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Women approaching the onset of menopause face a 40% higher risk of depression than in their earlier years, according to new research, showing the need for support and screening. Experts from University College London performed a meta-analysis of seven studies involving more than 9,000 women in the US, Australia, China, the Netherlands, and Switzerland, finding women experiencing perimenopause, the transition period that begins three to five years before the onset of menopause (marked by a year without menstruation), are “at a significantly higher risk for depressive symptoms and diagnoses” compared with premenopausal women, per the Guardian.

Perimenopause, a period in which estrogen and progesterone levels fluctuate, is associated with anxiety, mood changes, low self-esteem, memory and concentration issues, hot flashes, sleep problems, muscle and joint pain, and weight gain. “It appears to (be) the variability in hormone levels—rather than absolute levels— that can trigger these symptoms in vulnerable individuals,” Dr. Stephanie Faubion, medical director of the Menopause Society, who wasn’t involved in the research, tells CNN. Estrogen “has been found to affect the metabolism of neurotransmitters (dopamine, norepinephrine, endorphin, and serotonin), all of which influence emotional states,” the study authors note, per the Guardian.

One limitation of the study, published in the Journal of Affective Disorders, is that it couldn’t determine whether participants had a previous history of depression, which is associated with depression in menopausal women. Still, “this study shows that women in the perimenopausal stage are significantly more likely to experience depression than either before or after this stage,” senior author Dr. Roopal Desai says in a release. Lead author Yasmeen Badawy adds “these findings cannot be attributed to cultural factors or lifestyle changes alone.” Researchers say this shows the need to provide support and screening for vulnerable women. The researchers previously found therapy to be an effective treatment for nonphysical symptoms of menopause. (More mental health stories.)

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