Antidepressants
Mixed evidence
SSRIs and SNRIs
Commonly prescribed for menopause — but often not the right first choice.
30-second summary
SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors) are antidepressants that are increasingly prescribed for menopausal symptoms — particularly hot flashes and mood changes. They have genuine but modest evidence for these uses. The concern is that many women are prescribed them without being offered HRT, which has stronger evidence and addresses the hormonal cause directly.
What it is
SSRIs include fluoxetine (Prozac), paroxetine (Paxil), escitalopram (Lexapro), and sertraline (Zoloft). SNRIs include venlafaxine (Effexor) and desvenlafaxine (Pristiq). For menopause, paroxetine (Brisdelle — FDA-approved for hot flashes) and venlafaxine have the most evidence.
What the evidence shows
Paroxetine reduces hot flash frequency by approximately 60% compared to 65-75% for HRT. Venlafaxine shows similar modest benefit. Both have reasonable evidence for mood improvement in perimenopausal women — though it is difficult to separate hormonal mood effects from general antidepressant effects. SSRIs do not help vaginal dryness, joint pain, or bone density.
Honest about risks and side effects
Side effects are significant and often underemphasised — sexual dysfunction (reduced libido, difficulty with orgasm) affects 30-40% of users and is particularly problematic for menopausal women already experiencing low libido. Weight gain, nausea, sleep disruption, and difficulty stopping the medication (discontinuation syndrome) are common. These are not trivial trade-offs.
What we do not know
Whether SSRIs are more or less effective than HRT for the subset of perimenopausal women whose mood symptoms are primarily hormonal has not been adequately studied in head-to-head trials. The optimal duration of SSRI use for menopausal symptoms has not been established.
Who it is best for
Women who cannot take HRT and have significant hot flash burden. Women with genuine depression or anxiety that predates or is independent of menopause. Women who have tried HRT and found it insufficient for mood symptoms.
Who should be cautious
Women taking tamoxifen should avoid paroxetine and fluoxetine — they interfere with tamoxifen metabolism and reduce its effectiveness significantly. This is a serious interaction.
How to access this
Prescription required. Often offered at GP level. Rose recommends ensuring HRT has been properly discussed and considered before starting an SSRI for menopause symptoms.
Questions to ask your doctor
• Have we discussed HRT as an option before moving to an antidepressant?
• Which specific SSRI or SNRI would you recommend for hot flashes versus mood?
• Am I on tamoxifen? (paroxetine interaction)
• What are the sexual side effects and how common are they?
• How long would I need to take this and how do I stop safely?
Rose honest take
"Many women are prescribed antidepressants for menopause symptoms without being told that HRT is an option and has stronger evidence. If you have been offered an SSRI for hot flashes or mood without a thorough discussion of HRT, that conversation still needs to happen."