Maturitas 70 (2011) 302–306
Contents lists available at ScienceDirect
Maturitas
journal homepage: www.elsevier.com/locate/maturitas
The reciprocal relationship between menopausal symptoms and depressive
symptoms: A 9-year longitudinal study of American women in midlife
Judy R. Strauss ∗
Pheonix University, Jersey City, NJ 5550, United States
a r t i c l e
i n f o
Article history:
Received 22 January 2011
Received in revised form 5 August 2011
Accepted 10 August 2011
Keywords:
Menopause
Depression
Longitudinal research
a b s t r a c t
Objectives: The present study sought to examine: (a) the association between depressive symptoms
among pre-menopausal and peri-menopausal women and subsequent difficulty with menopausal symptoms; and (b) the relationship between initial problems with menopausal symptoms and subsequent
levels of depressive symptoms.
Study design: Prospective Longitudinal Regression Analysis (n = 986) of survey data from a national sample
of non-institutional women in midlife (mean age = 39.9 years at Time 1).
Main outcome measures: Menopausal symptoms and symptoms of depression.
Results: Initial levels of depressive symptoms predicted 9-year follow-up levels of menopausal symptoms
controlling for initial menopausal symptoms and demographic covariates (beta = .074; t(980) = 2.425;
p < .05). Initial levels of menopausal symptoms predicted follow-up levels of depressive symptoms controlling for initial depressive symptoms and demographic covariates (beta = 110; t(980) = 3.442; p < .001).
Conclusions: Women who have more symptoms of depression in their early 40’s may be at heightened
risk for problems with the menopausal transition. Conversely, efforts to address more severe symptoms
of menopause may help to reduce the onset of depressive symptoms among middle aged women.
© 2011 Elsevier Ireland Ltd. All rights reserved.
There are notable individual differences in women’s responses
to the menopausal transition. While some women experience
menopause as a normative life transition that is not marked by
severe problems, for other women, the transition is marked by
heightened levels of stress and problematic symptoms. Numerous
reviews of the impact of the menopausal transition suggest that
greater attention needs to be given to factors that account for individual differences in adaptation to menopause [1–3]. The present
study will utilize a prospective longitudinal design to examine the
extent to which levels of depressive symptoms predict increases in
menopausal symptoms. Attention will also be given to the potential reciprocal influence of menopausal symptoms on symptoms
of depression. The implications of the menopausal transition for
depression merit attention because depression poses a substantial
burden on the well-being of women and their families, particularly during midlife. The World Health Organization estimates
that major depression affected approximately 340 million people
a year during the 1990s [4]. A disproportionate number of those
affected are women aged 40–49 [5], the prime years for the onset
of menopause.
∗ Correspondence address: Fieldston Road, Riverdale, NY 10471, United States.
Tel.: +1 718 432 5388; fax: +1 718 601 2031.
E-mail address: [email protected]
0378-5122/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.maturitas.2011.08.002
Numerous studies suggest that physiological symptoms of
menopause are likely to be more severe for women who are
depressed [6,7]. Women who report more symptoms of depression also rate menopause as more stressful [8]. However, the
cross-sectional nature of these studies imposes constraints on the
inferences that can be drawn from the data. While these studies suggest that depressive symptoms and menopausal symptoms
are associated, due to the cross-sectional nature of the research,
the data are open to an explanation that reverses the direction of
causality by positing that menopausal symptoms increase symptoms of depression. Investigators have given less attention to the
possibility that individual differences in the level of menopausal
symptoms increase risk for depressive symptoms.
A number of studies have examined the extent to which the
menopausal transition might increase women’s risk for symptoms
of depression. Epidemiological studies have found that women
show the highest rates of recurrent depression between the ages of
45 and 54 [5]. While the age of peak risk for clinical depression coincides with the climacteric, the relationship between menopause
and depression is complex. The onset of menopause in itself is
not consistently associated with an increased incidence of depression among women [9–12]. Depression may increase in severity
between the age of 45 and 54 due to other stressors that occur
in midlife, such as divorce and job loss [13]. Numerous studies
suggest that the nature and severity of menopausal symptoms,
rather than the onset of menopause itself, that increases women’s
J.R. Strauss / Maturitas 70 (2011) 302–306
303
risk for depressive symptoms. Frequently reported symptoms of
menopause include depressed mood, tension, loss of energy, memory and attentional difficulties, and insomnia [14–18]. During
menopause, a subset of women who experience more severe levels of symptoms of menopause may be at heightened risk for the
onset of clinical depression [19–21]. The duration as well as the
severity of menopausal symptoms might also contribute to the incidence and severity of depressive symptoms: longitudinal studies
have found that women who undergo an extended perimenopausal
period may be at increased risk for depressive symptoms [20].
Menopause entails numerous changes in neuroendocrine functioning that have been found to be associated with increased levels
of anxiety and depression, including changes in estradiol, progesterone deficiency, and declining levels of androgen [23]. Changes
in these neuroendocrines have been directly linked to depressed
mood, tension, loss of energy, memory and attentional difficulties, and sleep disorders. Initial longitudinal studies suggest that
the relationship between changes in neuroendocrine functioning
during menopause and symptoms of depression may be explained
by women’s experiences of menopausal symptoms associated with
neuroendocrine changes. Illustratively, while levels and changes in
estradiol are associated with depressive symptoms, this association
is mediated by menopausal symptoms [23] (i.e., estradiol levels
increase symptom severity, which in turn increases depressive
symptoms, while estradiol has no direct contribution to depressive symptoms independent of its effects on menopausal symptom
levels). Cumulatively, these investigations are consistent with the
view that increases in depressive symptoms among women in
midlife may, in part, be explained by symptoms of menopause such
as those associated with disturbances in sleep patterns, mood, and
cognitive functioning.
To better understand between and the relationship between
menopause and symptoms of depression, it might be helpful
to examine the degree to which experiences directly linked to
menopause are associated with increased levels of depressive
symptoms. Such research would also address the need to better
understand the impact of menopausal symptoms on women’s functioning and psychological well-being [24]. Such an understanding is
critically important not only for the women concerned, but also for
family members, as women in midlife are often primary caregivers
for their parents as well as their children [25,26].
In order to disentangle the direction of influence between
menopausal symptoms and depressive symptoms, more research
using a prospective longitudinal research design is needed. This
design examines the extent to which initial levels of depressive
symptoms predict subsequent levels of menopausal symptoms,
controlling statistically for initial levels of menopausal symptoms.
The same design will also examine the reciprocal influence of
menopausal symptoms on symptoms of depression. In a prospective design, initial levels of menopausal symptoms are utilized to
predict subsequent levels of depressive symptoms, controlling statistically for initial levels of depressive symptoms. The results of
these prospective analyses also suggest ways in which information on women’s well-being in early middle age can be utilized
to forecast the trajectory of their adjustment to the menopausal
transition.
MIDUS study. All data records released for analysis were anonymous; none contained individual identifying information.
1. Method
1.3.2. Depressive symptoms
To measure symptoms of depression, a survey measure of
depressive affect and anhedonia was administered. Women were
asked to indicate whether or not they had experienced each of
seven symptoms of depressed affect and six of anhedonia for
two weeks during the past twelve months. Items were drawn
from the Composite International Diagnostic Interview section of
the National Comorbidity Study [28]. A total score for depressive
1.1. Ethics statement
Ethical approval for the original collection of these data, and
their public release for secondary analysis, was provided by the
Social and Behavioral Science Review Board at the University of
Wisconsin. Subjects gave informed consent for participation in the
1.2. Sample
The study employed data from the National Survey of Midlife
Development in the United States (MIDUS). The MIDUS dataset
was selected because it includes measures of menopausal symptoms, depressive symptoms, and background covariates. The
MIDUS data are available from the University of Michigan website: The Inter-University Consortium for Political and Social
Research (www.icpsr.umich.edu). This study contains two panels: MIDUS I (1994–1996) and MIDUS II (2004–2006). Technical
information concerning the selection of the sample and data
collection procedures is available from the MIDMAC website:
(http://midmac.med.harvard.edu/tech.html).
Briefly, the initial MIDUS I panel was based on a nationally
representative random-digit-dial sample of non institutionalized,
English-speaking adults, aged 25–74, who had a working telephone
number located in the coterminous United States. The response
rate to the MIDUS I survey was 61%, based on the proportion of
participants who completed both the telephone survey and selfadministered questionnaires Comparisons of the MIDUS I sample
with census data suggest that African Americans and adults with
a high school education or less are slightly under-represented. The
sample is representative of the general population in terms of gender and marital status. All of the participants in the MIDUS I panel
were contacted for the MIDUS II follow-up study. The longitudinal
response rate for MIDUS II is 75%, adjusting for mortality.
From this broader sample, the present study utilized data from
986 women who completed both the MIDUS I panel and the MIDUS
II follow-up study, who were born between 1946 and 1964, and
who had complete data on measures of depressive symptoms,
menopausal symptoms, and demographic covariates.
1.3. Measures
Participants were asked to complete measures of menopausal
symptoms and depressive symptoms. Measures of age, education, and financial security were utilized as control variables.
The measure of depressive symptoms was administered through
a telephone interview. Measures of menopausal symptoms and
demographic variables were collected through a self-administered
questionnaire.
1.3.1. Menopausal symptoms
The measure of menopausal symptoms used items was based
on the work of Rossi [27]. Women were asked to rate how often
they experienced each of five menopausal symptoms in the past
30 days (insomnia, heavy sweating, painful intercourse, hot flashes,
and irritability). Women responded on a six-point scale (1 = almost
every day, 2 = several times a week, 3 = once a week, 4 = several
times a month, 5 = once a month, 6 = never). For the present study,
the direction of scoring of these items was reversed so that a higher
score indicated higher symptom levels. The menopausal symptom scale score exhibited acceptable levels of internal consistency
(Cronbach’s alpha = .67 at Wave I and .65 at Wave II).
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J.R. Strauss / Maturitas 70 (2011) 302–306
Table 1
Sample characteristics (n = 986).
Wave I
Wave II
Characteristic
M
SD
M
SD
Age
Number of roles
Menopausal symptoms
Depressive symptoms
39.90
2.37
1.90
1.05
5.52
1.01
0.87
2.20
48.87
2.16
2.58
0.96
5.48
0.96
1.04
2.13
Characteristic
Education
HS graduate or less
Some college
4 or 5 yr. college grad
Post college grad
Financial comfort
More money than needed
Just enough money
Not enough money
N
%
N
%
328
300
200
158
33.3%
30.0%
20.3%
15.9%
388
305
200
193
29.1%
31.0%
20.3%
19.6%
142
548
296
14.4%
55.6%
30.0%
230
527
229
23.3%
53.4%
23.2%
symptoms was computed by adding the number of symptoms of
depressed affect and anhedonia that were checked. Scores on this
measure have been found to possess high test–retest reliability as
well as agreement with clinical assessments of depression [28].
1.3.3. Age
Women were asked to indicate the year in which they were
born.
1.3.4. Financial comfort
Financial comfort was measured by one question that asked
women “In general, would you say you (and your family living with
you) have more money than you need, just enough for your needs,
or not enough to meet your needs”. For the regression analyses,
financial adequacy was coded as a binary variable (0 = not enough
money; 1 = enough or more than enough money).
1.3.5. Education
Education was coded into the following specific levels: junior
high school, some high school, GED, high school graduate, 1–2 years
of college with no degree, 3 or more years of college with no degree,
graduated from 2-year program, college graduate, some graduate
school, and a professional or doctoral degree.
2. Results
2.1. Sample description
Characteristics of the sample are summarized in Table 1. The
median age of participants was 39 at Wave I and 48 at Wave II. The
median level of education was 1–2 years of college in Wave I, and
3 years of college in Wave II. In Wave I, 70% of the respondents indicated that they had enough or more than enough money to meet
their needs. In Wave II, 76.8% of the respondents indicated that they
had enough or more than enough money to meet their needs. Levels of menopausal symptoms increased significantly from Wave I
(M = 1.9) to Wave II (M = 2.7), t(985) = 20.022, p < .001, while scores
on the measure of depressive symptoms did not change significantly. With only four exceptions, women in Wave I were not
post-menopausal. By contrast, approximately two-thirds of the
women in Wave II were post-menopausal (i.e., had not had a period
for one year or more).
2.2. Bivariate relationships among study variables
In order to examine the bivariate relationships between predictor and outcome variables in this study, Pearson correlation
coefficients were computed (see Table 2). The overall magnitude of
the correlations among variables suggested that multicollinearity
would not be a problem. As expected, women with more severe
menopausal symptoms in Wave I and Wave II had significantly
lower levels of education and financial security, and were older,
at Wave I. These women also reported higher levels of depressive
symptoms at Wave I and II. Women who reported more symptoms
of depression in Wave I and Wave II had significantly lower levels of education and financial security, and reported more severe
menopausal symptoms at Wave I and Wave II.
2.3. Prospective analysis of the relationship between menopausal
symptoms and depressive symptoms
In order to examine the prospective contribution of depressive symptoms to increases in menopausal symptoms, a multiple
regression analysis was employed. Wave II menopausal symptoms
were regressed onto Wave I depressive symptoms after controlling statistically for Wave I menopausal symptoms and background
covariates. In the first stage of the regression analysis, demographic
factors that have been associated with menopausal symptom levels were entered. Although findings are not uniformly consistent,
higher symptom levels have been reported for women who have
lower incomes [1,29–31], and lower education levels. Income and
education levels are often found to be associated with levels of
depressive symptoms among women [32]. In order to control for
initial differences in menopausal symptoms, the Wave I measure
of menopausal symptoms was also included in the first stage of
the regression. In the second stage of the regression analysis, Wave
I level of depressive symptoms was added to the model already
containing the demographic covariates and initial menopausal
symptoms. Collinearity tests revealed no problems with multicollinearity among the predictor variables The addition of Wave
I depressive symptoms to the model resulted in a statistically
significant increase in the amount of variance accounted for in
menopausal symptoms, R2 change = .005, F(1,980) = 5.883, p < .05.
Coefficients for the full regression model are shown in Table 3.
Women who had higher scores on the measure of menopausal
Table 2
Correlations between menopause symptoms, symptoms of depression, and initial demographic covariates.
Age
Education
Age
Financial security
T1 menopause symptoms
T1 depression symptoms
T2 menopause symptoms
***
p < .001.
.010
Finances
.129***
−.022
Wave 1
Wave 2
Menopause
symptoms
Depression
symptoms
Menopause
symptoms
Depression
symptoms
.181***
−.104***
.169***
−.133***
.031
−.167***
.308***
.177***
−.128***
.142***
.393***
.203***
−.132***
−.008
−.152***
.217***
.332***
.255***
J.R. Strauss / Maturitas 70 (2011) 302–306
Table 3
Regression of Wave II menopausal symptoms on Wave I depressive symptoms,
controlling for Wave I menopausal symptoms and demographic covariates.
Wave I
Predictor
Beta
Education
Age
Financial security
Menopausal symptoms
Depressive symptoms
−.100
.091
−.059
.333
.074
t (df = 980)
−3.396***
3.133***
−1.988*
10.722***
2.425*
Note: R2 = .184.
*
p < .05.
**
p < .01.
***
p < .001.
Table 4
Regression of Wave II depressive symptoms on Wave I menopausal symptoms,
controlling for Wave I depressive symptoms and demographic covariates.
Wave I
Predictor
Beta
Education
Age
Financial security
Depressive symptoms
Menopausal symptoms
−.065
−.030
−.079
.278
.110
t (df = 980)
−2.144*
−.922
−2.602**
8.809***
3.442***
Note: R2 = .137.
*
p < .05.
**
p < .01.
***
p < .001.
symptoms at Wave II (indicating more severe problems), had
significantly lower levels of education, b = −.100, t(980) = −3.396,
p = .001, and financial security, b = −.059, t(980) = −1.988, p = .047,
and tended to be significantly older, b = .091, t(980) = 3.133, p = .002,
and to have more symptoms of depression, b = .074, t(980) = 2.425,
p = .015, at Wave I.
2.4. Prospective analysis of the relationship between depressive
symptoms and menopausal symptoms
In order to examine the prospective contribution of menopausal
symptoms to increases in symptoms of depression, a multiple
regression analysis was employed. The Wave II measure of depressive symptoms was regressed onto Wave I menopausal symptoms
after controlling statistically for Wave I depressive symptoms and
background covariates. In the first stage of the regression analysis,
demographic covariates and Wave I depressive symptoms were
entered into the regression equation, then Wave I menopausal
symptoms were added. Collinearity tests revealed no problems
with multicollinearity among the predictor variables The addition
of Wave I menopausal symptoms to the model resulted in a statistically significant increase in the amount of variance accounted for
in depressive symptoms, R2 change = .01, F(1,980) = 11.847, p < .001.
Coefficients for the full regression model are shown in Table 4.
Women who had higher scores on the measure of depressive
symptoms at Wave II had significantly lower levels of education, b = −.065, t(980) = −2.144, p = .032, and financial security,
b = −.079, t(980) = −2.602, p = .009, and tended to have more severe
menopausal symptoms, b = .110, t(980) = 3.442, p = .001 at Wave I.
3. Discussion
The results of the present study agree with the findings of earlier cross-sectional studies suggesting that depressed women will
have more difficulty adapting to physical changes and symptoms
during the menopausal transition [4,5]. The results of the
305
prospective longitudinal analysis are consistent with the view
that depressive symptoms may have a causal role in shaping
adaptation to physical symptoms. Because a longitudinal design
was employed, the evidence for this viewpoint is stronger than
that provided by cross-sectional analyses of depressive symptoms
and menopausal symptoms. The finding of a prospective link
between depressive symptoms and symptoms of menopause
may also carry implications for practice. These findings raise the
question of whether treatment of depression among women in
their late 30’s may serve to prevent the onset of difficulties with
coping with menopause in the subsequent decade of life.
The findings of the present study also provide initial evidence suggesting that women who experience more severe
menopausal symptoms are more likely to exhibit increased levels of depressive symptoms as they move through the menopausal
transition. These findings are among the first to demonstrate a
longitudinal association between menopausal symptoms and subsequent levels of depressive symptoms, and are consistent with
the findings of Avis and colleagues [22,23]. Such an association might have important implications for clinical practice. For
women who experience more severe menopausal symptoms during the perimenopausal period, effective management of these
symptoms might make a broader contribution to psychological well-being in middle age. This finding makes a contribution
toward understanding the ways in which menopausal symptoms impact upon women’s psychological adaptation during the
period of maximum risk for the development of clinical depression. A greater understanding of the impact of menopausal
symptoms on women’s well-being, and of psychosocial systems
that can support women through menopause, is important for
multiple generations, including women in midlife as well as children and parents for whom they have primary care-giving roles
[25,26].
The prospective and reciprocal relationships found between
menopausal symptoms and symptoms of depression may be consistent with biological and psychosocial models of menopause and
depression. The findings may be explained by a model in which
underlying physiological changes in endocrine functioning and
hormone levels result in increased levels of menopausal symptoms,
as well as depressed affect and anhedonia. Within a psychosocial framework, relationships between menopausal symptoms and
symptoms of depression may be mediated by women’s cognitive
appraisal of menopausal symptoms, as well as their impact on
social interactions and role functioning. A potentially fruitful direction for further research would incorporate measures of hormone
levels, social functioning, and cognitive appraisals of menopausal
symptoms into the dataset in order to identify mediators and
common antecedents to increases in symptoms of depression and
menopause.
The findings of the present study may have serendipitous value
for studying the contributions of social context to coping with the
menopausal transition, as well as increased levels of depressive
symptoms in midlife. While the relationship between demographic
covariates and menopausal symptom levels was not the primary
focus of the present study, it is worth noting that increases in
menopausal symptoms were significantly higher for women who
had lower levels of education and financial security, even after controlling for initial levels of depressive and menopausal symptoms.
This finding suggests that the impact of the menopausal transition
may be more problematic for women from lower socio-economic
backgrounds. Similarly, increases in depressive symptoms were
greater for women with lower levels of educational attainment and
financial security, even after controlling for initial levels of depressive and menopausal symptoms, suggesting that socio-economic
status may be associated with increased risk for midlife depression,
independent of menopausal symptom levels.
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J.R. Strauss / Maturitas 70 (2011) 302–306
Some limitations to the present study should be noted. While the
prospective effects of depressive and menopausal symptoms are
statistically significant, the effect sizes obtained in the regression
analyses are relatively modest: the incremental contribution of key
predictors is one percent or less of the variance. This pattern may,
in part, reflect random error in the measurements of menopausal
symptoms and symptoms of depression. Illustratively, the internal
consistency of the menopausal symptoms measure is .67. Random
error in this measure would serve to obscure, and underestimate,
the strength of the relationship between menopausal symptoms
and symptoms of depression. Given the influence of measurement
error on the results of the analyses, it is likely that the underlying relationship between menopausal symptoms and symptoms of
depression is somewhat stronger than the level suggested by these
findings.
Contributors
Judy Strauss conceived the survey design, obtained the data
from ICPSR, performed the statistical analyses, wrote the paper,
and has sole responsibility for the final content.
Competing interests
The author of this work has no conflict of interest or commercial
interests in the research.
Funding
The author carried out this research without external funding.
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