The Mental Health Aspects of Menopause

Vanessa Haygood, MD ’78, remembers when the referrals started rolling in to her obstetrics and gynecology practice in Greensboro, North Carolina. What gave her pause wasn’t that primary care physicians would send women in their forties and fifties to her with complaints of anxiety or depression. It was how often the accompanying notes indicated that the cause boiled down to “just menopause” and that the women simply “needed some hormones.”

Thirty years of clinical experience taught Haygood what more clinicians and researchers appreciate with each passing year: that changes in mental health can indeed accompany the transition into menopause, sometimes with such intensity that they damage physical health, quality of life, relationships, and work, and that the causes are complex and the treatments many.

Yet the reductionist, even dismissive, tone of the referrals reflected broader trends in mainstream U.S. culture and in the medical profession about which populations and conditions deserve attention. Attempts to address changes in mood and mental health around the time of menopause suffer from an unholy trinity of neglect: the patients affected are mostly women and women’s health isn’t studied or treated as thoroughly as men’s, the women are typically heading into older adulthood in a society that clings to youth, and the problems are psychological in a health care system disposed to prioritizing the physical.

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As a result, many women and their care providers don’t fully appreciate the risk of developing new, relapsed, or worsened mental health conditions as menopause approaches. Those who are aware may not know how best to treat the symptoms. And researchers have barely begun to quantify menopause-associated mood changes and mental illnesses, pinpoint their causes, and compare the effectiveness of treatments.

“More attention should be given to the mental health aspects of menopause,” says obstetrician-gynecologist Laurie Green, MD ’76. “Women are suffering in silence.”

Haygood, who retired last year, appreciated the referrals because she felt she could legitimize patients’ concerns and discuss options. She only wishes more women enjoyed such support. “I’d like to see this attitude that it’s ‘just menopause’ change. It would be a real advancement in care.”

Signs and signifiers

Clinicians, such as Laura Payne, an HMS assistant professor of psychology in the Department of Psychiatry at McLean Hospital, offer a quantitative way to understand the problem when they explain that the menopausal transition “is a vulnerable time for women in terms of mental health struggles.”

Patients, such as British journalist Rose George, paint the qualitative picture. “I am one of the women of menopause, who struggle to understand why we feel such despair, why now we cry when before we didn’t, why understanding what is left and what is right takes a fraction longer than it used to … I miss myself, the woman who didn’t feel like this,” George wrote in The New York Review of Books in 2018. For her, as for a subset of women, terms like “low mood” and “brain fog” fail to capture the extent to which natural menopause “doesn’t feel natural. It feels like a derangement.”

Menopause, defined as having had no periods for one year, represents one of life’s rites of passage: a bookend to the onset of menstruation in adolescence, marking the end of fertility and the beginning of a new stage of life. It can be a source of joy, relief, pride, or darker sentiments. While some sail through the gradual winding down of the reproductive system known as perimenopause with no trouble other than missed periods, most must navigate stormy waters for anywhere from a few months to more than a decade, often without a compass—or even a raincoat. Clinicians have no way to predict how long an individual’s journey will take or how smoothly it will go.

Physical hallmarks such as hot flashes and night sweats, which strike about three-quarters of perimenopausal women, don’t tell the whole story.

Mood swings turn familiar emotional rhythms into a pinball game. Risks of depression, anxiety, and alcohol and substance use rise. So may those for psychiatric illnesses: Many women with bipolar disorder or schizophrenia find that their symptoms intensify during perimenopause, and schizophrenia, most often diagnosed in young adulthood, has a second, smaller peak of onset in women around menopause. Cognitive troubles commonly include having difficulty concentrating, experiencing short-term memory failures, and losing motivation. These can be frustrating or downright frightening. The North American Menopause Society, or NAMS, reports that many perimenopausal women who struggle to think clearly or remember obvious words fear that their symptoms herald not menopause but dementia.

“Women don’t know who they are anymore,” says Sheryl Spitzer-Resnick, ​MD ’85, a family medicine physician based in Madison, Wisconsin, who specializes in peri- and postmenopausal management.

Several large initiatives, including the landmark Study of Women’s Health Across the Nation, or SWAN, the Nurses’ Health Study, the Harvard Study of Moods and Cycles, and the Women’s Health Initiative, or WHI, have advanced menopause knowledge and care in recent decades. Still, researchers haven’t fully characterized the scope of menopausal mental health. Many studies don’t include mental health as a primary outcome. Investigators use diverse criteria to measure it. Prevalence estimates for perimenopausal depression alone are as high as 40 percent, says Payne. Stigma, poor access to health care, and other barriers that can impede reporting mental health symptoms don’t help.

What is clear is that if approximately 2 million U.S. women begin perimenopause each year, as the MGH Center for Women’s Mental Health estimates, then “a large number of women may be at increased risk” for depression and other mood disorders “for an extended time,” wrote Hadine Joffe, an HMS professor of psychiatry at Brigham and Women’s Hospital and current president of NAMS, and colleagues from the MGH center in The American Journal of Medicine in 2005.

Treating mental health as part of an overall menopause management strategy would improve individuals’ emotional well-being and quality of life and even help prevent stress-related chronic disease—a particularly important effort during this stage of women’s lives, says JoAnn Manson, the Michael and Lee Bell Professor of Women’s Health at HMS and Brigham and Women’s and a former NAMS president.

“This should be a time for clinicians and patients to devote even more attention to risk-factor management, lifestyle modifications, and other approaches to reducing risks of chronic diseases, which rise after menopause,” she says.

We are losing women’s energies in our families, our workforce, and our communities because we have not given parity to mental health.

Addressing mood and cognitive symptoms would also offer social, financial, and communal benefits, given that poor mental health may diminish perimenopausal women’s work and relationships. Marriages may grow strained. Personal productivity and confidence may fall.

“Women can’t fully contribute to the things they care about,” says Spitzer-­Resnick, “nor are they as tolerant or resilient in how they manage stress.”

“We are losing women’s energies in our families, our workforce, and our communities because we have not given parity to mental health,” says Haygood.

Alleviating this quiet tragedy requires understanding its origins in and around the body.

Lived experience

Chronic pain from endometriosis and recurrent ovarian cysts drove Spitzer-­Resnick to have her uterus and ovaries removed at 39. The aftermath, she says, taught her “hormones by fire.”

She couldn’t sleep past 4 a.m. She snapped at her husband. She “hot flashed [her] brains out.” Wearing the maximum allowed dose of estradiol patches finally helped her sleep through the night.

At first, she attributed the remaining anxiety and irritability to her “crazy busy life” running a family medicine and obstetrics practice and raising a child. Then she heard about natural progesterone supplements at a conference, started taking them, and felt calmer. The hot flashes ebbed.

At its essence, menopause is hormones. The ovaries shut down, taking with them the estrogen, progesterone, and testosterone they produce. As ovary activity lessens, the levels of these hormones surge and drop unpredictably. A person’s baseline levels seem to matter less than the fluctuations.

It’s impressive to consider how much havoc two organs weighing a few tenths of an ounce can wreak. Then again, there are estrogen receptors distributed throughout the body.

Researchers, including Joffe, continue to uncover ways in which reproductive hormones, particularly estrogen, affect the brain. Low estrogen levels in the hypothalamus have been shown to drive hot flashes, night sweats, chills, and insomnia. Concentrations of estrogen receptors in the hippocampus help explain the hormone’s involvement in memory and cognition. Studies indicate that estrogen modulates dopamine, serotonin, and norepinephrine activity from the amygdala to the prefrontal cortex, influencing mood stability and offering one explanation for the association with schizophrenia.

Clinicians such as Spitzer-Resnick remind researchers not to discount the potential effects of low progesterone, either: “your happy, anti-anxiety, anti-inflammatory hormone.” Having seen natural progesterone supplementation ease her own and an array of her perimenopausal patients’ symptoms, including panic attacks and uncontrolled crying, she’s eager for scientists to dig deeper into progesterone’s role at the root of menopausal mental health. Measuring women’s reproductive hormone levels, especially at different times of the month, would provide invaluable data, she and others say.

Hormones can affect perimenopausal mental health indirectly as well. The constellation of possible physical symptoms—thermostat swings, unpredictable periods, weight gain, breast changes, thinning hair, lower libido, discomfort during sex—can leave women anxious and depressed. Sleep disruption tanks mood and clarity of thought. Brain fog may generate worry about professional life.

“If you’re a doctor, a university president, a writer, really all women need their words,” says Spitzer-Resnick. “Lowering estrogen levels seems to make people forget their nouns.”

Yet hormones account for only a piece of the puzzle. Simple lines can’t be drawn from most perimenopausal mental health symptoms to changes in biochemistry. Notably, clinical trials have failed to find a direct link between menopause and major depression. Research may unearth additional biological and genetic contributors. Psychosocial factors also appear to play a significant role.

Experts point to life events that tend to coincide with menopause, which U.S. women reach at an average age of 51. Middle-aged women may be dealing with ailing parents, children leaving or returning home, or changes in their domestic relationships. They may shoulder new responsibilities at work or confront the first hints of ageism. The passage of time can’t be ignored.

“Menopause is the undeniable indicator of aging,” says Green. “It brings a lot of existential questions to the fore.”

The intersection of menopause and middle age makes it hard to track every symptom to its source. “Hormonal and physiological changes overlap with, and compound, the stressful life circumstances many women experience in midlife,” says Manson.

Going through menopause earlier than expected carries its own set of mental health issues. A 2019 article in Post Reproductive Health described how patients undergoing induced menopause via procedures that remove or disrupt the ovaries, along with the approximately 1 to 3 percent of women who experience natural menopause before age 40, may experience grief, anger, depression, and anxiety.

And people with ovaries who don’t identify as women may need support as they traverse a traditionally female phenomenon.

External pressures to hide or overcome symptoms take an additional toll. Women are often expected to prioritize the needs of others. Cultural standards of femininity may clash with bodily changes. Workplaces typically don’t accommodate the need to adjust temperatures or leave meetings to ride out hot flashes, and many women don’t feel comfortable raising menopause-related issues at work while they still struggle for equal pay and respect compared to men. Mental health issues continue to carry a stigma of weakness, says Haygood. Too many women who reach out on social media with their struggles over menopause and mental health end up feeling shamed or inadequate, says Green. Silence often wins out—and women lose.

“Menopause and mental health is still a forbidden topic in our society,” says Payne. “It’s mind-boggling. Every woman will go through menopause, yet how often do we talk about it?”

Unfortunately, the medical profession is not ideally positioned to help.

Ask the question

Stigma certainly prevents some perimenopausal women from telling care providers about mental health struggles. Obstacles arise on the other side, too, starting with the constraints on the time a physician can spend with a patient.

“Any clinician with a schedule to keep will often not ask women about mental and sexual health for fear they’ll open a Pandora’s box that will make them late for their next patient,” says Green. She resists these tendencies in the women’s health practice she cofounded in San Francisco.

Even when women disclose, insurance reimbursement practices, instances of medical sexism, and gaps in physician education can create barriers to effective care. Lobbying for equitable coverage of mental health services and other treatments and for implementation of standard mental health screening in perimenopausal women would make a big difference, say Green, Haygood, and others.

While discrimination has fallen in recent years, the medical profession can do a better job of listening to female patients, sources say. Perimenopausal women of color may be at an even greater disadvantage, considering studies have demonstrated that women of color are routinely treated differently and have a harder time accessing mental health services than white women, says Haygood.

“Some providers take Black women less seriously when they seek remedies for mental health concerns, just as they do with other symptoms,” she says.

Awareness of the need to address mental health issues around menopause has outpaced provider training in how to do so. A 2013 survey published in Menopause found that only one in five U.S. OB-GYN residents receives formal training in menopause care. Medical school curricula tend to offer “quite limited” information on menopause, Manson says.

HMS faculty are trying to change that. This spring, Manson and colleagues launched an elective course focusing on sex- and gender-informed medicine. Among the topics covered are hormonal, vascular, and mental health changes at various life stages and the best ways to address related health issues.

Follow the science

Most women don’t need prescription medications to traverse perimenopause. For those who do, hormone replacement therapy offers a top option—or would, if it weren’t for widespread misinterpretation of findings from the WHI in 2002. That study saved lives by revealing that a type of estrogen-progestin therapy raises risk of heart attack, stroke, and breast and endometrial cancers when prescribed to late menopausal and postmenopausal women solely to prevent chronic disease. Inappropriate use of hormone therapy plummeted, but so did other, safer applications.

The WHI report went public on a Wednesday. Green watched in growing alarm on Thursday as news story after news story “took something that was statistically interesting but not overwhelming and turned it into a crisis.” Friday morning, as part of her weekly medical segment on KTVU news in the Bay Area, Green went on the air and tried to impress upon her audience the difference between relative and absolute risk. Yes, she explained, breast cancer risk doubled, but that amounted to only one extra case per 12,000 women per year.

Green’s voice, along with colleagues’, was drowned out. The message got lost that hormone therapy remains a good strategy for managing “moderate to severe” symptoms such as night sweats in perimenopausal women who don’t have a high risk of breast cancer or other contraindications—and that steadying the hormonal seesaw can improve mental health. To this day, many doctors do not prescribe FDA-approved hormones, many women have been afraid to take them, and most health plans won’t cover many of the safest forms of estrogen replacement.

Research is still in its infancy regarding the menopausal experiences of transgender men who keep their ovaries.

Manson served as a principal investigator in the WHI and several other women’s health studies. She pursued women’s health to prevent disease after her mother died of ovarian cancer early in Manson’s medical training. Although encouraged by progress in the field, she says it’s “been frustrating to see the WHI results extrapolated to women in their forties and early fifties who are grappling with severe and distressing menopausal symptoms.”

Communication and education could help. So could more research into formulations that the original WHI report didn’t cover, such as estrogen patches and bio­identical hormones. Evidence would then replace conflicting anecdata, such as natural progesterone serving as a magic bullet for Spitzer-Resnick while causing endometrial buildup that necessitated a hysterectomy for Green. More research into the safety of long-term hormone therapy would inform care for cisgender women and for transgender women who take estrogen and anti-androgens and who have the option to continue hormones indefinitely or to taper them for a menopause-like experience. A survey of transgender women in the UK reported in the International Journal of Transgenderism in 2018 found that most respondents over 50 had not changed regimens; the hormones provided critical mental health support by helping them look and feel more feminine, boosting self-confidence, and reducing depression.

The other common strategy for tackling perimenopausal women’s mental health is to prescribe antidepressants and anxiolytics. One theory holds that these drugs compensate for estrogen’s waning effects on serotonin and gabapentin. There’s some suggestion that they tamp down hot flashes and night sweats, further improving mood and cognition. A concerning number of studies, however, have found perimenopausal depression and anxiety resistant to these drugs.

While the jury deliberates on whether antidepressants or hormones provide the better first-line pharmacologic treatment, researchers seek more options. Cognitive behavioral therapy helps many perimenopausal women. HMS faculty are investigating a wide range of therapeutics, including neurosteroids and dietary supplements. Studies have begun to probe the roles of inflammation and the gut microbiome. Research is still in its infancy regarding the menopausal experiences of certain populations, such as transgender men who keep their ovaries.

As menopause research and care enter a new phase, so do those who cross the threshold. Postmenopausal health requires just as much attention as—if not more than—health before menopause. With U.S. female life expectancy hovering around 81 years, one third of menopausal women’s lives still lie ahead.

Stephanie Dutchen is a science writer in the HMS Office of Communications and External Relations.

Images: Jon Black (Haygood); Kat Schleicher (Spitzer-Resnick); John Soares (Manson)