The menopause (also known as the climacteric) refers to the entire transitional period before, during, and after a woman's final menstrual period. On average, this transition lasts between seven and ten years.

The three phases are perimenopause, menopause, and postmenopause.

Perimenopause

• The phase lasting several years before the final menstrual period.
• On average, this phase usually begins in a woman's mid-40s.

Menopause

• The phase from the point of the final menstrual period up to 12 months afterward.
• Menopause typically occurs between the ages of 49 and 55.

Postmenopause

• This phase begins twelve months after the final menstrual period.
• On average, it starts between the ages of 50 and 56 and lasts for the rest of a woman's life.

The hormones estrogen and progesterone are the most important actors when it comes to your cycle and your mood. Estrogen not only ensures the maturation of egg cells but also serves many protective functions in the body, such as for the bones and the heart. Progesterone, on the other hand, is often called the "calming" hormone: it has a relaxing effect and helps regulate sleep.

During menopause, your body begins to gradually phase down the production of both these hormones. Particularly during perimenopause, the levels of both hormones fluctuate wildly before remaining at a permanently low level in postmenopause. These hormonal ups and downs are the primary cause of hot flashes, sleep disturbances, and can increase vulnerability to menopausal depression.

Menopause is a gradual process during which the hormonal balance reshapes itself in stages. During perimenopause, the hormone levels of estrogen and progesterone fluctuate particularly wildly. Production spikes and drops unpredictably and has not yet permanently decreased. This hormonal rollercoaster can lead to irregular menstrual cycles, hot flashes, and sleep problems. It is precisely this phase that carries the highest risk for developing menopausal depression.

By the onset of menopause—the time of the final menstrual period—hormone production by the ovaries has already declined significantly. In the postmenopause stage, which follows 12 months later, hormone levels then remain permanently low. The intense hormonal fluctuations of perimenopause come to an end, allowing the mood to stabilize once again.

When hot flashes and night sweats regularly interrupt your sleep, you quickly become exhausted. Chronic sleep deprivation can alter key neurotransmitters in the brain and impair your ability to regulate stress. Additional physical symptoms that may arise—such as headaches, joint pain, or vaginal dryness—can further weigh down your mood.

If these physiological shifts coincide with major life-changing events—such as a separation, children moving out of the house, parents requiring care, or career transitions—the cumulative stress can significantly increase the risk of developing clinical depression.

A depressive episode is diagnosed when either a significantly low mood or a loss of joy and interest persists for a period of at least two weeks. This is accompanied by additional symptoms such as sleep disturbances, feelings of guilt, concentration difficulties, changes in appetite, or suicidal thoughts. Crucially, the severity is determined by how much these symptoms disrupt your daily life, work, and relationships.

Many symptoms that hint at menopausal depression can also stem from other underlying causes that only a physician can accurately assess and differentiate. These include:

• Anxiety disorders
• Chronic stress (burnout)
• Side effects of medication
• Thyroid disorders
• Anemia (blood loss/iron deficiency)
• Vitamin deficiencies (e.g., Vitamin D or B12)

This is why a thorough medical evaluation—including blood work and a review of your current medications—is absolutely crucial right at the beginning. It is important to note: during perimenopause, depression cannot be diagnosed solely on the basis of hormone levels. Your first point of contact should be your primary care physician or your gynecologist.

If depression is suspected, the doctors mentioned above may have already referred you to a psychotherapeutic practice. If not, you can contact the appointment service of the National Association of Public Health Insurance Physicians online or by calling the phone number 116 117. In either case, your contact with a psychotherapist will begin with an initial psychotherapeutic consultation. This is an initial consultation with a psychotherapist to determine whether a mental health condition is present and what type of therapy might be helpful. It also serves as an opportunity to get to know each other, does not require a referral, and is free of charge for patients.

In Case of Suicidal Thoughts: Call the emergency services immediately (112), go to a psychiatric emergency room, or contact the medical on-call service (116 117) or a regional crisis hotline. Please do not hesitate!

The treatment of depression during menopause is most effective when it is tailor-made: it must fit you, your current life situation, and the severity of your symptoms perfectly. It is best to act according to the principle: "First clarify—then treat."

You hold three simple but proven, highly powerful levers in your own hands.

• Better sleep: Maintain regular sleep schedules, keep your bedroom well-ventilated, avoid alcohol as a sleep aid, and dim screens in the evening.
• Regular physical activity: Moderate endurance and strength training is proven to reduce depressive symptoms while simultaneously improving your sleep quality.
• Stress reduction: Relaxation techniques such as mindfulness exercises, nurturing social connections, and reducing alcohol and nicotine consumption lower the risk of developing depression during menopause.

Psychotherapy, such as Cognitive Behavioral Therapy (CBT), is an effective way to identify negative thought patterns, reactivate daily routines, and interrupt distressing loops of rumination. Medical guidelines recommend psychotherapy as the first choice for mild to moderate depressive episodes. If the depression is more severe, it can be combined with medication.

Hormone Replacement Therapy (HRT) is an important treatment option consisting of estrogen which—in women with an intact uterus—is combined with progesterone. The hormones are taken in an individually tailored dosage. HRT is the most effective treatment for severe hot flashes and vaginal dryness. Since hot flashes heavily disrupt sleep, HRT often improves sleep quality, which in turn indirectly stabilizes mood and can alleviate overall menopausal symptoms.

An individualized decision is crucial here: the timeline of initiation, the dosage, the method of administration, and the duration of use must be determined in consultation with your physician. During this process, risks such as breast cancer, thrombosis, or strokes must be regularly monitored. Before starting, your doctor will perform a thorough medical check that includes family history risks, blood pressure, Body Mass Index (BMI), migraine history, liver values, as well as breast and uterine examinations to weigh your personal risk profile against the expected benefits.

For moderate to severe depressive episodes, or when psychotherapy alone does not achieve the desired success, antidepressants become a viable option. The choice of medication and dosage depends on the potential therapeutic effect, expected side effects, concurrent medical conditions, and your personal preferences.

deprexis is a certified online program designed to support individuals dealing with depression. As a Digital Health Application (DiGA), it offers practical exercises, psychoeducation, and everyday tips. deprexis can be prescribed by your general practitioner, and the costs are typically covered by health insurance.