Is It Menopause--or Your Mental Health?

It’s a good bet that if you are a woman around the age of perimenopause and you visit your primary care doctor’s office with complaints of brain fog, irritability, sadness, anxiety, poor sleep, and/or a lack of energy, these issues may be written off as “just signs of getting older.” You may be diagnosed with anxiety or depression and be given recommendations to exercise more or take antidepressant medications. Unfortunately, this treatment scenario misses the very real possibility that the hormonal fluctuations of perimenopause may be responsible for some or all of your symptoms. Awareness among physicians that perimenopause and menopause may contribute to emotional and mental health problems is improving, but many women still leave their doctors’ offices feeling unheard.

Treating perimenopause and menopause symptoms with medication aimed only at relieving anxiety and depression does not dig deeply enough to uncover the reasons for these symptoms. Might these medications be a piece of the puzzle? Might counseling and therapy factor in? Absolutely. But in order to know that, we need to look at the whole picture—and that means time. Time to listen and to evaluate.

We need your history—a detailed history, including medical diagnoses, medications and supplements, family history, and information about your menstrual cycle and its connection to your various emotional symptoms. It is well known that women who have experienced symptoms of depression or anxiety surrounding times of hormonal shifts (puberty, pregnancy, and postpartum) are more likely to experience these symptoms again during the transition from perimenopause to menopause.

It is true that changes in mood, or “mood swings,” are very common in perimenopause. There may be a sense of calm and well-being one minute, followed by irritation and rage the next. Often, there seems to be no particular trigger for these changes. These mood shifts may happen occasionally, or they may happen frequently enough to interfere with your daily activities. However, we cannot just blame it all on perimenopause. Relationship issues, life stressors, other medical problems, and poor sleep may cause—or at least contribute to—bouts of emotional upheaval.

In perimenopause, hormone levels, especially estrogen, begin to fluctuate wildly, and in menopause, all hormone levels sink to pretty much zero. The ovaries are done. Estrogen is strongly connected to serotonin and dopamine, two brain neurotransmitters important for feelings of well-being, good sleep, a calm mood, and sharp cognitive function. When estrogen fluctuates and then disappears, so do some of the benefits of adequate dopamine and serotonin. Progesterone, the hormone associated with ovulation, is also considered a “calming” hormone and is closely connected to restorative, deep sleep.

If anxiety and depressive symptoms appear or worsen during a period when hormones are likely to be fluctuating, hormone therapy in the form of estrogen and/or progesterone replacement, combined contraception, or progesterone-only contraception can all be considered as first-line therapy, especially if there are other symptoms like hot flashes and insomnia. However, hormones are not a solution for every symptom or for every woman. If emotional symptoms and irritability persist even after a period of time on a stable hormone plan—and especially if hot flashes and night sweats have been relieved with that plan—it makes sense that all of these symptoms may not have been corrected with hormones.

Often, at that point, we might offer to add medication or therapy directed at relieving those specific depressive or anxiety symptoms. We find that combination therapy—along with a healthy diet, exercise, sleep hygiene, and possible supplements—is very often the most effective treatment, addressing both the biology and the brain.