In 2025, the International Federation of Gynecology and Obstetrics - the body representing obstetricians and gynaecologists across 130 countries - published its first comprehensive best practice recommendations specifically addressing the mental health of women during the menopausal transition. These guidelines synthesise evidence across 13 clinical questions and represent the strongest international consensus to date on perimenopausal mental health. They shift how the medical community is expected to understand, screen for, and treat mood symptoms during midlife in ways that matter practically for every woman approaching or moving through this stage.
What they confirm is something many women have already lived without being given language for it: perimenopause is not just a reproductive transition. It is a neurobiological event. And the mental health consequences of that event are both common and chronically underrecognised.
How Common Are Mood Symptoms in Perimenopause?
The scale of the problem is not small. Multiple large-scale longitudinal studies consistently find that between 40% and 68% of women experience clinically significant mood symptoms during the menopausal transition - depression, anxiety, significant emotional disruption. UK Biobank data from over 128,000 women found a 52% increased risk of first-onset mental disorder during perimenopause compared to pre- and postmenopausal peers (Glynne et al., British Journal of Psychiatry, 2025).
The SWAN study - the Study of Women's Health Across the Nation, a landmark 10-year longitudinal study of over 3,000 women across five ethnic groups - found that women were significantly more likely to experience high depressive symptom scores when perimenopausal or postmenopausal than when premenopausal, and that this was independent of life stress, socioeconomic factors, and baseline mood. The menopausal transition itself conferred independent risk. This is not women struggling with life circumstances. It is women responding to a biological shift that directly affects brain chemistry.
And yet most women still reach this transition without being warned, without being screened, and without being offered a clinical response that addresses the full picture.
The Neurobiology of Perimenopausal Depression
One of the most important contributions of the FIGO 2025 guidelines is the explicit framing of perimenopausal mood symptoms as neurobiological events, not psychological failings or lifestyle problems. This matters because it changes what the appropriate response is.
17-beta-estradiol, the primary form of oestrogen active during the reproductive years, is a potent neurosteroid. It acts simultaneously on multiple neurotransmitter systems: it upregulates serotonin receptors and increases serotonin availability; it modulates GABA-A receptor sensitivity; and it enhances dopaminergic signalling. When estradiol begins to fluctuate - which can start years before a final menstrual period - these systems are directly destabilised.
Perimenopause is not a single hormonal event. It is a prolonged period of erratic fluctuation, often more volatile than the eventual hormonal decline of menopause itself. This means the destabilisation of serotonin, GABA, and dopamine activity can be persistent, unpredictable, and repeated over years. The anxiety that feels physical but has no obvious trigger, the irritability that arrives without warning, the anhedonia that makes everything feel flat, the exhaustion that sleep does not fix - these are not signs of psychological weakness. They are the neurological consequences of hormonal instability affecting brain systems that regulate mood, motivation, and nervous system regulation.
Prior Depression History: The Risk Most Women Are Not Told About
The FIGO 2025 guidelines specifically highlight prior psychiatric history as the single strongest predictor of perimenopausal depression. The statistic that follows is one of the most consistently replicated findings in this field, and one of the least communicated to women: 59% of women with any prior history of major depressive disorder will experience another depressive episode during the menopausal transition, compared to 28% in women without that history (Bromberger et al., Psychological Medicine, 2015; SWAN cohort, 13-year follow-up, 443 women).
More than half. And this is not confined to women with severe or long-standing depression. Any prior depressive episode - even a single one, even one that resolved fully decades ago, including postnatal depression - elevates risk during this window.
The FIGO guidelines also identify prior premenstrual dysphoric disorder (PMDD), a history of trauma, and high psychosocial stress as additional risk factors, reflecting a pattern of hormonal sensitivity that runs across reproductive life stages.
The clinical implication is direct: women with any of these histories should be proactively informed about this risk window before they enter perimenopause. They should not be waiting until they are already struggling to be told that the window was predictable.
What Treatment Now Looks Like: The FIGO 2025 Recommendations
The most significant development in the 2025 guidelines is the formal identification of transdermal estradiol as a primary treatment option for mood symptoms during the menopausal transition. This represents a departure from the historical pattern of treating perimenopausal mental health with antidepressants alone, without addressing the hormonal driver.
The evidence base is substantial. A 2018 JAMA Psychiatry randomised clinical trial found that transdermal estradiol combined with micronised progesterone prevented the onset of clinically significant depressive symptoms in euthymic perimenopausal women - a preventative effect, not merely a reactive one. A double-blind, randomised, placebo-controlled trial by Soares et al. (Archives of General Psychiatry, 2001) found that transdermal estradiol led to significant reduction in depressive symptoms over 12 weeks in perimenopausal women with confirmed depressive disorder, with most participants achieving complete remission. A 2025 real-world retrospective cohort study of 920 women at the UK's largest specialist menopause clinic found that transdermal 17-beta-oestradiol with micronised progesterone led to meaningful reductions in both depressive and anxiety symptoms.
The mechanism is clear. Transdermal delivery bypasses first-pass hepatic metabolism, providing steady physiological estradiol levels directly to systemic circulation. This stability in estradiol translates into greater stability in serotonin, dopamine, and GABA activity - the very systems disrupted in perimenopausal mood disorders.
What About Antidepressants?
The FIGO endorsement of transdermal estradiol does not make antidepressants obsolete. The guidelines are nuanced on this. For mild to moderate mood symptoms driven primarily by hormonal fluctuation, particularly in early perimenopause, transdermal estradiol is identified as the preferred primary approach. For moderate to severe major depressive disorder meeting diagnostic criteria, SSRIs and SNRIs remain first-line pharmacological treatments, consistent with NICE and CANMAT guidelines. FIGO notes explicitly that combined treatment - antidepressants alongside hormone therapy - may offer greater efficacy and faster response than either alone. Cognitive behavioural therapy has strong evidence for menopause-related insomnia, anxiety, and depressed mood and is specifically recommended as an adjunct. Aerobic exercise, sleep hygiene, and stress reduction are identified as foundational components of any treatment plan.
What the guidelines challenge is not the role of antidepressants as such. It is the reflex prescription of antidepressants without any consideration of whether the underlying hormonal biology is being addressed. Treating the symptom without treating the driver is, at best, incomplete.
What Adequate Clinical Care Now Requires
The FIGO 2025 guidelines call for a fundamental shift in standard midlife care. Routine mental health screening is now explicitly recommended as part of every consultation with a midlife woman. This is not because women cannot report their own symptoms - it is because perimenopausal mood symptoms frequently present atypically. Irritability, rage, cognitive fog, emotional lability, and sleep disruption are common presentations that can be missed entirely when clinicians are looking only for classic low mood.
The consequences of underrecognised and untreated depression during this transition extend beyond mood: the guidelines cite impacts on cardiovascular health, cognitive function, bone density, relationships, and occupational functioning. The case for proactive screening is not merely psychological. It is systemic.
What this means for individual women: if your mental health is being assessed without any consideration of your hormonal status, and your hormones are being evaluated without any consideration of your mental health, you are not receiving integrated care. If you have a prior history of depression and are approaching perimenopause, and no one has mentioned the risk window ahead, that is a gap in your care. You are entitled to ask for this conversation, and entitled to a clinician who takes the neurobiological evidence seriously.
What Changes When We Understand This Differently
There is a particular kind of weight that comes with struggling and believing the struggle reflects something fundamentally wrong with you - a weakness, a failure to manage, an inability to cope with what other people seem to handle. Many women I work with carry this weight into the perimenopausal years without any frame of reference for what is actually happening biologically.
What the FIGO 2025 guidelines represent, beyond the clinical recommendations, is a shift in attribution. When depression and anxiety in midlife are recognised as neurobiological events driven by hormonal instability - rather than psychological fragility or life circumstances - the clinical response changes. And when the clinical response changes, so does what women are offered, and what they understand about their own experience.
This is not a small thing. It matters enormously whether a woman understands that her nervous system is responding to erratic estradiol fluctuations that are directly disrupting her serotonin and GABA systems - or whether she believes she is simply not coping well with the second half of life. The first framing opens the door to informed, targeted treatment. The second closes it and adds shame on top of an already difficult experience.
The 2025 FIGO guidelines represent the strongest international consensus to date on the neurobiological reality of perimenopausal mental health. What they ask of clinicians is proactive screening, integrated assessment, and a treatment response that includes hormonal biology alongside psychological support. What they ask of healthcare systems is that the evidence already in existence stops being withheld from the women it concerns. And what they confirm, for women who have been struggling in silence and wondering why - is that they were right to suspect that something real was happening to them.