An audit was conducted at Richford Gate Medical Practice, which is part of the Hammersmith and Fulham Partnership Primary Care Network, to assess the extent of inappropriate antidepressant prescribing for perimenopausal symptoms. The audit was aimed at evaluating current prescribing practices, exploring opportunities for earlier HRT intervention and assessing the potential to deprescribe antidepressants where appropriate. This work was carried out in collaboration with the lead independent prescribing pharmacist, who specialises in managing perimenopause and menopause in primary care and oversees the clinic. The clinic offers holistic, patient-centred care through thorough assessment and shared decision-making. Where appropriate, HRT is initiated to address hormone-related symptoms.

Although antidepressants can be effective for clinical depression, they carry significant risks when used inappropriately. Long-term use of selective serotonin reuptake inhibitors is associated with an increased risks of falls, fractures, strokes, seizures and potentially diabetes, especially in older adults^​2,3​. 

Common perimenopausal symptoms, such as low libido, weight gain and mood changes, are often treated with antidepressants; however, certain classes of antidepressants can worsen these symptoms because of their side-effect profile and do not address the root hormonal cause. By contrast, early and appropriate use of HRT can provide symptom relief and offer broader health benefits, including improved cardiovascular health, cognitive function and bone density. 

Using the electronic patient record system ‘SystmOne’, 124 patients aged 40–51 years were identified as potentially suitable for review. These patients had repeat prescriptions for antidepressants related to mood symptoms. Those with complex mental health histories or a personal history of breast cancer were excluded.

After further assessment by the lead pharmacist, 17 patients met the audit criteria. These were grouped into two categories:

• Group one — patients on both HRT and antidepressants;
• Group two — patients on antidepressants alone.

In group one, five patients agreed to initiate a weaning process. Deprescribing plans were developed using Maudsley Deprescribing Guidelines and patients are being monitored for further hyperbolic tapering^​4​. Group two will be the next focus, which has been scheduled for review at the menopause clinic with the site lead pharmacist. Patients with more complex mental health histories will be reviewed in collaboration with the mental health lead, to ensure that any deprescribing is carried out safely and appropriately.

This audit led to educational sessions for clinicians that highlighted the importance of recognising early perimenopausal mental health symptoms and addressing them appropriately. They also reviewed the long-term risks of antidepressant use, including the potential for persistent withdrawal symptoms.

The findings underscore the need for:

• Greater awareness of the hormonal basis of perimenopausal symptoms;
• Earlier consideration of HRT when appropriate;
• More cautious and evidence-based prescribing of antidepressants.

We advocate for enhanced training in perimenopause and menopause management across primary care to support better outcomes for women during this critical life transition. Future work will involve continued assessment of prescribing practices and exploration of safer, more effective treatment pathways.

Marwa Daraoui, trainee pharmacist; and Kaly Mohammad, lead clinical pharmacist specialising in perimenopause and menopause, both at Richford Gate Medical Practice, part of the Hammersmith and Fulham Partnership Primary Care Network.