Mental Health in Menopause
Mental Health in Menopause
Although some women sail through menopause - for others it is a tough time which causes significant physical health issues and significant mental distress. This may be the first time in their lives they reach out for support for their mental health.
As a mental health nurse, I was a little confused when women in their 40s all of a sudden entered the mental health system.
Often their lives were pretty settled, they had been well or high-functioning women until now. It didn't make sense to me that they would now be experiencing mental health issues.
Their diagnoses were never clear - depression? Anxiety? Borderline personality disorder? Adjustment disorder?
And treatment was not always successful.
Menopause causing mental health problems?
A few years ago, it finally dawned on me - what we were seeing were signs of perimenopause. Unfortunately, as health professionals - we were diagnosing these symptoms as a psychiatric illness.
Perimenopause or menopause was never mentioned in psychiatry as a contributing factor to their presentation. And yet half the population are likely to experience symptoms related to this.
If you are in your 40s or 50s and struggling with mental health and yet have never had issues before, consider that it may very well be menopause related.
What is HAPPENING? - Menopause and mental health.
For those of you with primarily female hormones (oestrogen and progesterone) - unless you have experienced early menopause, these hormones begin to decline in your 40s. How much they decline and how this impacts you can depend on a number of things. Testosterone also declines as we age, however, unlike oestrogen and progesterone, post-menopause testosterone levels actually increase - and can revert back to levels that we experienced in our earlier years.
Oestrogen and progesterone don’t only affect our periods and sexual health - these hormones also impact our immune function, inflammatory response, cardiovascular health and our brain function. The decrease in these hormones can have a significant impact on our overall health and well-being.
What is perimenopause and menopause exactly?
Before we continue - to help you understand a bit of terminology. The term ‘menopause’ or ‘menopausal ‘ is often used to describe what is technically called perimenopause (or the menopause transition). This is the time defined as ‘persistent cycle irregularity’, when you may begin noticing changes such as:
Irregular periods
Hot flushes
Increasing aches and pains
Increase susceptibility to viruses and infections
Poor memory
Poor sleep
Reduction in libido
Vaginal dryness
Mood changes, depression, irritability, increased anxiety, decreased resilience.
Perimenopause can last from 4 - 7 or so years (longer for some, shorter for others). Hot flushes and night sweats are the strongest symptoms of those reported by women affected by the changes experienced during the menopause transition.
As levels of estrogen decrease, neurons in the brain region of the hypothalamus undergo significant hypertrophy (enlargement). The hypothalamus is in charge of sending messages to the pituitary and gonadal (ovaries) system (termed the HPG axis) and also governs temperature control. It’s thought that the overactivation of these neurons (due to the enlargement of this area) results in rapid heat response that women experience symptomatically as a hot flush (1).
Actual menopause is defined as not having a period for 12 months or more. Of course - we can’t say we are in menopause - until we have hit that 12-month mark. Some of the peri-menopausal symptoms can continue well into menopause.
The two main female ‘sex’ hormones aren’t the only hormones changing - many other hormones and neurotransmitters are affected during perimenopause, and this can affect how we think, feel and even behave during this transition.
Mood and Mental Health in Menopause:
Studies have shown an association between the menopause transition and an increase in depressive & anxiety symptoms. Although there is no clear evidence as to why exactly this may occur - there are a number of possible factors.
The first one - is that the symptoms experienced above are alone enough to cause low mood and feel more stressed. Hot flushes are exhausting and can disrupt concentration, focus and sleep - impacting daily function. Poor sleep is strongly associated with poorer mental health, decreased energy and decreased resilience.
But there are other hormone changes which are thought to have a significant impact on our level of resilience, mood and ability to cope with stress.
Stress inducing hormones
Research has found that alongside the basic what we consider ‘female’ hormone changes - other hormonal changes happen too. Our levels of cortisol, adrenalin and nor-adrenalin levels also increase (2). These hormones are often thought of as ‘stress’ hormones, are released by our adrenal glands and can have a significant impact on our physical and mental health.
Hot flushes, night sweats, heart palpitations and changes in blood pressure are associated with elevated levels of cortisol. In fact, cortisol rises about 20 minutes following a hot flush.
Chronically high levels of cortisol & adrenal hormones during this time of transition3 can:
contribute to osteoporosis
increase risk of diabetes
Increase incidence of hot flushes
increase abdominal fat
cause thinning skin
increase the risk of cardiovascular disease
contribute to mood changes; feeling irritable and anxious
lead to poorer memory and processing of information
increase the chance of infections - including viral infections
You may notice some of these similarities to the signs of ‘menopause’. Some studies suggest that it’s these changes in the hormones from the adrenal gland that may be more important than the decline in ovarian function and sex hormones.
Women who suffer from more severe perimenopausal hot flushes show changes in hypothalamus, pituitary and adrenal (HPA) axis activity (the communication between these three areas). Proper HPA axis function is necessary for controlling our response and recovery from stress and the release and governing of stress hormones.
Poor HPA function (ie communication) is associated with depression.
Studies have found that when treatment is given for menopausal symptoms, either through hormones, acupuncture or phytoestrogens, there is an associated decrease in cortisol levels (4,5).
Memory & Brain function in Menopause:
Studies suggest that our capacity to learn new things, our memory and our thinking skills are hampered by the menopause transition (6). From experience, I can honestly attest to this. I just don’t pick things up as well as I used to. The good news is that after menopause, learning levels in many cases appear to improve again.
One of the explanations for poor cognitive (memory and retention) health is that elevated cortisol, particularly in women, has been linked to decreases in memory and executive functioning - meaning it can be hard to focus, follow directions and carry out tasks.
Brain-derived neurotrophic factor (BDNF) is important for brain cell health and the growth of neurons. In postmenopausal women, lower levels of BDNF are associated with significantly worse memory performance. Lower levels of BDNF are also associated with depressed mood.
Immune and inflammation
There are also changes in the immune system with an increase in pro-inflammatory serum markers and a decrease in immune-fighting cells (7). This makes sense of your decreasing ability to fight off colds and infections and your increasingly achy body and joints.
Inflammation is also associated with a poorer mood.
Gut Microbiome changes
As we go through peri-menopause - there are also changes to our gut microbiome. Believe it or not - bacteria in our gut can impact how much of our hormones are excreted or kept for recycling in our body. There is a bi-directional relationship between sex hormones and the gut microbiome - changes to our hormones impact our gut bacteria as well. So you may also notice some changes to your gut function (and bowel habits) during this time.
Changes in gut microbiota can also influence mental health - with a greater diversity associated with better overall mental and physical health outcomes.
How to support mental health in Menopause
Although it’s a natural progression, our society does not always allow a smooth menopause transition. At a time that we should be easing into midlife, our children have left the nest and we can settle in to have more time on our hands and a more relaxed lifestyle, we often find that our jobs, careers and children who stay at home longer than they should - can dip into our natural reservoirs of energy and can deplete us of what little brain function we feel we have left.
We also tend to have dietary and lifestyle habits that are not conducive to reducing stress and we continue to act, exercise and work as if we are still in our 20s and early 30s.
We are not.
And research is clear that our bodies, minds and brains aren’t what they used to be. If you are a woman going through ‘the change’ - you may have already noticed this.
This may seem a little depressing all in itself - but I believe if we embrace ‘the change’, we can make the most of the benefits that are waiting on the other side of the menopause transition. With knowledge - we can understand what is happening in our brain and body and we can prepare our bodies and our minds for menopause.
So how can we make it easier for ourselves?
Top Tips for Supporting the Menopause Transition
Reassess our needs.
It really is a time to adjust our lifestyle accordingly. You may need to set priorities and boundaries. It may be the time to reduce work hours, reduce commitments that no longer serve you. Looking after our HPA axis - which means reducing stress levels and adjusting our lifestyle to support HPA axis function is incredibly important. Our cortisol levels are naturally rising, as are our androgens and adrenaline. If we have a dysfunctional HPA axis going into menopause - and are unable to regulate our stress hormone appropriately - this transition is not going to be smooth.
Research shows that improvement in symptom levels by any means (acupuncture, hormone therapy or phytoestrogens) reduces cortisol which can have long-lasting positive effects on the body and mind.
Psychological techniques
Meditation & mindfulness has been shown to be helpful in reducing menopausal symptoms and improve HPA axis function. Meditation also has been shown to
Increase resilience
Improve sleep
Reduce cortisol levels (8)
Reduce levels of subjective stress
Other psychological interventions such as cognitive behavioural therapy and relaxation techniques (9) have also been shown to reduce perimenopausal symptoms.
Diet
We know that food can have a substantial impact on mood, thinking, and behaviour. Research suggests that those following a ‘healthy’ dietary pattern tend to have less perimenopausal symptoms than those with an ‘unhealthy’ dietary pattern.
Omega three fatty acids may help with cognition in menopause, therefore eating a diet high in nuts, seeds and natural fish oils can be beneficial. Soy, tofu, soy-based products and other phytoestrogen-containing foods (linseeds, sesame seeds, dried fruit and cruciferous vegetables) may help reduce menopausal symptoms. Phytoestrogens may also have positive effects in lowering low-density lipoprotein cholesterol (LDL) levels.
Regular alcohol consumption raises cortisol - therefore you may wish to eliminate or significantly reduce during this time in your life (alcohol also significantly increases your rate of breast cancer).
A whole grain, Mediterranean-style diet is what is most often advised for menopause, mental health, cardiovascular health and overall health and longevity - so invest a little time and knowledge into what you put on your table and in your mouth.
Exercise
Strength-based resistance training can support healthy bones and simply walking can help reduce depression in inactive post-menopausal women (10).
Yoga has been shown to be both a useful therapy to manage vasomotor (hot flushes) and psychological symptoms of menopause (11). Depending on the type of yoga - it can also involve strength and resistance training, stress reduction and breathing and relaxation techniques - all useful for the menopause transition.
Avoid exercising like a 20-year-old! If you already have increased cortisol levels, over-exercising can result in more adrenaline and noradrenaline and cortisol / HPA dysfunction. Over-exercise is also associated with poor mood outcomes. A good tip is - if you struggle to recover from exercise - you are probably overdoing it. Exercise should be invigorating, improve energy, mental clarity and general well-being.
Support brain health
Look after your brain. Levels of BDNF can be modulated by various factors such as physical exercise, breathing exercises, circadian rhythm (a good sleep/wake cycle), and certain medications such as antidepressants (12). Increasing BDNF can be done with supplementation of zinc, curcumin and exposure to the sun, playing a musical instrument, Mediterranean diet rich in fruits and vegetables containing polyphenols (13).
Reducing cortisol through diet and lifestyle changes or supplementation is likely to improve brain health and function.
Acupuncture:
Acupuncture can be an effective therapy for perimenopausal symptoms, reducing cortisol (and susequent negative effects) (14) and is associated with blood pressure reduction (15).
Supplements which help to increase reduce cortisol levels and or perimenopausal symptoms include;
Ashwagandha - research has shown Ashwagandha to support the reduction of cortisol and relieve mild to moderate climacteric symptoms during perimenopause in women (16)
Rhodiola rosea can support brain function, mental performance, an appropriate stress response and potentially support healthy cardiovascular health (17).
Schisandra appears to be effective at alleviating some symptoms of menopause including hot flashes, sweating, and heart palpitations (18).
L- theonine (found naturally in green and black tea) has been found to support immune health, may support cognitive function.
Vitamins B12, B6, B9 (folate), magnesium, zinc, D and vitamin C all have the potential to support symptoms of stress reduction, emotional resilience, and immune health or support the adrenal gland function. The best source for these is always a whole food diet and healthy lifestyle.
Last but not least - a healthy gut microbiome can help the assimilation of vitamins and minerals essential for good health. An unhealthy gut microbiome can increase inflammation in the body contributing to stress, cardiovascular disease, poor immune system function and can impact mood.
Prescription medication
I’m going to directly quote this from an article published very recently:
“In new-onset low mood associated with the perimenopause, HRT (oestradiol and progestogen if needed) is the first line of treatment, and there is no evidence that antidepressants are beneficial. Current guidelines are to treat perimenopausal depression as any other depressive episode. However, it is known that peri- and postmenopausal people do not respond to selective serotonin reuptake inhibitors as effectively as other demographics, and rates of discontinuation due to adverse events are significant”. (Behrman & Crockett 2023)
So if your mood symptoms are new and are believed to be associated with peri-menopause - the first line of treatment is not anti-depressants but HRT! Talk with your GP about this before going straight on to antidepressants for your mood.
A few points:
We have such a long way to go in normalising, understanding and taking a holistic approach to supporting women through this time. In the meantime - it might be up to you to be proactive and do what you can to support yourself.
Allow your body to work at its best - eat well, sleep well, rest well and exercise well - but not to exhaustion. Although your brain might not be quite up to the task of what it used to be - you do have years of wisdom, intelligence and insight to refer to.
I like to think of menopause as a ‘midway pause’ - a time in our lives to reflect and realign ourselves to what we want the rest of our lives to look like.
Allow yourself to be drawn to creative tasks, working in the garden, being outside in nature and other activities to help you find a place of calm. These things are what I believe our body and mind truly desire at this time in our life.
References
1. Maki, P. M., & Thurston, R. C. (2020). Menopause and Brain Health: Hormonal Changes Are Only Part of the Story. Frontiers in neurology, 11, 562275. https://doi.org/10.3389/fneur.2020.562275
2. McConnell, D. S., Stanczyk, F. Z., Sowers, M. R., Randolph, J. F., Jr, & Lasley, B. L. (2012). Menopausal transition stage-specific changes in circulating adrenal androgens. Menopause (New York, N.Y.), 19(6), 658–663. https://doi.org/10.1097/gme.0b013e31823fe274
3. Woods, N. F., Carr, M. C., Tao, E. Y., Taylor, H. J., & Mitchell, E. S. (2006). Increased urinary cortisol levels during the menopausal transition. Menopause (New York, N.Y.), 13(2), 212–221. https://doi.org/10.1097/01.gme.0000198490.57242.2e
4. Sauer, T., Tottenham, L. S., Ethier, A., & Gordon, J. L. (2020). Perimenopausal vasomotor symptoms and the cortisol awakening response. Menopause (New York, N.Y.), 27(11), 1322–1327. https://doi.org/10.1097/GME.0000000000001588
5. Cagnacci, A., Xholli, A., Fontanesi, F., Neri, I., Facchinetti, F., & Palma, F. (2021). Treatment of menopausal symptoms: concomitant modification of cortisol. Menopause (New York, N.Y.), 29(1), 23–27. https://doi.org/10.1097/GME.0000000000001875
6. Karlamangla, A. S., Lachman, M. E., Han, W., Huang, M., & Greendale, G. A. (2017). Evidence for Cognitive Aging in Midlife Women: Study of Women's Health Across the Nation. PloS one, 12(1), e0169008. https://doi.org/10.1371/journal.pone.0169008
7. Gameiro, C. M., Romão, F., & Castelo-Branco, C. (2010). Menopause and ageing: changes in the immune system--a review. Maturitas, 67(4), 316–320. https://doi.org/10.1016/j.maturitas.2010.08.003
8. Koncz, A., Demetrovics, Z., & Takacs, Z. K. (2021). Meditation interventions efficiently reduce cortisol levels of at-risk samples: a meta-analysis. Health psychology review, 15(1), 56–84. https://doi.org/10.1080/17437199.2020.1760727
9. Samami, E., Shahhosseini, Z., & Elyasi, F. (2022). The effects of psychological interventions on menopausal hot flashes: A systematic review. International journal of reproductive biomedicine, 20(4), 255–272. https://doi.org/10.18502/ijrm.v20i4.10898
10. Bernard, P., Ninot, G., Bernard, P. L., Picot, M. C., Jaussent, A., Tallon, G., & Blain, H. (2015). Effects of a six-month walking intervention on depression in inactive post-menopausal women: a randomized controlled trial. Aging & mental health, 19(6), 485–492. https://doi.org/10.1080/13607863.2014.948806
11. Shepherd-Banigan, M., Goldstein, K. M., Coeytaux, R. R., McDuffie, J. R., Goode, A. P., Kosinski, A. S., Van Noord, M. G., Befus, D., Adam, S., Masilamani, V., Nagi, A., & Williams, J. W., Jr (2017). Improving vasomotor symptoms; psychological symptoms; and health-related quality of life in peri- or post-menopausal women through yoga: An umbrella systematic review and meta-analysis. Complementary therapies in medicine, 34, 156–164. https://doi.org/10.1016/j.ctim.2017.08.011
12. Konishi, K., Cherkerzian, S., Aroner, S., Jacobs, E. G., Rentz, D. M., Remington, A., Aizley, H., Hornig, M., Klibanski, A., & Goldstein, J. M. (2020). Impact of BDNF and sex on maintaining intact memory function in early midlife. Neurobiology of aging, 88, 137–149. https://doi.org/10.1016/j.neurobiolaging.2019.12.014
13. Gravesteijn, E., Mensink, R. P., & Plat, J. (2022). Effects of nutritional interventions on BDNF concentrations in humans: a systematic review. Nutritional neuroscience, 25(7), 1425–1436. https://doi.org/10.1080/1028415X.2020.1865758
14. Palma, F., Fontanesi, F., Facchinetti, F., & Cagnacci, A. (2019). Acupuncture or phy(F)itoestrogens vs. (E)strogen plus progestin on menopausal symptoms. A randomized study. Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology, 35(11), 995–998. https://doi.org/10.1080/09513590.2019.1621835
15. Palma, F., Fontanesi, F., Neri, I., Xholli, A., Facchinetti, F., & Cagnacci, A. (2020). Blood pressure and cardiovascular risk factors in women treated for climacteric symptoms with acupuncture, phytoestrogens, or hormones. Menopause (New York, N.Y.), 27(9), 1060–1065. https://doi.org/10.1097/GME.0000000000001626
16. Gopal, S., Ajgaonkar, A., Kanchi, P., Kaundinya, A., Thakare, V., Chauhan, S., & Langade, D. (2021). Effect of an ashwagandha (Withania Somnifera) root extract on climacteric symptoms in women during perimenopause: A randomized, double-blind, placebo-controlled study. The journal of obstetrics and gynaecology research, 47(12), 4414–4425. https://doi.org/10.1111/jog.15030
17. Ivanova Stojcheva, E., & Quintela, J. C. (2022). The Effectiveness of Rhodiola rosea L. Preparations in Alleviating Various Aspects of Life-Stress Symptoms and Stress-Induced Conditions-Encouraging Clinical Evidence. Molecules (Basel, Switzerland), 27(12), 3902. https://doi.org/10.3390/molecules27123902
18. Park, J. Y., & Kim, K. H. (2016). A randomized, double-blind, placebo-controlled trial of Schisandra chinensis for menopausal symptoms. Climacteric : the journal of the International Menopause Society, 19(6), 574–580. https://doi.org/10.1080/13697137.2016.1238453
19. Peters BA, Santoro N, Kaplan RC, Qi Q. Spotlight on the Gut Microbiome in Menopause: Current Insights. Int J Womens Health. 2022 Aug 10;14:1059-1072. doi: 10.2147/IJWH.S340491. PMID: 35983178; PMCID: PMC9379122.
20. https://www.cambridge.org/core/journals/bjpsych-bulletin/article/severe-mental-illness-and-the-perimenopause/8D072AACBCD3C7888C173B36635C08C3
Helen is a registered nurse, specialising in mental health from a holistic perspective. She is passionate about supporting people to have optimal mental health and well-being.
Based in New Zealand, Helen is available for speaking, education sessions and one on one appointments.