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September 05 2019

Menopause, Part II: Psychological Well-being

By Lindsay Taylor, PhD
4 Comments

In our previous menopause post, I mused on some perspectives of menopause that are positive and affirming for women. However, I don’t want to downplay the fact that many women experience menopause as a difficult, frustrating, and even disempowering time. (Again, I am using “menopause” to include the perimenopausal period.)

As I mentioned in the last post, some researchers estimate as many as 75% of women experience some type of “menopausal distress,” and we don’t talk about it enough. Today I want to examine some of the psychological and emotional facets of menopause. In the final post of this series, we’ll look at self-care techniques and non-hormonal therapies that seem to be the most beneficial. 

What Research Suggests About Emotional Well-being During Menopause

Obviously menopause is a major life transition—significant biological changes wrapped up in a complex web of personal and sociocultural beliefs, fears, stressors, and stories. It can be a time of great apprehension, confusion, even despair for some women. Others pass right through menopause with hardly a bat of an eye. Still, others welcome and embrace it. 

It’s extremely understandable why this would be a challenging time for women. Menopause can be a perfect storm of physical discomfort and cognitive symptoms (brain fog, forgetfulness), sleep deprivation (thanks to those night sweats and hot flashes), and emotional fluctuations. Besides how they feel, these symptoms can affect women’s personal relationships, ability to perform their jobs, and sense of self-worth and self-confidence. 

For many women, menopause also coincides with the dual stressors of aging parents and raising teenagers or having a newly empty nest. Plus, menopause is an unmistakable marker of aging, which can evoke complicated feelings as well. 

Overall, stress, depression, and anxiety seem to be fairly common during menopause. Recent Guidelines for the Evaluation and Treatment of Perimenopausal Depression commissioned by the Board of Trustees for The North American Menopause Society (NAMS) and the Women and Mood Disorders Task Force of the National Network of Depression Centers describe perimenopause as a “window of vulnerability for the development of both depressive symptoms and a diagnosis of major depressive disorder.”

It’s difficult to know exactly how many women are affected. Studies of depression and anxiety are usually conducted on women whose symptoms are severe enough to seek help from their doctors. Researchers estimate that up to 40% of women will experience depression at some point during menopause; it’s unclear how prevalent anxiety might be. 

It’s easy to assume that some women become depressed and anxious during menopause because their symptoms are so gnarly. To some degree, that narrative is probably true. Studies do find that women who experience more severe symptoms such as frequent hot flashes also exhibit more depression and anxiety. This makes sense—being physically uncomfortable and unable to get a good night’s sleep can certainly set the stage for poor psychological outcomes. 

On the other hand, it’s likely that for some women, depression and anxiety exacerbate the physical and emotional symptoms. That is, depression and anxiety might be a lens that magnifies how bad menopausal symptoms feel, so these women report having more severe symptoms. 

In any case, there’s more to it than “menopause is rough, and it makes women depressed and anxious.” One of the biggest risk factors for depression and anxiety during menopause is prior episodes of depression and anxiety. Women who are also experiencing other life stressors, including relationship stress and socioeconomic stress, are also more likely to become depressed. 

In other words, women who are otherwise vulnerable are more likely to experience poor psychological well-being when hit with the additional stress of the menopausal transition. 

Along these lines, one study compared depressed and non-depressed perimenopausal women on a variety of quality of life measures, including life enjoyment and satisfaction; ability to function in work, social situations, and relationships; and perceived social support. The researchers also assessed the severity of the women’s hot flashes. The depressed women scored lower than the non-depressed women on all quality of life measures. Severity of hot flashes had no effect for either group. 

The authors concluded that future studies “need to distinguish between those women with [perimenstrual depression] and non-depressed women to avoid attribution of decreased [quality of life] to the menopause transition alone.” In other words, don’t blame the hot flashes for what the depression wrought.

This is an important point: We assume that menopause interferes with women’s well-being and quality of life because the symptoms stink (and they definitely do for a lot of women). However, the degree to which menopause actually impacts a woman’s quality of life might depend, at least in part, on whether she experiences concurrent depression or anxiety.

This is not to say that if you’re having a hard time dealing with your symptoms, you’re definitely also depressed. Rather,  consider whether depression and anxiety are contributing so that you can address them directly.

Likewise, don’t assume that depression and anxiety will resolve on their own once the physical symptoms subside. Treating the physical symptoms is important, but for many women it might not be enough.

What We Need to Be Saying (To Each Other) About It

At the risk of stating the obvious, a lot of distress is surely rooted in the fact that women don’t feel like they can talk openly and honestly about their experience of menopause, perhaps especially the mental and emotional aspects. 

In Becoming a Menopause Goddess, author Lynette Sheppard asserts that all of her friends experienced sadness, if not full-blown depression, during menopause. All of them. More than anything, she says, they needed to hear that it was normal, that there was nothing inherently wrong with them. 

Instead, the stigma surrounding mental health struggles and the taboo nature of talking about menopause keep many women suffering in silence. Of course, it’s not like we talk freely about the physical symptoms, either. Sure, we can kvetch about hot flashes with our friends. How many women feel free to discuss brain fog and sleep deprivation with their bosses, even if they have very real consequences in the workplace? 

I understand that “just talk about it” is neither easy nor sufficient—I’m not trying to be trite. It’s not like posting your hot flashes on social media will do anything to stop them. Nor can I promise that your boss will be super understanding if you march into his/her office and announce that you can’t finish your project on time because you simply can’t focus. 

However, let’s think about what we can do to open up the channels of communication with our friends and partners at least to start. It’s no secret that social support can be an important factor in warding off depression during times of stress.

We Need A Multi-Pronged Approach

Besides talking about it, what else can women do to cope with physical, psychological, and emotional symptoms during menopause? Hormone therapy (HT) is the predominant approach that doctors prescribe (of course). I won’t cover the pros and cons, nor the safety questions, since Mark did so recently. Definitely check out that post if you are considering HT for yourself. Mark’s wife, Carrie, has also written about her experience with menopause symptoms in previous posts (1, 2). 

I will point out that most symptoms aren’t clearly caused by the hormonal changes that characterize menopause. Vasomotor symptoms (hot flashes, night sweats) are the most strongly linked to hormonal changes, but other symptoms seem to be more related to psychosocial factors. Even vasomotor symptoms don’t map perfectly onto hormone fluctuations. Women with the biggest drops in estrogen won’t necessarily experience the most hot flushes, for example. 

That doesn’t mean you shouldn’t try HT if you and your doctor decide it’s right for you. It clearly has benefits, including that it seems to help some women with depressive symptoms and anxiety. It’s not clear whether this is because it alleviates physical symptoms or because the depression and anxiety are directly caused, at least for some women, by hormone fluctuations

However, it’s a mistake to assume that if we “fix” the hormones, or get rid of the hot flashes for example, the rest will fall into place.

Thinking about the quality of life study I mentioned above, it’s important not to get wrapped up in the story that hormones plummet, hot flashes and night sweats ensue, and then women become grouchy and depressed as a result. 

In reality, the hormone stuff, the physical stuff, the emotional stuff, the sleep stuff, the relationship stuff, and more stuff all get thrown into the mix, each potentially feeding into and off of the others. 

What we need is a multi-pronged approach. (I feel like there’s a pun here about protecting the flanks—I’ll keep working on that one.) Besides treating underlying hormone fluctuations with HT or herbal remedies, women and their doctors should also separately address specific physical and cognitive symptoms, general health, and psychological and emotional well-being. 

The aforementioned Guidelines for the Evaluation and Treatment of Perimenopausal Depression, for example, offer this recommendation, “Proven therapeutic options for depression (antidepressants, cognitive behavioral therapy and other psychotherapies) should remain as front-line antidepressive treatments for major depressive episodes during perimenopause.” In other words, take care of the depression on its own. 

For women who want to be holistic in their approach, and who perhaps want to avoid or minimize HT, there are a number of non-hormonal, complementary practices that have been shown to help. In the next post in this series, I’ll highlight some of the ones that show the most promise for relieving menopausal symptoms specifically, as well as for stress reduction, emotion regulation, and coping more generally. 

Now I want to hear from you. Do you feel free to talk about your experience of menopause with the people in your life? Have you had positive or negative experiences when you have talked about it in the past?

Resources:

Deeks AA. Psychological aspects of menopause management. Best Pract Res Clin Endocrinol Metab. 2003 Mar;17(1):17-31.

Schneider M, Brotherton P. Physiological, psychological and situational stresses in depression during the climacteric. Maturitas. 1979 Feb;1(3):153-8.

Zhou B, Sun X, Zhang M, Deng Y, Hu J. The symptomatology of climacteric syndrome: whether associated with the physical factors or psychological disorder in perimenopausal/postmenopausal patients with anxiety-depression disorder. Arch Gynecol Obstet. 2012;285(5):1345–1352. 

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4 thoughts on “Menopause, Part II: Psychological Well-being”

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  1. Yes, I have and still do talk about this subject with friends that seem to be starting down this road. I’m 65 and began the journey when I was 37 like my mom and grandma. Usually it’s signs of perimenopause that bring on the discussion and I try to laugh about the symptoms I had and what it taught me. The one that was the big surprise to me was it “loosened up my tongue” and would actually speak my thoughts….. that looking back a few minutes later probably should have been just thoughts and NOT shared…… It did teach me to find control in that area…… I was not mean but I did “tell people off” when it probably wasn’t helpful to anyone…. I apologized but would rather not have to.
    Thank you for talking about this normal process. I took hormones until my health care person tested me to see if they were still needed, they weren’t so I went off them with no problems.

  2. This is an incomplete picture. Yes, for some women, there are natural therapies that can help, and yes, hormone replacement therapy is a medical tool. However, our society has been so flooded with cultural assumptions that hormone replacement is bad and unhealthy that there is reluctance to prescribe it. And reluctance amongst women to accept it. But hot flashes and night sweats are not the only downside to menopause.
    My mother and older sister had uneventful menopauses, with mild and occasional hot flashes being their only symptoms. I expected the same for myself, although, since I was more active, and ate more fresh vegetables, and had never had menstrual pains, I thought mine might be easier than theirs. WRONG!! I had endless hot flashes, frequent sleep interruptions – some due to night sweats, but others as well, and horrible muscle cramps and spasms in my legs, arms, and abdomen. I also had bladder spasms. (These are NOT caused by psychosocial aspects!!) I saw a urologist about the bladder spasms, who diagnosed me in such confusing language that it took months for me to tumble to the fact that this was ultimately one more menopause problem! She gave me an anti-cholinergic medication that caused me to fall asleep while driving home from that appointment, and go off the road. It took a comment from a friend to help me realize that menopause was what had thinned the tissues over the nerves to my bladder, and caused my issue.
    To finally get hormone replacement therapy, I had to basically self-diagnose, go to my Ob/Gyn doctor, and to insist on it. Now I can sleep again!! I no longer constantly feel a need to urinate. I no longer get painful cramping night and day, and no longer have hot flashes except perhaps 3 or 4 times a day. It has given me a large part of my old life back.
    Depression, for me, came with the constant exhaustion that resulted from not being able to sleep normally for over 3 hours at a shot. It also, I think, resulted from the loss of libido that came with menopause. These are not things that are easily addressed. Certainly, black cohosh and maca root did not help!
    What has helped the most, other than the hormone therapy, is exercise. As in all depressions that I know of, it lifts my spirits. However, this could only happen after I could sleep again, and my exhaustion abated.
    Everyone is different, and may have a different menopause. Don’t rule out anything that may return your quality of life!

  3. Thanks for Part 2 – very good!

    You made me realize how much my partner has helped me in this journey. He initially was very upset, as was I, about my symptoms. And I’m not saying he is fine with things now, but he has adjusted and that has really helped.

    For instance, he can’t hold me when we go to bed anymore, as that is a big hot flash time for me. Volcanic. During the summer especially. We both wish it wasn’t this way, but we have learned to make up for it in the morning hours, when my thermostat is working properly.

    Also, we learned new language to describe depressed moods and panic attacks. During those times, I am to feel it, not fight it — think of the concept of “softening into it.” Seems to help greatly. Another great idea of his is using all five of my senses when having a fear or sadness attack. He has me taste something (usually chocolate, ya got me), listen to music or white noise on headphones, sniff essential oils, pet the dog, and look at nature or close my eyes.

    So I think the “talk about it” approach is much more profound than it seems at first blush.

    Looking forward to your next installment, Lindsay.