Perimenopause and mental health: what you need to know

8 Aug

Estimated Reading Time: 6 minutes

Are you feeling out of sorts? Unusually irritable, bad-tempered, or anxious? Do you find that you’re second-guessing yourself, worrying irrationally, or that your self-confidence is slipping? If so, you could be experiencing symptoms of perimenopausal depression.

The years leading up to menopause can be a turbulent time for many women. Having experienced this ‘midlife unravelling’ myself, I am hoping this article will help raise your awareness of the increased risk of depression and anxiety that exists during this time. We’ll also explore the main treatment options which can help you regain a sense of balance amidst the hormonal chaos.

Is it really perimenopause? But I don’t have any hot flashes!

I began worrying constantly about small things and was getting more and more agitated and anxious

But could it really be perimenopause? When we think of menopause we tend to think of hot flashes and night sweats but few of us appreciate that menopause often creeps up on us a lot earlier than we might expect!

In hindsight, I realise now that I was perimenopausal for a good 8 years before I had my first hot flash. My earliest symptoms were episodes of low energy and disturbed sleep, followed by mood changes that at times felt debilitating but would then resolve as quickly as they started.

I also began to feel overwhelming anxiety over the most innocuous, everyday events. I blamed a major move, raising teenage boys, lockdown… at the time it never occurred to me that my symptoms could have been due to my hormones.

A key message is this: in the absence of other typical menopausal symptoms, the link between anxiety, depression and perimenopause can often be missed.

It’s true that depression can occur in any woman at any time for a number of reasons that may not have anything to do with her hormones. In fact, often a woman’s hormones are blamed for her low mood or mood swings, when all she is actually responding to is extremely negative life stressors.

However, women are also more likely to develop depression at particular periods in their lives, one of which is during the menopause transition period. It seems that the specific combination of hormonal changes and life stressors can contribute to a temporal shift in mental health. Therefore, let’s explore perimenopausal depression in more depth.

How do I know I have perimenopausal depression?

Perimenopause typically begins for women during their mid to late 40’s and lasts 4 to 5 years before menopause, but it can begin up to 8 years before. It is defined as that period that precedes menopause, the point at which a woman has not had a period for at least 12 months.

The levels of your sex hormones fluctuate widely during perimenopause which can cause a variety of physical and emotional symptoms. These hormonal changes have a direct effect on the production of our neurotransmitters and those regions in the brain that regulate our mood.

So, how can you tell whether low mood is being caused by hormonal changes or other factors?

There are a few symptoms that are believed to be more characteristic of perimenopausal depression such as anger, irritability and paranoia.

Mood changes are often sudden, lasting for minutes to hours and then they spontaneously resolve. Mood symptoms may be accompanied by other symptoms such as muscle and joint pain, weight gain, low energy levels, low self-esteem, feelings of isolation, forgetfulness and difficulty concentrating, low libido, disturbed sleep, and of course hot flashes and night sweats.

What else impacts perimenopausal depression?

As we lose the protective effect of oestrogen we become much more vulnerable to lifestyle stressors. For example, smoking and a lack of physical activity can make depressive symptoms worse.

There are many psychosocial factors that may impact your experience of perimenopause. It has been reported that women living in societies that value older women are less likely to experience perimenopausal depression.

If you are in your mid to late 40’s you are also more likely to be dealing with stressful family issues like raising teenagers and possibly taking care of ageing parents. Many women have reached a high level of responsibility in their workplace and with children getting older, have their sights set on advancing their careers.

All of these external factors can have a negative impact on your mental health as you transition through perimenopause and into menopause.

How can you support your mental health during perimenopause?

The first and most important step is recognizing that the way you are feeling could be due to hormonal changes and is not because there is something fundamentally wrong with you.

Depression is largely treatable with many different options from therapy to medication to healthy lifestyle changes.

There is no single treatment that works best for all women. Become as informed as possible to find a treatment that works best for you.

Remember, depression during perimenopause may be missed because the accompanying physical symptoms such as headaches, body aches and joint pains are not included in assessments for major depressive disorder.

If you think you are in perimenopause and want to take steps to improve your mental health, there are some options to consider.

Medication options

Most women visiting their primary health care providers with symptoms of depression will be offered antidepressants – either selective serotonin reuptake inhibitors (SSRI’s) or serotonin noradrenaline reuptake inhibitors (SNRI’s).

However, women experiencing perimenopausal depression may respond differently to these medications as compared to women with depression outside perimenopause or menopause and results vary. If you have been prescribed an antidepressant but you feel this isn’t working for you, speak to your health care provider about other options.

Hormonal treatment options

Menopausal hormonal treatment (MHT) has been shown in double blind, randomised control trials to have a significant antidepressant effect in perimenopausal women with depression. But, again, MHT may not be suitable for all women, and it is definitely not a panacea.

Cognitive behaviour and mindfulness options

With all the stressors that perimenopausal women face, it can be extremely helpful to talk things through with an impartial, experienced professional to improve the way you cope with those stressors - and there are a few good options.
Both cognitive behavioural therapy and mindfulness-based therapies have been found to reduce the severity of depressive symptoms. Combining the two has been reported to be even more effective. Mindfulness-based Cognitive Therapy (MBCT) is a modified form of cognitive therapy that incorporates mindfulness practices. Studies have shown that it is just as effective as antidepressant medication for mild to moderate relapsing depression.

MBCT is most commonly offered as an 8-week program during which you will learn to recognise unhelpful thinking patterns and how they relate to your feelings and behaviour. The mindfulness techniques help you to become aware of those negative thought patterns before they take hold and cause a downward spiral into a relapse of depression.

The realisation that you are not your thoughts, that thoughts are simply mental events that come and go, can be transformative. Learning to be compassionate and kind towards yourself during this challenging time is highly therapeutic.

Summary

Perimenopause can be an unsettling and confusing time for women especially in terms of your mental health. It’s helpful to know that what you are experiencing is very normal for a woman in her 40’s. You are not alone.

A positive aspect is that it can also serve as a turning point, spurring you on to reassess your needs; emotional, mental and physical. It’s never too late to start taking better care of yourself.

There are a few options available to help you improve your mental health during perimenopause, including medication, hormonal treatment, cognitive behaviour therapy and mindfulness intervention. Simple lifestyle changes can also be effective.

As we begin to lose oestrogen’s protective effects on our brain, cardiovascular and bone health in particular, this period of our lives becomes a most critical time to empower and motivate yourself to do whatever is necessary to safeguard yourself and increase your resilience, so that you can continue to thrive as you age.