SSRIs and other antidepressants for menopause

SSRIs, selective serotonin reuptake inhibitors, and SNRIs, serotonin and norepinephrine reuptake inhibitors, are two closely related families of antidepressants. The British Menopause Society notes that some also help anxiety.

They also turn up in menopause care, for two different reasons. Some are used as a non-hormonal treatment for hot flushes and night sweats. And some women in midlife are given one for low mood or anxiety that started around the same time as their other menopause symptoms.

Those are two different jobs. Knowing which one your prescription is doing is the first question to ask.

The Pakistan Menopause Society's table of non-hormonal treatments for hot flushes and night sweats (Table 11) lists two SSRIs, paroxetine and escitalopram, and two SNRIs, venlafaxine and desvenlafaxine.

The British Menopause Society's guide for clinicians lists the same family, with some cautions. These medicines are often used outside their licence when the reason is menopause symptoms. Side effects across the SSRIs include nausea, dizziness, a short-term rise in anxiety at the start, and sexual side effects. Paroxetine can make tamoxifen, a breast cancer medicine, less effective, and the BMS says fluoxetine should be avoided with it too. It names venlafaxine as possibly the safest choice for women on tamoxifen.

The European Menopause and Andropause Society (EMAS) adds a note on blood fats: sertraline and paroxetine can raise triglycerides, and venlafaxine may raise blood fat levels too.

NICE NG23 is clear on hot flushes: "Do not routinely offer selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs) or clonidine as first-line treatment for vasomotor symptoms alone." (1.5.4) The guideline's first recommendation for hot flushes is to offer HRT (1.5.1).

On mood, NG23 separates two situations. For low mood that does not amount to a diagnosis of depression and began around the same time as other menopause symptoms, it says to consider HRT (1.5.21) and menopause-specific CBT (1.5.22). For a woman who has, or may have, depression, it asks doctors to follow the menopause guideline and the depression guideline together (1.5.23).

The Pakistan Menopause Society's recommendations point the same way. They list SSRIs and SNRIs for when HRT is not suitable or a woman declines it, and keep antidepressants for moderate to severe mood disorders after a specialist has assessed her (7.2). For women who have had breast cancer, they say an SNRI such as venlafaxine may be considered for flushes (7.1.2).

Why this matters here

An audit of 250 women aged 45 to 55 treated for depression at Benazir Bhutto Hospital in Rawalpindi, presented at a conference in 2024, found that 78% had significant perimenopausal symptoms that had been missed, and that 82% were being treated with antidepressants (Gul, 2024). EMAS gives the wider picture: depressive symptoms affect 45 to 68% of women in perimenopause, against 28 to 31% in the years before it.

None of that means an antidepressant is the wrong medicine for you. It may be exactly right, especially if you have depression. It does mean that is this for my mood or for my menopause? is a fair question, and one you are allowed to ask.

If you are on an antidepressant and think perimenopause may be part of the picture, book an appointment to talk it through. Bring a record of your symptoms; the symptom score is one way.

Talk to whoever prescribed your antidepressant before changing anything. The PMS table notes that these medicines are reduced gradually when stopped.

The PMS recommendations list severe depression and a risk of self-harm among the things a doctor should investigate or refer on (Table 4).

In many families, depression ki dawa carries a weight that a blood pressure tablet does not. Some women refuse it for fear of what people will say. Others take it quietly and never mention it to anyone. Both are understandable.

Some women are told, or tell themselves, that low mood means their faith has grown weak. It is a heavy thing to carry and a hard one to say out loud. If faith questions are part of what is weighing on you, a scholar you trust can be part of the conversation. The medicine itself is a conversation for your doctor.