The Menopause Transition and Mental Health

Menopause is the natural conclusion to the fertile years of a woman, typically recognized as 12 months after the last period. Technically, menopause only lasts a day, and everything after that time is considered post-menopause. The transition towards menopause is called perimenopause, and it usually begins around 45-55 years of age, although some women enter this transition phase much earlier. Menopausal transition lasts as little as seven years and as long as 14 years. 

During these perimenopausal years, the body’s production of estrogen and progesterone vary, leading to physical changes in the body such as changes in the monthly cycle, hot flashes, weight gain, lower energy levels, as well as changes in heart health, bone health, and body shape, and more. Along with all the physical changes, hormonal fluctuations can also affect mental health and emotions. Due to the stigma often associated with mental health issues, some of these serious medical conditions are sometimes ignored.

Depression and Anxiety in Perimenopause

One of the biggest mental concerns in about 15-50% of menopausal women is new onset or worsening depression, anxiety, and overall emotional instability typically caused by hormonal fluctuations, especially declining estrogen levels. Added to the fact that 40s and 50s are typically the age range when the pressures and stressors of life are most intense (demanding jobs, raising children, college-bound children, aging parents, balancing marriage and relationships, building a home), and achieving balanced mental health during perimenopause can be more challenging.

The risk of developing new-onset depression or experiencing worsening depression symptoms increases from early to late menopause and then gradually decreases during postmenopause. People with a history of depression are up to five times more likely to develop a major depressive disorder (MDD) during perimenopause.

Anxiety also tends to increase during the menopause transition. Approximately 1 out of every four women experienced anxiety during perimenopause and menopause, and anxiety symptoms tended to correlate with the severity of menopause symptoms experienced.

 Other types of emotional instability that can occur in perimenopause include irritability, feelings of sadness, lack of motivation, aggressiveness, difficulty concentrating, and mood swings.

Hormonal Changes in Perimenopausal Mental Health

Estrogen, one of our major sex hormones, ebbs and flows throughout perimenopause and eventually settles at a low level during menopause. Estrogen plays an important role in regulating our body’s neurotransmitter systems, including those that produce serotonin and dopamine, two important chemical molecules that regulate mood and our sense of well-being. When estrogen is imbalanced or low, the brain does not produce enough serotonin or dopamine. This disrupts the brain’s ability to regulate mood, disrupts cognitive function, and increases the risk of depression and anxiety.

Progesterone, our steroid sex hormone, also drops during the menopause transition. Progesterone plays an essential role in creating the Gamma-aminobutyric acid (GABA), a neurotransmitter that can exert a calming effect on the nervous system. Low GABA levels lead to increased anxiety and depression.

Insomnia in Menopause Transition

Insomnia is a common complaint in up to 60% of women during the menopause transition. Difficulty sleeping can be caused by night sweats (hot flashes experienced at night), chemical changes in the brain that impact the sleep-wake cycle, and sleep apnea (interruptions in breathing) worsened by low progesterone levels. Poor sleep can decrease well-being, memory, and cognitive function and can increase the incidence of depression and anxiety.

 Body Image in Menopause Transition

The complex internal changes that take place during the menopause transition can change the way your body uses and stores energy. Even without a change in food consumption or exercise frequency, it is common for menopausal women to gain weight more easily and store it around the abdomen. This undesirable change in body image and body composition can negatively impact mental health, leading to an increase in stress, depression, and anxiety, especially if you feel less attractive or feel like you do not have control over your own body.

 What Can You Do to Protect Your Mental Health?

 There are numerous lifestyle changes that protect you from depression and anxiety as you go through this significant life change.

•     Cultivate excellent sleep hygiene – consistent with your bedtime, keep your bedroom dark and cool, turn off your phone, and avoid caffeine and alcohol before bed.
•     Exercise – find a way to move that feels good to you and something you can do consistently. Aerobic exercises like swimming, cycling, walking, dancing, and gardening are excellent ways of easing anxiety and depression. 
•     Minimize alcohol and tobacco consumption since these products can worsen anxiety and depression symptoms.
•     Practice Mindfulness – meditation improves mood and overall sense of well-being and reduces psychological symptoms.
•     Examine your diet – eating brain-friendly, anti-inflammatory foods can have a positive impact on mood and mental health. Talk with your healthcare provider or nutritionist to find the best diet for you. Mediterranean diet can lead to a lower incidence of depression, and the ketogenic diet also shows promise of reducing symptoms of mental illness.

Sometimes, you might need more support than just lifestyle changes, and some medical interventions can be useful. 

•     Hormone Therapy (HT) – not only can HT minimize many of the negative symptoms of menopause, but it can also possibly improve depressive symptoms brought about by low estrogen levels. Not everyone is a candidate for HT, so consult your healthcare provider to see if this will work for you or not.
•     Therapy (including CBT – Cognitive Behavioral Therapy) can help with anxiety and depression symptoms. CBT can even help improve insomnia. Work with a therapist who specializes in menopause-related issues.  
•     Anxiety and depression medication – medications such as selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) are first-line treatments for depression and anxiety. Your doctor can determine if your brain can benefit from a boost of these essential neurotransmitters.

 Menopause is challenging, and it is common for mental health to suffer under its psychological and physical burdens. Self-care becomes deeply important during this transition. Whether having compassion for your changing body, getting help from a doctor, or feeding yourself well, you can learn to give yourself what you need and strengthen and improve your mental health during this transitional time.