Antidepressants, women, and the hormones nobody is checking

What the prescribing data actually shows

In England alone, roughly 8.6 million people were prescribed antidepressants in 2022–23, and the curve has only bent upward since the pandemic. Women account for about two-thirds of those prescriptions. The signers of the BMJ letter were blunt: this scale of prescribing cannot be explained by a sudden epidemic of clinical depression. It reflects a system that has medicalised distress, under-resourced talking therapies, and offered the prescription pad as the path of least resistance.

What the 2024 follow-up made painfully clear is that women are bearing the brunt of this. Perimenopausal women — many in their early 40s — are being handed SSRIs for symptoms (anxiety, low mood, sleep disruption, brain fog, irritability) that are textbook features of declining and erratic oestrogen and progesterone. Postpartum women are prescribed without a thyroid panel. Teenage girls are prescribed without anyone asking about their cycle.

Suicide in women is rising — and that should change the conversation

Between 2017 and 2022, suicide rates in women in England and Wales rose to their highest level in two decades, with the steepest increase in women under 25 (ONS, 2023). Globally, the WHO has flagged a similar trend in younger women. If antidepressants were the answer to female mental distress, more than two decades of escalating prescriptions should have moved this needle in the opposite direction. They haven't.

This isn't an argument that antidepressants never help — they clearly do for some people, particularly in severe depression. It's an argument that they are being asked to do a job they were never designed for: to compensate for unaddressed hormonal change, nutrient depletion, trauma, isolation, sleep deprivation, and the cumulative load women carry across the life stages.

If a 46-year-old woman walks into a clinic with anxiety, insomnia and low mood, the first question shouldn't be 'which SSRI?' It should be 'where is she in her cycle, what's her FSH, oestradiol, progesterone, thyroid and ferritin, and what has changed in the last two years?'

How HRT was buried in 2002 — and what the data actually said

To understand why so many women are on antidepressants instead of hormones, you have to go back to July 2002. The Women's Health Initiative (WHI) trial, the largest RCT ever run on hormone therapy, was halted early and its results announced at a press conference before the paper was fully digested. The headline message was that combined HRT increased the risk of breast cancer. Within months, HRT prescriptions in the UK and US collapsed — by some estimates by more than 70%. An entire generation of women was effectively cut off from treatment that, for many, had been transformative.

The problem is that the headline wasn't a clean reading of the data. The WHI cohort had an average age of 63 — over a decade past menopause. The hormones used were conjugated equine oestrogens and synthetic medroxyprogesterone acetate, not the body-identical oestradiol and micronised progesterone used today. The absolute increase in breast cancer risk in the combined-therapy arm was small (around 8 extra cases per 10,000 women per year) and, crucially, was not seen in the oestrogen-only arm — which actually showed a reduction in breast cancer incidence.

Re-analyses published from 2017 onwards (including the long-term WHI follow-up in JAMA, and work led by Professor Robert Langer, one of the original WHI investigators) have made clear that for women starting HRT under the age of 60 or within 10 years of menopause, the benefits — on bone density, cardiovascular risk, cognition, mood, sleep and quality of life — substantially outweigh the risks. In 2025 — 23 years on from that press conference — the UK is finally beginning to formally re-address the damage that misinterpretation did, with the Royal College of Obstetricians and Gynaecologists, the British Menopause Society, and a growing cohort of GPs openly calling the original messaging an error of historic proportions.

Twenty-three years is a long time. Two and a half decades of women dismissed, medicated, and told their symptoms were psychological. And here is the bitter irony: breast cancer rates in UK women have not fallen since HRT use collapsed — they have continued to rise. The 'protection' that withdrawing HRT was meant to deliver never materialised, because the drivers of breast cancer in the population are far more complex than one hormone intervention started a decade after menopause.

Why bHRT is a different conversation

Body-identical HRT (bHRT) — transdermal oestradiol and oral micronised progesterone — is structurally identical to the hormones a woman's own ovaries produce. This matters. Transdermal oestradiol bypasses the liver and does not carry the clotting risk associated with older oral synthetic oestrogens. Micronised progesterone has a far better safety and tolerability profile than medroxyprogesterone acetate, and is associated with improved sleep and reduced anxiety in its own right.

For perimenopausal and postmenopausal women, well-prescribed bHRT can do what no SSRI can: restore the hormonal substrate the brain, bones, blood vessels and gut have evolved to expect. Many women describe the return of HRT as the return of themselves — the lifting of a fog that talking therapy and antidepressants had not touched, because the problem was never primarily serotonergic.

• Improved sleep architecture, particularly with night-time micronised progesterone.
• Reduced vasomotor symptoms (hot flushes, night sweats), which alone can transform mood through restored sleep.
• Better bone density and reduced fracture risk — a critical, under-discussed outcome.
• Reduced long-term cardiovascular risk when started in the menopause transition window.
• Improved mood, cognition, and libido in a meaningful proportion of women.
• Lower risk profile than older synthetic regimens, particularly for VTE and breast tissue.

Where antidepressants fall short for women

SSRIs and SNRIs were developed and trialled largely in mixed or male-dominated cohorts. Female-specific factors — cycle phase, hormonal contraception, perimenopause, pregnancy, postpartum — were rarely stratified. Yet hormones modulate serotonin receptors directly. Oestrogen up-regulates serotonin synthesis and receptor sensitivity; progesterone modulates GABA. Treating the downstream neurotransmitter without addressing the upstream hormonal driver is, in many women, treating the smoke and ignoring the fire.

Then there is withdrawal. The 2023 BMJ letter explicitly highlighted what patients have been saying for years and what Public Health England formally acknowledged in 2019: antidepressant withdrawal can be severe, prolonged, and frequently misdiagnosed as relapse, leading to re-prescription rather than support to taper. For women already on these medications, this is not a small footnote — it is the central reason so many feel trapped.

None of this is anti-medication. It is anti-defaulting. Medication has a place. Hormones have a place. Talking therapy has a place. The question is whether the right intervention is being offered to the right woman at the right life stage — and for too many women, the answer has been no.

What better care could look like

• A proper hormonal workup before an antidepressant is prescribed to a woman in perimenopause, postpartum or with cyclical symptoms — FSH, oestradiol, progesterone, thyroid (TSH, free T4, free T3, TPO antibodies), ferritin, vitamin D and B12.
• Routine screening for symptoms of perimenopause in women from their late 30s onwards, rather than waiting until periods stop.
• Genuine access to bHRT through NHS pathways, and clinicians trained to titrate it properly rather than starting and abandoning at the first side effect.
• Nutritional, behavioural and nervous-system support as first-line — not as the thing offered after medication has been started and failed.
• Honest, informed-consent conversations about antidepressant withdrawal at the point of prescribing, not years later when a woman is trying to stop.

References

• Horowitz MA, Moncrieff J, et al. Letter to the BMJ on antidepressant prescribing. BMJ 2023;383:p2873. https://www.bmj.com/content/383/bmj.p2873
• BMJ 2024;384:q220 — follow-up on antidepressant prescribing and women's health. https://www.bmj.com/content/384/bmj.q220
• Beyond Pills APPG. Politicians, experts and patient representatives call on the government to reverse the rate of antidepressant prescribing, December 2023. https://beyondpillsappg.org/2023/12/05/politicians-experts-and-patient-representatives-call-on-the-government-to-reverse-the-rate-of-antidepressant-prescribing/
• Office for National Statistics. Suicides in England and Wales: 2022 registrations. ONS, 2023.
• Rossouw JE et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Women's Health Initiative randomized controlled trial. JAMA 2002;288(3):321–333.
• Manson JE, Aragaki AK, Rossouw JE, et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women's Health Initiative Randomized Trials. JAMA 2017;318(10):927–938.
• Langer RD et al. Hormone replacement therapy — where are we now? Climacteric 2021;24(1):3–10.
• Public Health England. Dependence and withdrawal associated with some prescribed medicines: an evidence review. PHE, 2019.
• NICE NG23 — Menopause: diagnosis and management. Updated 2024.
• Cancer Research UK — Breast cancer incidence statistics. https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/breast-cancer/incidence