Managing Mental Health During Menopause

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Are you wondering whether you can survive menopause without feeling like you’re losing your mind?

Many menopausal women feel like they are “going crazy.” Sound familiar? You are not alone.  Learn more about the mental health effects of perimenopause so that you can stay sane while navigating this hormonal storm.

I’ve heard of menopause, but what is perimenopause?

Menopause and its associated hormonal changes are a normal part of aging for women. The average age of menopause ranges between 50-52 worldwide.  Menopause is defined as the stage after a woman goes an entire year without a menstrual period.  Perimenopause is the confusing time before menopause happens.  It can last between 4-8 years.  Most women start experiencing perimenopausal symptoms in their 40’s.

The most common symptoms of perimenopause are changing menstrual cycles, hot flashes, mood changes, vaginal dryness, and difficulty sleeping.  Nearly two-thirds of women experience hot flashes at some point during the menopausal transition.

Hormones are chemical messengers in your body. The main hormonal culprits behind your menopause misery are estrogen, progesterone, and testosterone, all released by your ovaries. Estrogen and progesterone’s fluctuating levels can impact the specialized chemical messengers in your brain, called neurotransmitters.  Changes in neurotransmitter levels can cause mood swings and anxiety.  Fluctuating estrogen levels and the resulting hot flashes and night sweats disrupt sleep.  Sleep disruption increases your vulnerability to depression, anxiety, and mood swings.

Menopausal symptoms can come and go, be very bad for several months, and disappear altogether.  The ovaries do not close up shop overnight. Instead, they gradually decrease the amount of estrogen they produce. Every so often, one might be able to squeeze out an egg (with an accompanying burst of estrogen) that temporarily relieves your symptoms caused by low estrogen levels (hot flashes, mood changes, or sleep problems). This unpredictability can make a woman feel as though she is “going crazy.”

A psychological storm of emotions and symptoms

During menopause, your moods can be as volatile as the physical symptoms of menopause. Women report feeling an entire spectrum of emotions, feelings, and symptoms such as:

• Irritability
• Unpredictable emotional responses exceeding the gravity of the situation
• Anger
• Tearfulness not caused by a sad event
• Excessive worry
• Anxiety
• Decreased energy
• Sadness and depression
• Loss of concentration (also known as brain fog)
• Feelings of low self-esteem
• Loss of memory
• Insomnia (difficulty falling asleep or staying asleep)
• Loss of libido

Why is perimenopause so hard on my mental health?

Biology, socio-economic changes, and increased psychological stressors all converge in the middle-aged years. This strain exceeds your coping mechanisms and can make you vulnerable to depression, anxiety, and other mental health conditions.  As many as twenty-three percent of peri-and postmenopausal women report mood disorders. That percentage is probably an underestimate because it only counts the women who seek help for their symptoms. Some of the risk factors playing a part in the timing of this hormonal storm are:

• The unpredictability of hormonal fluctuations and symptoms which leave women feeling powerless and out-of-control
• Sleep disruption and deprivation severely limit coping resources and emotional resilience
• Rapid drops in estrogen levels in your body (by as much as 10%) can cause temporary cognitive changes such as brain fog, word-searching, or short-term memory loss
• Increased life stress related to changing life roles, children leaving for college, and growing professional responsibilities with promotion as women age
• Lowered self-esteem as a result of ageism, the stigma of menopause, and your negative perception of your changing body
• Relationship difficulties with menopause-related physical changes 

Perimenopause and menopause can be very challenging but also rewarding times for women. Reframing this process and addressing biological and emotional imbalances can be extremely empowering and essential to the mental health challenges that arise. -Dr. Katherine Kessler, DO, Integral Wellness Psychiatry

Am I at risk for a menopausal mood disorder?

Each woman reacts to the hormonal changes of menopause differently. It is difficult to predict who might be at greater risk for menopause mental health challenges. Some women may have noticed that their mental health is more sensitive to hormones if they: 

• Have a prior history of mood changes around the time of their periods
• Experienced postpartum depression
• Have a prior history of a mental health disorder such as clinically-diagnosed depression
• Underwent surgical or medical menopause. If a woman has surgery to remove her ovaries or takes medicine to induce a menopause-like hormonal state, she may be at greater risk for mental health changes.  Women may choose such treatments to reduce their risk for certain diseases, such as cancer.

Depression or menopause?

No clinical trials have been able to prove that, in and of itself, menopause causes depression. We know that women are twice as likely as men to suffer from depression in their lifetimes. Nearly 18% of women take antidepressants. Talking with your women’s health provider, your primary care provider, and a trained mental health professional will help you sort through your symptoms of depression. Multiple providers may need to help untangle all your moods from menopause. There may also be more than one approach to helping you feel better.

Suppose you have a prior history of hormone-related mood disorders (such as premenstrual syndrome or postpartum depression). In that case, treatment with medications that have worked in the past may be an excellent place to start. Psychotherapy (talk therapy) is another essential part of feeling better.

Can menopause cause anxiety or panic attacks?

It is normal for women riding the turbulent waves of perimenopause to feel anxious. Worries about performance at work with brain fog, changes in your sexual relationship due to decreased interest in sex, or fear of someone noticing the sweat pouring down your face during a hot flash will make anyone feel on edge. Fluctuating estrogen and progesterone levels can cause mild anxiety but have not been shown to cause panic disorders or severe anxiety.

Panic disorder during menopause can be hard to diagnose because panic disorder and menopause share similar symptoms: the sensation of your heart beating quickly, shortness of breath, and increased sweating. Experiencing isolated panic attacks does not mean you have a panic disorder.  Some women may have their first panic attack ever in menopause, and this can be terrifying. If you have more questions about other anxiety-related conditions, make sure to take a look at WebShrink’s helpful explanations of the different types of anxiety disorders. Women who experienced anxiety during their postpartum period may be more likely to develop a panic disorder during menopause. 

To make sure you get the best treatment for your symptoms, be sure to talk with both your doctor and mental health professional.  In addition to counseling, anti-anxiety medication can be very effective in treating anxiety symptoms, regardless of whether you have a panic disorder or menopause-associated anxiety.

Will my Bipolar Disorder or Schizophrenia get worse in menopause?

Research has shown that a reduction in estrogen can trigger or aggravate mental health disorders, including psychotic conditions. With good communication and close follow-up with ALL of your doctors, your mental health can stay stable through perimenopause. Research suggests that women with bipolar disorder are more sensitive to perimenopausal hormonal shifts. Bipolar-related symptoms can increase in perimenopause, especially depressive episodes.

There is an observed increase in the diagnosis of schizophrenia in perimenopausal women. Other studies show that treatment with estrogen in hormone replacement therapy (HRT) improves the severity of psychotic episodes. Symptoms may worsen in women with pre-existing chronic schizophrenia during menopause. Your psychiatrist may need to increase your medication dosage to remain stable during perimenopause. Of course you should not change your medications without the advice of your doctor.

Perimenopause challenges women’s sexuality

Falling levels of estrogen and testosterone during perimenopause cause symptoms such as decreased libido, vaginal dryness, or painful intercourse.  Just like we rarely prepare youth for what puberty brings, women are often left in the dark about the sexual changes of perimenopause.

The biochemical and emotional shifts that are happening can impact our desire and arousal often causing distressing feelings about sex frequency and interest causing women to blame themselves and feel adrift. -Jennifer Wiessner, LSCW, AASECT-certified Sex Therapist

The combination of this psychological distress, the physical changes happening in their bodies, and the resulting turmoil in their most intimate relationships leave many women vulnerable to mood swings, depression, and anxiety.  Difficulty talking about these sexual difficulties with partners, health care providers, or mental health counselors make women feel even more alone and confused.

How can I stay sane through perimenopause?

Keep in mind that perimenopause is the most significant hormonal change in your body since puberty.  We all remember, unless we have blocked it out, how traumatic and puberty was. Try to go easy on yourself. Who wouldn’t feel slightly crazed having to face all of these changes in their body, coming and going without rhyme or reason, for 4-8 long years? Some other helpful ways to change your menopause mindset for mental health survival are:

Misery loves company.  Remind yourself that many other women are experiencing similar symptoms and struggling as well. Seek out online support groups, talk with friends, or even ask your mom, aunts, or other older women in your life how they survived menopause.

This, too, shall pass.  Whatever you might be suffering through right now will not last forever. Some of the conversations with menopause survivors mentioned above may offer you some hope.

Break the silence. Be honest with people in your life who matter about how you are feeling. Get support from friends, family, or a counselor. Don’t feel you need to hide your symptoms or that you are struggling. You can help end the stigma of menopause by starting the conversation.

Knowledge is power.  Seek out well-researched books about menopause like the ones on this list. Search reputable websites such as the North American Menopause Society  NAMS website or Webshrink for more information about menopause or mental health.  Be careful reading online forums, social media posts, and internet articles about menopause that medical providers have not reviewed.

Become an expert in you.  Tracking and recording your symptoms will give you and your provider a better sense of where you might be in your perimenopausal transition. NAMS has a free online menopause symptom tracker. You will feel more in control of your menopause mental health and less like the helpless victim of your body’s hormonal fluctuations.

Seek specialty care. Look for those who are experts in the fields of women’s mental health and reproductive health. Different providers approach the perimenopausal transition from different perspectives.  The North American Menopause Society keeps an online directory listing specially-trained menopause providers. Post-pandemic, many more providers are now offering telehealth services, so expert-level care and consults may be available, regardless of where you live.

Build your menopause support team. Doctors, psychologists, psychiatrists, counselors, women’s health physical therapists, acupuncturists, yoga teachers, reiki practitioners, nutritionists, sex therapists, and so many other complementary and alternative types of providers may be able to offer you relief at different times in your perimenopause transition.  Broaden your horizons beyond traditional medical management of menopause.

What are my options if I want to treat my symptoms with medication?

Every woman experiences the menopausal transition differently. Despite what you might read online or hear advertised, there is no one-size-fits-all miracle menopause drug. Instead, you may find relief from different combinations, medications, and dosages at different points in time as you experience menopause.

It is crucially important for women to speak with someone who understands the mind-body link as much as the physical aspects of menopause. Menopause is a mind body affair, and therefore must be addressed from the whole person perspective.  -Dr. Joanne Hobson, Menopause and Psychosexual Medicine Specialist

Your healthcare provider may choose to treat some of the physical symptoms, such as hot flashes, that might be causing you increased anxiety and stress. Or they might treat the psychological symptoms you are experiencing as a result of your menopausal symptoms.  Some of the most effective and more thoroughly-researched treatments for psychological distress during menopause include:

• Hormone replacement therapy (HRT) in a variety of types and formulations. HRT is most commonly estrogen prescribed to relieve hot flashes, night sweats, and vaginal dryness. There are risks associated with HRT. These risks depend on the type of hormone therapy, the dose, how long you take the medication, and your individual health risks. Short-term HRT (5 years or less) is the most effective treatment for physical symptoms of menopause such as hot flashes, sleep disturbances, and vaginal dryness. For women with mood swings, taking a continual daily dose of HRT can help stabilize moods. However, taking HRT during perimenopause or up to ten years after menopause does not appear to improve brain fog or other cognitive symptoms experienced by menopausal women.

• Local estrogen treatment of your vagina and vulva (outside of the vagina) with estrogen-containing creams, pills, or rings is a highly effective and low-risk way to treat vaginal dryness and pain with intercourse. Treating these symptoms can help your sexual relationship and reduce your emotional distress related to sexual problems.

• Antidepressants For those feeling depressed for two or more weeks, having suicidal thoughts, or moderate to severe anxiety, a class of antidepressant medications called SSRIs may be prescribed by your doctor or psychiatrist.  While SSRIs are some of the most popular and effective medications for depression and anxiety, about one-half of people who take them experience sexual side effects. These can include decreased interest in sex, reduced ability to orgasm, and difficulty staying aroused. Discuss the impact of these possible side effects with your provider if you are already experiencing troubling changes in your sex life.

Do I have to take medications to feel better?

No, you do not. Many women find that making some lifestyle changes to reduce stress helps them cope with the perimenopause storm.  Research shows that stress makes the symptoms of perimenopause worse. The more you can build in self-care and ways to relax, the better you will feel. Some of the ways women take care of their mind and their bodies during perimenopause are:

• Mindfulness activities
• Meditation
• Yoga
• Exercise (this will help beat menopause-associated weight gain and improve sleep quality)
• Eating a healthy, well-balanced diet.
• Avoiding or limiting hot flash triggers (spicy food, caffeine, smoking, and alcohol) 

Mind your mental health during menopause 

Although more than half of the world’s population will go through menopause in their lifetime, we are still learning how best to support women during their tumultuous hormonal upheaval. Stigma, insufficient research, and ineffective treatment options conspire to leave many women suffering mentally and physically. Ageism and sexism make women afraid, especially in professional settings, to say “the M-word. ” Our cultural silence around menopause limits women’s ability to find strength, support, and inspiration from one another. It may not be easy to embrace your body and mind’s changing landscape. Finding the courage to break the silence and to advocate for your well-being will help you better weather the mental health storm of perimenopause.