Menopause and Mental Health - May 2022

The Canadian Menopause Society defines menopause as "the time a women's menstrual period has stopped for 12 consecutive months." The average age of menopause is 51, but rarely, it can occur in the thirties or younger. The Mayo Clinic explains that perimenopause, meaning "around menopause," is "the time during which your body makes the natural transition to menopause, marking the end of the reproductive years." The menopausal transition refers to the period from the moment of increased variation in a menstrual cycle until the moment immediately before the last day of menstruation.


Unique symptoms
Each woman will have their own unique experience of perimenopause and menopause. The experience will differ in symptom duration, severity (mild to severe) and impact. While some women have a problem-free menopause experience, most women, up to 80 percent, will experience some symptoms. Symptoms can last around five to seven years, but about 10 percent of women will continue to have symptoms indefinitely. Women can experience hot flashes or flushes (the most common symptom of menopause, occurring in three out of four menopausal women), vaginal dryness, weight gain, sleeping problems, low libido, night sweats, dry mouth, skin changes, thinning hair, aches and joint pain, low energy, period changes, sensitive bladder, more frequent urinary incontinence and urinary tract infections, painful sex and headaches. The mental health impact is significant. A UK study found that half of the women in their fifties reported that their mental health was adversely affected by menopause.

The list of mental health symptoms reported by women include:

  • Irritability and feelings of sadness (the two most common emotional symptoms according to WebMD author Dr. Traci Johnson)
  • Increased crying
  • Loss of motivation
  • Aggressiveness,
  • Agitation,
  • Brain fog - Dr. Jen Gunter, author of the Vagina Bible and the Menopause Manifesto, describes brain fog as having difficulty finding words or forgetting when walking into a room. Brain fog is a common and temporary experience. Depression and sleep problems can contribute to brain fog. Brain fog, in turn, can cause frustration and lead to anxiety, increased stress and sleep problems. Women may worry they have dementia
  • Mood swings - perimenopausal mood swings are similar to premenstrual syndrome (PMS), e.g., feeling sad, sluggish, irritable, not controlling their mood, and edgy. Dr. Hadine Joffe is the Paula A. Johnson Associate Professor of Psychiatry in Women's Health at Harvard Medical School and executive director of the Connors Center for Women's Health and Gender Biology at Brigham and Women's Hospital. She notes that most women "will navigate their perimenopause without serious mental health issues" and that mood swings are manageable. Harvard Medical School reports that an estimated 10 to 20 percent of women during perimenopause experience mood symptoms. Australia's SANE website comments that research suggests women who had severe PMS in their younger years or postpartum depression may have more severe mood swings during perimenopause
  • Depression - Anita Riecher-Rössler, MD, PhD, is a professor of Psychiatry and Head of the Center for Gender Research and Early Detection at the Psychiatric University Clinics in Basel, Switzerland, and the author of Menopause and Mental Health. She comments that the relationship between menopause and depression is controversial when it comes to the increase in cases during this time, and the extent of the contributions of hormonal changes, biological changes from aging, and psychosocial changes. Factors associated with depression during menopause include hormonal changes and menopausal symptoms. Dr. Hadine Joffe comments that it is not surprising that women experience mood changes from changes in female hormone levels, as this is the case in other life stages. The good news is that mood shifts for perimenopause and menopause are mild for most women. About 18 percent of women in early perimenopause and 38 percent of women in late perimenopause have depressive symptoms. While research has linked milder depression to hormone level changes, the link between hormonal changes and clinical depression "is not clear." Stress, poor overall health, and depression history are the best predictors of mood symptoms in midlife. Dr. Riecher-Rössler notes that most women who develop significant mood issues during perimenopause have a history of depression or anxiety. It is "relatively rare" to develop severe depression or anxiety at menopause without a history of these mental health conditions. One theory for the increase in depressive symptoms is that changes in hormones upset the equilibrium in several brain neurotransmitters. Evidence comes from higher depression rates during perimenopause, which can have the most intense and fluctuating hormone changes than postmenopause's stable estrogen levels. Another theory is the "domino theory" - physical symptoms of menopause, e.g., night sweats and hot flashes, lead to physical changes such as sleep disturbance, which impacts mood. The hormones that control the menstrual cycle also affect the brain chemical that promotes well-being and happiness (serotonin), so a decrease in these hormones is accompanied by a drop in serotonin levels, increasing irritability, sadness and anxiety. The North American Menopause Society (NAMS) encourages women to confirm if their depression is clinical depression. Doctors may prescribe antidepressants and cognitive behavioural therapy (CBT). If a woman has disruptive menopause symptoms, a doctor may suggest a trial of systemic estrogen therapy
  • Anxiety disorders - not much is known about the relationship between anxiety and menopause. Research indicates that panic attacks are more likely during and after the menopausal transition. The difference between a hot flash and a panic attack is that hot flashes do not cause shortness of breath. Similar symptoms between hot flashes and panic attacks include extreme anxiety, sweating, trembling, or heart palpitations. An overactive thyroid, more common with aging, may trigger anxiety, as will a lack of sleep
  • Bipolar disorder and schizophrenia - with menopause, there is an increased risk of exacerbating pre-existing mental health conditions such as bipolar disorder (bouts of severe depression and episodes of mania or increased energy) and schizophrenia (delusions and hallucinations) and an increased risk of developing schizophrenia. The onset of schizophrenia is typically in the early adult years, but there is a second peak in females in the menopausal transition. Why might this be the case? Research suggests that many women with bipolar disorder are more sensitive to hormonal shifts during menopause. Researchers have indicated that falling estrogen levels may modulate certain brain neurotransmitters, which may lead to an increase in symptoms of schizophrenia during this hormonal transition
  • Eating disorders - hormone changes increase the risk of developing eating disorders, e.g., anorexia, bulimia, and binge eating, due to fluctuations in estrogen. Estrogen is involved in feeling hungry, feeling full, and regulating food intake
  • Early menopause - mental health issues such as grief, anger, depression, and anxiety can occur in women who have early menopause (before age 45 and resulting from the removal of ovaries or chemotherapy and radiation for cancer or autoimmune conditions). Compared to women who have menopause at the expected age, women with early menopause are more likely to experience clinical depression because of the sudden drop in hormones with surgical menopause or related to the illness that caused the surgery, e.g., cancer
  • Increased risk of alcohol and substance abuse 

Midlife and mental health 
In an editorial entitled "The Psychology of Menopause," the authors note that this period in a women's life increases the risk of mental health concerns. Laura Payne, PhD, an HMS assistant professor of psychology in the Department of Psychiatry at McLean Hospital, states that the menopausal transition "is a vulnerable time for women in terms of mental health struggles." Women may be dealing with midlife-specific stressors such as caregiving, changes in relationships, grandchildren, career and economic changes, and ageism. While some cultures celebrate puberty, this is not the case for menopause. The internalized stigma can impact women and their moods. Interestingly, research shows that women often have less trouble with menopause symptoms in societies that respect older adults. 


Lack of support for menopause and mental health in particular 
Laurie Green, MD, tells Harvard's Transformation newsletter that "more attention should be given to the mental health aspects of menopause" since women are suffering in silence. University of Alberta pharmacy professor Nese Yuksel, PhD, agrees, stating that there is "not enough awareness, especially on the mental health issues, and we need to be talking more about it." The problem is that family doctors and even OB-GYNs receive little training in menopause. Alicia Jackson, PhD, is the founder of Evernow, a US direct-to-woman company providing access to medical experts in menopause and proven treatments through a telemedicine platform. She notes that most family doctors get about one to two hours of training in menopause, while only one in five gynecologists receive training. Short appointments do not allow for discussion on mental health and sexual health. Western culture's lack of attention to menopause affects how women experience menopause in the home, the workplace, the doctor's office, and the media.  According to a New England Journal of Medicine study, only 25 percent of women seek help for menopausal symptoms. 


Research on mental health and menopause lacking
Vanessa Haygood, MD, an OB/GYN, explains to Harvard Medicine that little research has focused on mental health and menopause. She points to the lack of attention stemming from the "holy trinity of neglect" - more research is devoted to men, society values youth, and society sees mental health as less important than physical health. In a 2019 editorial for Post Reproductive Health, author Hannah Short states that "the connection between reproductive hormones and mental health remains poorly understood and vastly under-researched." This area of research is underfunded. Many menopause studies do not include mental health as an outcome measure. 

Anita Riecher-Rössler lists the challenges in researching mental health and menopause as a lack of definitions for menopause, perimenopause, late and early menopause, weak study designs, and differentiating the contributions of normal aging from the menopause transition. 


Hormones
An outdated view is that mental health issues stem from the "empty nest syndrome." Today, experts see hormonal changes impacting physical and emotional and mental health. With decreased levels at menopause, the hormone estrogen modulates dopamine, serotonin and norepinephrine activity in the brain and impacts mood. The hormone progesterone, lower in menopause, is an anti-anxiety and anti-inflammatory hormone. Hormonal changes directly impact the brain and cause symptoms that affect mental health. Dr. Catherine Hansen, an Evernow medical consultant and OB/GYN, explains that the brain areas for high-level cognitive functioning, learning and memory have a lot of estrogen receptors. Declining estrogen levels affect cognition. Mood problems can cause sleep problems. Johns Hopkins Medicine shares that poor sleep can make you up to 10 times more likely to become depressed. Sleep problems can result from hot flashes and night sweats. Changes in mental health can impact physical health, quality of life, relationships and work. 


Treatment 
Researchers are not clear on what should be the first line of treatment for mental health issues in menopause. The Cleveland Clinic reports that while the evidence increases that hormone replacement therapy can help with emotional symptoms, it is not adequate for treating more severe mental health conditions. 


* Hot flashes and night sweats (causing sleep disturbance and an increased risk of mental health issues) - the UK Mental Health Foundation notes that doctors may prescribe small doses of antidepressants for hot flashes and night sweats

* Perimenopausal women - more recent research has suggested estrogen for improving mood and cognition in this group. Some randomized controlled trials indicate menopausal hormone therapy is as effective as other antidepressants in perimenopausal women but is ineffective in post-menopausal women. Anita Riecher-Rössler points out, however, the lack of well-designed studies on the role of estrogen replacement in perimenopausal women who are at risk of or who have mental health disorders

* Clinical depression - The Australasian Menopause Society website states that menopausal hormonal therapy is not the first line of treatment for depressive disorders. Dr. Traci Johnson tells WebMD that hormone replacement therapy alone may not be effective for clinical depression, which may require antidepressants, psychotherapy, or both. According to the 2020 Menopausal Hormone Therapy Guidelines published by the Academic Committee of the Korean Society of Menopause, there is a lack of clinical evidence supporting menopausal hormone therapy for treating depression

* Each woman will have their own unique experience of perimenopause and menopause. The experience will differ in symptom duration, severity (mild to severe) and impact. While some women have a problem-free menopause experience, most women, up to

Each woman will have their own unique experience of perimenopause and menopause. The experience will differ in symptom duration, severity (mild to severe) and impact. While some women have a problem-free menopause experience, most women, up toAnxiety - The National Institute for Health and Care Excellence (NICE) is an organization that produces guidelines for healthcare professionals in the UK. They recommend cognitive behavioural treatment (a talking therapy) for anxiety during the menopause transition. The Center for Treatment of Anxiety and Mood Disorders reports that CBT can help women modify their behaviour to reduce the severity of menopausal symptoms. Dr. Radhika Vohra, a medical advisor for the Menopause Charity and an NHS and Private GP in Surrey, tells the UK Patient website that if anxiety is hormone-related, then replacing the hormones with hormone replacement therapy should help.

 
Research on other treatments for menopause 
Harvard Medical School's science writer Stephanie Dutchen reports that Harvard researchers are exploring different treatments, including neurosteroids and dietary supplements. Other research areas include the gut microbiome and the contribution of inflammation. 


What about complementary and alternative therapies?
These therapies have become increasingly popular in the last decades, partly from confusion over hormone therapy's risks and benefits. Examples include soy products, herbs and botanicals such as black cohosh and red clover. According to the Canadian Menopause Society, "these products are neither rigorously tested nor approved and regulated by government bodies, and therefore may lack evidence of efficacy and safety." The organization suggests speaking with your doctor to determine if these therapies are the best option based on your circumstances. 


What can you do? 
The Canadian Menopause Society states, "Healthy living is the key to getting the best out of your menopausal years."


Know that mood changes may be part of other menopausal symptoms

If you have a history of mental health conditions, make a plan for mental health care

If symptoms become disruptive, speak with your doctor. The US National Public Radio, in a survey of their listeners, found that the majority of women were not getting information or help from their physicians for perimenopause and menopause symptoms, especially for mental health symptoms. Laura Payne suggests that the number one thing a woman can do is be honest with their doctor about their symptoms and how they impact their life. Monitor symptoms carefully to have informed communication. Dr. Joffe's observation is that women are accustomed to coping with physical discomforts and life challenges and think that it is "normal," but "it doesn't have to be this way." Seek professional help if you have difficulty coping or feel overwhelmed. JoAnn Manson, the Michael and Lee Bell Professor of Women's Health at HMS and Brigham and Women's Hospital and a former NAMS president, calls for including mental health as part of menopause management Quit smoking - smoking can result in earlier menopause and can be a trigger for hot flashes

Avoid excessive alcohol consumption because it can increase hot flashes and is associated with an increased risk of breast cancer

Avoid hot flash triggers such as caffeine and spicy foods if you find they affect you

Engage in healthy behaviours - the British Menopause Society comments that a healthy lifestyle can "minimize the effects of the menopause." Dr. Lucy A. Hutner is a New York City-based reproductive psychiatrist and co-founder of Phoebe, a digital platform for pregnancy and postpartum. Dr. Hutner sees sleep as an under-recognized and crucial issue. She states, "Using sleep hygiene and adequate exercise to foster restorative sleep is super important for midlife mental health." WebMD suggests using self-calming practices such as yoga, meditation, mindfulness, and rhythmic breathing. A meta-analysis found that low- to moderate-intensity exercise reduces depressive symptoms in midlife and older women

Engage in something creative that builds a sense of achievement

Reach out to others. Do not suffer in silence and stay socially connected

Know that the symptoms for most women will be temporary. Antidepressants are temporary and not long-term

Educate yourself - Dr. Gunter comments that knowing about the relationship between menopause and mental health can help women know that their reactions and experiences are shared, typical and expected

Resources

Canadian Menopause Society website has a "Consumer" section

The North American Menopause Society (NAMS) website has the "Menopause & Me" section for women UK National Health Service video "Menopause Myths - It only affects you physically"UK Pausitivity website "Menopause Support Pack" website Sources: HealthLink BC website, HealthLink BC website, Harvard Medical School website, NAMS website, British Menopause Society Women's Health Concern website, SANE Australia website, Forbes website, UK Mental Health Foundation website, Sigma Special Interest Group on Menopause and Aging brochure, Frontiers in Global Women's Health website, Harvard Medicine website, Women & Children's Health Research Institute website, Menopause and Mental Health book, Mayo Clinic website, University of Alberta Folio website, MGH Center for Women's Mental Health website, UK Action Mental Health website, Australasian Menopause Society information sheet, Cleveland Clinic website, WebMD website





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