"I was sitting at a beautiful beach with these beautiful waves and not even feeling a part of it. I just couldn't get happy," says Wesorick.

At age 39, the mother of three and registered nurse suddenly had begun to feel anxious and panicked. Sadness had become her constant companion.

But Wesorick hung on. She looked to the medical literature for an answer. A psychiatrist prescribed the antidepressant Prozac. It brought some relief. But it was another doctor who ultimately suggested what Wesorick had come to suspect. Her body was starting to be affected by fluctuations in hormone levels in her bloodstream. She had entered the transition to menopause, a time now called "perimenopause."

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Perimenopause, which comes near the end of a woman's childbearing years but before the actual menopause, is the time in a woman's life when the levels of key hormones that control the reproductive system begin to change.

Perimenopause has recently gotten more attention than ever before. A growing body of research strongly suggests that the hormonal shifts that produce the physical and psychological symptoms commonly associated with menopause — such as hot flashes and mood swings — actually start (and can be more troublesome) during perimenopause. And for some women, like Wesorick, symptoms can develop at a relatively young age.

Menopause begins on the last day of a woman's final menstruation and is clinically confirmed after a year without periods. But the absence of menstruation, which is the most obvious sign of menopause, is only one aspect of the transition. Perimenopause, in fact, spans a few or many years leading up to menopause.

"The constant change of hormone levels during perimenopause can have a troubling effect on emotions," reports the American College of Obstetricians and Gynecologists. "Some women have mood swings, memory lapses and poor concentration. Some say they cry for no reason. Some feel irritable or are depressed."

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More than 50 percent of women experience some perimenopausal symptoms before reaching the menopause, including depression, says Claudio de Novaes Soares, Ph.D., M.D., a Harvard Medical School psychiatrist who specializes in reproductive health at Massachusetts General Hospital in Boston.

During the perimenopausal phase of a woman's life, Dr. Soares says. "The body's reproductive physiology is going through a tremendous series of changes and adjustments. Women, as a whole, are more vulnerable to physical and emotional problems during this time."

Studies by Dr. Soares and others illustrate this point. In the December 1998 issue of Climacteric, a medical journal devoted to the study of menopause and perimenopause, Dr. Soares and a colleague studied clinically confirmed perimenopausal women.

Of the 101 women studied, nearly one-third suffered from a depressive disorder. Of those, half were experiencing major depression, while the other half were experiencing a milder condition called dysthymia.

According to a letter to the editor Dr. Soares wrote in the March 2001 issue of the Archives Of General Psychiatry, his findings highlight a controversial question. To what extent does the perimenopause constitute a period of increased risk for depression?

Theoretically, any increased risk of depression would result from "abrupt fluctuations" — surges and ebbs — of estrogen and progesterone levels in the bloodstream of perimenopausal women, Dr. Soares says. "It's like having high levels of progesterone and low levels of estrogen one day, and the next day, significantly higher levels of estrogen and lower levels of progesterone."

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The links between hormonal fluctuations and physical symptoms during perimenopause are becoming clearer. Take hot flashes, for example. "The temperature-regulating center in the hypothalamus [of the brain] appears to be influenced by estrogen and progesterone," Dr. Soares explains. Researchers speculate that during perimenopause the fluctuations of these hormones can cause the hypothalamus to regulate body heat less efficiently, he says.

Dr. Soares reminds us that fluctuations in reproductive hormones are associated with depression at other points in the reproductive cycle. For instance, women may experience depressed or irritable mood in the premenstrual part of their cycle — which, depending on severity may be called either premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). In addition, some new mothers develop symptoms of depression in the days, weeks or months following the birth of their baby (the postpartum period).

Antidepressant medication and psychotherapy continue to be the treatments of choice for depression occurring during the perimenopausal period. Estrogen-replacement therapy can reduce symptoms of mild-to-moderate depression in some perimenopausal women, but this option is less attractive given the additional concerns about estrogen-replacement.

Doctors might consider estrogen for short-term treatment of depressive symptoms in some perimenopausal women, especially those who also are experiencing other symptoms, such as hot flashes.

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But Dr. Soares warns that while estrogen may offer some women a two-for-one benefit — reducing physical and emotional symptoms — it's not the treatment of choice for every perimenopausal woman suffering from depression. Estrogen-replacement therapy comes with drawbacks, such as increased risk of breast and uterine cancer. Women who are severely depressed, should seek comprehensive psychiatric treatment, including an evaluation for traditional antidepressant therapy, Dr. Soares says.

Each woman must carefully weigh the benefits and risks of even short-term estrogen-replacement therapy for the depression that occurs during perimenopause. Many women will want to consider consulting their primary-care physician, their gynecologist and a psychiatrist to help them make the best decision. Such factors as the specific symptoms, the medical and psychiatric history, and the family's medical history are very important, he says.

Wesorick, meanwhile, now reaches out to educate other perimenopausal women. As supervisor of family education at St. Mary's Mercy Medical Center in Grand Rapids, Mich., she co-facilitates a perimenopause support class. She readily shares with the women in these classes the problems she experienced during her own perimenopausal phase.

"There would not be anything that would trigger it," she says of her inexplicable dark moods. A feeling of worthlessness would just wash over her, making her ask, "Why even go on living?"

She also tells them about the feelings of joy and happiness she has rediscovered, thanks to an aggressive course of treatment that includes Prozac and estrogen-replacement therapy.

Prozac helped some, she says. But the addition of estrogen, "made all the difference in the world."

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