Research reports suggest that menopause phases could initiate physical or psychological issues that can in turn stimulate minor life changes. Some physical problems increase susceptibility to psychiatric distress or modify typical life patterns that then influence how women interpret menopause and aging. Previous psychological adjustment to fighting aging, dealing with previous personal stressors, and available social support can determine the mental health symptoms that occur in menopausal women. Hormonal correction may benefit women suffering from depression who concurrently possess low endocrine hormone values. The ultimate goal is to help women appreciate and manage an event in life that some may perceive as limiting and irreversible with a sense of flexible ability.
Menopause is a significant transition in a woman’s life due to its psychological, social, and physical implications. A decrease in the production of sex hormones from the ovaries, primarily estrogen, marks the onset of menopause that occurs in women between the ages of 40 and 60, with an average age of 51 in the United States. Symptoms vary greatly from slight to severe and intolerable, depending on numerous factors such as genetics, prior gynecological history, physical health, and psychological health. Hot flashes, vaginal dryness, discomfort during sexual intercourse, and sleep disorders are common, along with alterations in weight gain that are distributed unevenly and an increase in the chance of developing osteoporosis. Being well-informed and prepared to cope with menopausal changes serves to reduce the adverse effect that menopause has on a variety of women’s lives.
Definition and Stages of Menopause
The average age of menopause in the United States is 51 years, and it generally occurs between ages 45 years and 55 years. The symptoms of menopause may gradually begin and last for years or may occur abruptly. In fact, the amount and type of symptoms women experience can greatly vary. Some women may have no symptoms at all, while others may temporarily experience some severe, emotionally and physically debilitating symptoms impacting the quality of life. The average duration of perimenopause/menopause is 4 years and can go up to 12 years. However, symptoms generally continue for an average of 7.4 years. After that, hormone depletion symptoms usually diminish, and the effects of aging may take their place. Most women can expect to live up to one-third of their lives after menopause begins. But as we have already mentioned, women can start experiencing symptoms up to 5 years earlier.
Menopause, from the Greek roots “men” (month) and “pausis” (cessation), is the time that marks the permanent cessation of most of a woman’s reproductive capability and corresponds to the end of the menstrual cycle. A woman is considered menopausal after she has gone 12 consecutive months without a menstrual period. She may begin experiencing symptoms before actually reaching menopause, a period of time called perimenopause. At this time, the amount of estrogen the ovaries produce starts to fluctuate and will eventually decrease. As menopause approaches, the ovaries do not release eggs during the menstrual cycle, and the body produces less progesterone and estrogen. In the last 1-2 years before the menstruations stop, menstruations may become more frequent, last longer, or be associated with heavy bleeding.
Hormonal Changes During Menopause
When the ovaries are removed from a premenopausal woman, her menses will stop and she will begin a rapid decline in estrogen levels. She will also experience estrogen withdrawal symptoms and general signs of aging. High levels of FSH in a woman are indicative of a low estrogen level. FSH levels, which go up when estrogen levels go down, are important to the process of menopause. The negative feedback in the hypothalamic-pituitary-ovarian axis (HPO axis) is interrupted, and so an increased amount of FSH is released causing an increased amount of estrogen. This is another way to track menopause because women going through menopause will often experience periods of time when their estrogen levels suddenly spike.
Menopause is the time in a woman’s life when the ovaries stop producing hormones. Menopause is a normal event that happens to every woman when she reaches the end of her reproductive years. This is due to a natural depletion of the ovarian follicles, which are finite in supply from early gestational life. There is a drop in the estrogen level and cessation of menses that occurs because the woman no longer has eggs available for fertilization. The timing is different for every woman, and so are the symptoms. The exact mechanism by which menopause occurs is still not well understood. It is related to some hormonal changes.
Estrogen and its Impact on Mental Health
Estrogen seemingly improves the cognitive and mental health of both pre-menopausal and menopausal women. A decline in estradiol levels in women is associated with an increased susceptibility to stress-depression-related mental illnesses including involutional melancholia and bipolar disorder. Depressive symptoms mainly occur during the post-menopause, when the tissue estradiol levels are low consequently. Decreased mood is one of the first symptoms that perimenopausal women express; they also have a higher risk of committing suicide compared to premenopausal women. A sustained reduction in circulating estradiol is observed in depressed postmenopausal as compared with normal postmenopausal women. While replacement therapy increases the circulating estradiol levels. Furthermore, a lack of ovulation increases mood-associated problems through decreased levels of estrogen and an increase in the sensitivity to stress. Finally, the increased activity of the hypothalamic-pituitary LH/FSH axis has been linked with depression during the post-menopausal stage. However, the increased estrogen level diminishes that risk.
The most important risk factor for menopausal mental health effects is the declining production of the sex steroid hormone estrogen. This hormone modulates the peptide neuromodulators in the female brain by regulating the concentration of their respective enzymes and receptors. For example, estrogen has been shown to increase the mRNA for proopiomelanocortin, tyrosine hydroxylase, choline acetyltransferase, and glutamic acid decarboxylase. By increasing the amount of mRNA available for enzyme synthesis, estrogen increases the peptide content of specific neurons. Additionally, estrogen has been shown to enhance the density of beta-endorphin, dopamine, and serotonin receptors. This selective modulation of neurotransmitter systems to modulatory neurotransmitters in different regions of the brain allows relatively small changes in circulating levels of estrogen to affect a broad array of physiological functions, both in the central nervous system and in the periphery.
Common Mental Health Symptoms During Menopause
The neurobiological effects of the menopausal transition on major depression have been partially explained by other hormones. The decrease in estrogen receptor site occupancy has been found to be correlated with a change in the cerebrospinal fluid (CSF) level and binding activity of corticotropin-releasing hormone. Increased corticotropin-releasing hormone has been linked to cortisol hypersecretion and hypocortisolism, two HPA dysfunctions observed in melancholic depression. Furthermore, polymorphisms in the estrogen receptor gene have been associated with mood disorder comorbidity and melancholic features of major depression. These findings imply that there may be direct estrogenic effects on the activity of systems affected in major depression. As reviewed in the sections to follow, there is a substantial body of literature trying to clarify the role of estrogen in depression, but the research has been inconsistent.
Up to 20% more women aged 45 to 55 are diagnosed with depression than men of the same age, and these statistics increase by 12% every year in the 55 to 65 age group. The increased prevalence of depression around menopause indicates a possible correlation between menopause and depression. During menopause, the large decrease in estrogen influences affective regulatory processes, sensation seeking motives (i.e. sexual behavior), and the firing of neurons in estrogen-sensitive brain regions. Impaired regulation of limbic system activation by estrogen may also result in depressive symptoms reported by perimenopausal women. Hormone replacement therapy has been associated with lower rates of depressive symptoms among some groups of women, suggesting that the frequency of depressive symptoms at midlife might be associated with hormonal changes due to menopause.
Depression and Anxiety
It is not possible to use HRT for late postmenopausal women with major depression. The most common symptom of depression is the sense of worthlessness and the majority of the patients tend to kill themselves while they are depressed. In a study, it was found that 17% of the depressed premenopausal women and 41% of the depressed perimenopausal women had previous suicide attempts and thoughts. Besides, with the reduction in estrogen levels, the risk of cardiovascular morbidity becomes equal for men and women and it is known that menopause is associated with the increase in the ischemic heart disease risks. In other words, symptoms of menopause develop in the same period when the risk of ischemic heart disease is increased. Antipsychotic-like effects of progesterone have been found on the response to d-amphetamine behavioral sensitization.
The link between menopause and mood disorders is well established. In a review article, it is stated that 15% of women have mood disorders during the menopausal transition period and after reaching the postmenopausal period, there is a decline. Therefore, it is suggested that endocrinological factors are associated with the development of mood disorders observed in the menopausal transition. Estrogens stimulate the production of serotonin and enhance the effect of opioids in this process. Another way estrogen affects is the decrease in MAO-B enzyme activity. Progesterone prevents GABA-A receptor-gamma subunit reduction and provides an antidepressant effect both by allo-pregnanolone and di-hydro-progesterone. In parallel to these, the decrease in estradiol level during the menopausal transition period is thought to cause mood. However, when selective serotonin reuptake inhibitor (SSRI) and hormone treatment are compared in the case of mood disorders during the menopausal transition period, SSRI and hormone treatments are shown to be equal.
Risk Factors for Mental Health Issues During Menopause
Prevalence of major depression is still strikingly high, and the relapse rate of depression in the menopausal transition and early menopause is still 3.6 times higher than in premenopause. Having an increased risk of depression and medication use in the weeks leading up to menopause, many women suffer. Major Depressive Disorder (MDD) occurs during the menopausal transition and increases throughout this period by 2 to 6 times. Logistic of fourfold in women with no history of depression compared to fivefold in women with a history of depression, the odds differ from woman to woman. Women with a pre-existing mood disorder were 3 to 5 times more likely to develop new-onset depression during the menopausal transition per RN. Chou papers in 2013, Michèle reported that women with depression or vasomotor symptoms have a 3.12-fold increased risk of developing insomnia symptoms, and the relationship goes both ways, suggesting that a bidirectional relationship occurred among vasomotor symptoms, estrogen (E) levels, and restorative sleep.
The menopausal transition is an especially vulnerable time for women with a history of depression, a more complicated clinical picture, and significant concern due to the possibility of symptom recurrence. Women who have a personal or family history of mood disorders premenstrually, postpartum, or using exogenous hormones are at risk for depression and possibly anxiety during perimenopause. With perimenopausal blues, personal or family history reporting rates are unknown, so it’s difficult to determine such a risk for this disorder.
Although perimenopausal depression and anxiety can happen in both women with and without a history of these disorders, there are certain groups at higher risk for these mood disorders during menopause. It’s unclear why some women develop a perimenopausal mood disorder, while others do not, but it is theorized that these risk factors are associated with a woman’s prior mental health history, hormonal fluctuations, environmental stress and cultural attitudes, and personal context and preferences.
Personal and Family History of Mental Health Disorders
Personal history of mental health disorders appears to exacerbate the occurrence of MD and HC, whereas family history of mental health disorders has minimal implication in the experience of MD and HC. Sleep disorders, as a component of menopause, appear to exacerbate MD risk. This data suggests that screening for sleep disturbance is an important aspect of peri-menopause and the post-reproductive period. However, while sleep disturbance is highly prevalent during this period, not all women will necessarily develop MD or HC. Consequently, such expensive screening programs are optimally directed at those at risk.
The risk for women with a personal history of mental health disorders (MD, n=194; HC, n=107) was almost double that of women without this history (MD, LRT, p<0.001; HC, LRT, p=0.001). Family histories of depression, anxiety, and sleep disorders were not associated with an alteration in risk for MD or HC. However, the risk for women with a personal history of sleep disorders was five times higher than for women without sleep disorders (MD, LRT, p<0.001; HC, LRT, p=0.005). The risk for women with a family history of sleep disorders was 1.6 times higher than for women without sleep disorders (MD, LRT, p=0.023; HC, LRT, p=0.034).
Management and Treatment Options
Exercise is an evidence-based nonmedical intervention for conditions associated with menopause, such as hot flashes, sleep disturbance, mood disturbance, nausea, and fatigue. A meta-analysis of 29 RCTs identified the benefits of aerobic exercise. Women showed improvement in muscle mass, executive function, depression, hot flashes, anxiety, tension, and overall psychosocial and physical symptoms. Yoga exercise can improve hot flashes, regardless of an individual’s physical exercise status. Mindfulness-based stress reduction (MBSR) has already been found to be a beneficial treatment modality for women going through menopause. Additionally, newer research has explored the use of virtual MBSR intervention as a cost-effective and efficacious treatment. Acupuncture is another lasting, accessible, effective therapy for hot flashes. Women with hot flashes who received electroacupuncture reported decreased intensity in 57 percent of women, compared with 7 percent of women receiving standard care.
In some cases, menopause does not necessarily warrant treatment as long as symptoms are manageable and do not affect quality of life. Hot flashes and vaginal dryness, for example, can improve with time. However, sometimes menopausal symptoms do require interventions, including medications and lifestyle changes. Although hormone replacement therapy (HRT) is a common treatment for menopausal symptoms, its use has declined in recent years. Some guidelines recommend against its use for clinically diagnosed depression, anxiety, and other mood disorders due to the potential for harm related to these hormone changes. In response to the risks of HRT, some women are interested in herbal supplements that are natural and less harmful.
Hormone Replacement Therapy
The connection: The psychological symptoms of menopause are strongly related to the hormonal changes that occur during this time, particularly with estrogen and testosterone. Reductions in these hormones have a significant effect on a woman’s mental health. Menopause symptoms only show up in a hormonal environment that has lower than normal concentrations of the hormones in question. Studies consistently show that the symptoms, particularly the depressions during, after, or leading up to, menopause are not just something that happens and will fix itself or that is a woman’s inability to handle a normal life transition – but something that can be significantly helped by addressing the changing hormonal environment.
Hormone replacement therapy: Evidence has been found that the use of hormone replacement therapy (HRT) after menopause makes a difference in the relief of many of the psychological symptoms experienced by women during hormone decline. HRT can help with mood swings, as well as the ability to concentrate and think clearly. It can help relieve depression and anxiety. And it can also help with energy levels.