Depression in women and hormones: PMDD, menopause and the thyroid

Depression in women: what does it have to do with hormones?

Depression in women is more common than in men, and hormones play a real part, but they are not the only cause. Hormonal changes before periods, during pregnancy and after childbirth, and in the years before menopause can make some women more prone to mood swings and depression. Common physical conditions in women, such as an underactive thyroid and anemia, also produce symptoms that look like depression. The good news is that a medical assessment and blood tests can tell these causes apart, and each one has a treatment.

The World Health Organization (WHO) estimates that in 2023 depression affected about 6.2% of adult women worldwide, compared with 4.1% of men, and that more than 10% of pregnant women and women who have just given birth experience depression. The US National Institute of Mental Health (NIMH) explains that depression is common among women because of biological, hormonal and social experiences specific to them, and that some types are linked to particular stages of a woman's life.

But remember that mood swings in women on certain days are one thing, and depression is another: depression is sadness or loss of pleasure that lasts most of the day, nearly every day, for at least two weeks according to WHO, and disrupts your life. For the full picture, read the psychological and physical symptoms of depression.

PMDD symptoms: when do premenstrual mood swings become a disorder?

Many women feel irritable, sensitive or tired in the days before their period; this is known as premenstrual syndrome (PMS). Premenstrual dysphoric disorder (PMDD), which many people call "premenstrual depression", is described by NIMH as a more severe form of PMS. Its symptoms include:

• Depressed mood, intense sadness or a feeling of hopelessness
• Anger and irritability stronger than usual, affecting the people around you
• Tension, anxiety and changes in appetite
• Physical symptoms such as bloating, breast tenderness and joint or muscle pain
• Suicidal thoughts in some women, which need help right away even if they disappear after the period

What sets this disorder apart is timing: according to MedlinePlus, symptoms build up in the week before bleeding and tend to ease within a few days once the period begins. No exam or blood test can confirm it. A doctor asks about your medical history, examines you, and arranges a thyroid test and a mental health assessment to rule out other conditions, and Cleveland Clinic notes that you may be asked to track your symptoms in a diary through one or two cycles. Its exact cause is unknown; hormonal changes during the cycle seem to play a role, and it is more likely if you have anxiety or depression, or a family history of premenstrual or mood disorders.

Menopause and depression: what is hormonal and what counts as depression?

The transition before periods stop, which doctors call perimenopause, comes with major hormonal changes. NIMH notes that mood swings, hot flashes and sleep problems are common at this stage, but if irritability, anxiety, sadness or loss of enjoyment become stronger than usual, it may be perimenopausal depression.

This is not just an impression: a systematic review and meta-analysis published in 2024 in the Journal of Affective Disorders found that the likelihood of depressive symptoms or a depression diagnosis was about 40% higher in perimenopausal women than in women before this stage, while the study found no clear increase in risk after periods had stopped for good. In other words, the years of fluctuation themselves are the most sensitive time.

How can you tell hormonal symptoms from depression?

• More likely hormonal: hot flashes, sleep problems, and mood swings that come and go without stopping you from enjoying your day
• More likely depression: persistent sadness or emptiness most of the day, loss of pleasure in things you used to love, feeling guilty or worthless, withdrawing from people, and thoughts of death
• The two can overlap: poor sleep wears you out and exhaustion weighs on your mood, which is why you need an assessment that looks at the whole picture

Don't treat this stage as "something natural you just have to endure". Depression during it is treated like any other depression, and the hormonal symptoms have treatments too.

Thyroid and mood changes: a treatable cause to rule out

An underactive thyroid (hypothyroidism) is a well-known physical cause of symptoms that can resemble depression. According to the UK's National Health Service (NHS), its most common cause there is an autoimmune condition called Hashimoto's disease, which is more common in women and usually starts between the ages of 30 and 50, and the risk is higher if someone in your family has had a thyroid condition. Its symptoms include:

• Severe tiredness and low energy
• Feeling the cold more than usual
• Weight gain and constipation
• Low mood or depression and difficulty concentrating
• Dry skin and hair or hair loss, and irregular or heavy periods

Diagnosis is simple: a blood test measuring thyroid-stimulating hormone (TSH) and thyroid hormone (T4). Treatment is usually tablets that replace the thyroid hormone, prescribed and monitored with blood tests by a doctor. Cleveland Clinic explains that blood tests can rule out other causes of depression symptoms such as thyroid problems, which is why a doctor may request it as part of the assessment. If the thyroid is brought under control and the sadness and loss of pleasure remain, the depression needs its own treatment alongside the thyroid treatment.

Anemia and vitamins: tests your doctor may request

Tiredness and low energy are symptoms of depression, but they are also among the main symptoms of iron deficiency anemia, according to the NHS, together with shortness of breath, heart palpitations, pale skin and headaches. Among its most common causes in women are heavy periods and pregnancy, and it is detected with a full blood count.

So, depending on your age and symptoms, your doctor may request tests such as:

• A full blood count to look for anemia
• Thyroid function tests
• Levels of some vitamins when needed: Cleveland Clinic lists vitamin deficiencies among the causes tests can rule out
• Tests decided by a gynecologist if periods are very heavy or irregular

These tests do not diagnose depression, but they make sure a treatable physical cause is not missed. Don't start iron tablets, supplements or hormones on your own before testing and a doctor's advice.

When should your gynecologist and psychiatrist work together?

Many situations need both doctors, with you as the link between them. This teamwork matters especially in:

• PMDD, when the options are between a psychiatric medicine, hormonal pills, or both
• Perimenopause, when hormone replacement therapy (HRT) is being considered and there is clear depression at the same time
• Planning a pregnancy, pregnancy or breastfeeding while you have depression or take psychiatric treatment
• Heavy periods with tiredness and sadness, or irregular periods with symptoms that resemble an underactive thyroid
• After childbirth, if sadness or anxiety lasts or becomes severe; read about postpartum depression

Tell each doctor everything you take, including birth control pills, hormones and supplements, and take each one's report to the other so there is a single plan.

When to get help: warning signs that need urgent action

Book an appointment if sadness, loss of pleasure or irritability lasts more than two weeks, if premenstrual symptoms damage your relationships or work every month, or if your mood hasn't improved despite treatment for thyroid problems or anemia. These signs, however, need mental health help today:

• Thoughts of death or self-harm, even if they come only before your period
• Feeling completely hopeless or like a burden on your family
• Being unable to eat, sleep, or look after yourself or your children

If you are worried about your wife, mother or daughter, ask her calmly and directly whether she is thinking about harming herself, listen without blame, don't leave her alone, remove anything she could use to hurt herself, help her reach help and follow up with her afterward.

Depression treatment for women: what suits each stage?

Treatment is built on the diagnosis and the stage of life you are in. WHO stresses that psychological treatments are the first choice for depression and can be combined with antidepressants in moderate and severe depression, while mild depression does not need medication.

• PMDD: regular sleep, exercise and diet, and cognitive behavioral therapy (CBT); a doctor may decide on a selective serotonin reuptake inhibitor (SSRI), which MedlinePlus describes as usually the first choice, or on birth control pills if a gynecologist sees fit.
• Perimenopause: the NHS explains that HRT can ease anxiety and low mood caused by menopause, and that its benefits are likely to outweigh its risks for women under 60 who have menopausal symptoms and no high risk of breast cancer or blood clots. This refers to low mood linked to menopause; if depression is clear, therapy and medication when needed remain the basis of its treatment. The decision is an individual one with your doctor, and guidance may differ between countries.
• Pregnancy, breastfeeding and planning a pregnancy: always tell your doctor, as this changes the options, and the decision weighs the benefits and risks for you and your baby. Don't stop a medicine suddenly on finding out you are pregnant before talking to your doctor. Read more about psychiatric medication in pregnancy and breastfeeding.
• Physical causes: treating an underactive thyroid or anemia if present, then keeping an eye on your mood afterward.

Don't start or stop a medicine or hormone on your own; as NIMH explains, finding the most suitable treatment can take some trial with your doctor.

At Oxygen Center the path starts with an appointment with a psychiatrist that assesses your symptoms and their timing and requests any tests needed, followed by a plan that may combine therapy sessions with medication when needed, coordinated with your gynecologist if required. The appointment is confidential, and you can contact us 24/7. Oxygen Center sees women in its outpatient services, such as doctor appointments and therapy sessions, while inpatient stays are for males only, aged 15 and over, so in an emergency call 123 or go to the nearest emergency department.

What you feel is not self-indulgence, and not "just hormones that will pass". It is a condition with understandable causes and effective treatment, and getting better is possible.