Menopause and mental health

Did you know that mental health symptoms may be the first sign of the menopause?

The hot flushes, the night sweats, the brain fog, the poor sleep … many of us are aware of the common physical health symptoms of the menopause, but less is known about its close link with mental health.

It’s no exaggeration to say that the two things, menopause and mental health, often go hand-in-hand. In fact it’s fairly common that the first tell-tale signs of menopause aren’t hot flushes and night sweats but low mood, anxiety, irritability and tearfulness.

And while these symptoms may initially be downplayed or normalised by the individual (chalked up to the stresses of life and work) they absolutely need to be on everyone’s radar so we can ensure women quickly get the support and care that they need.

Because, devastatingly, mental health symptoms in midlife can be so severe that they lead some women to contemplate the unthinkable.

Biology, body and brain

Oestrogen is one of the key female hormones that winds down during menopause and women have oestrogen receptors in pretty much every cell of their body, including the brain.

Think of it like this: a woman’s brain has received a regular and consistent supply of nourishing hormone fuel for 30 years or more. Her brain has built a certain routine and emotional balance on the strength of that fuel supply. To a greater or lesser extent, hormones have contributed to cognitive function; decision-making; resilience; mood control and so on.

So when this reliable gush of hormone fuel suddenly slows to a trickle, the brain finds itself in uncharted territory. It now has to continue vital jobs and management tasks on a near-empty tank. It’s a tall order and it’s completely logical, then, why some midlife women go into a mental and emotional tailspin.

The data gap

A key reason we’re still behind in joining some of the major menopause dots dates back to a watershed moment 20 years ago, which has left a stain on how we perceive, treat and talk about menopause.

In 2002, a Woman’s Health Initiative (WHI) study – the first of its kind – stopped clinical trials early and raised the alarm over the “significant risks” of Hormone Replacement Therapy (HRT).

The study effectively denounced HRT and the world’s media leapt on its findings. Pretty much overnight, HRT was recast as harmful and doctors immediately took patients off it; due to its supposed links with breast cancer, heart disease and other life-changing conditions.

The WHI study was later described as “melodramatic” and its findings were revised. Subsequent studies demonstrated that, with the right clinical support, hormone replacement therapy is a safe treatment for the menopause.

But it wasn’t until 2015 that NICE guidance stated that HRT was now the first line treatment for the menopause. Since then, awareness, training and education have improved rapidly and menopause has become a much bigger priority.

Still, the WHI chapter left its mark on a generation of medics and health professionals. Progress was somewhat arrested for a period of years in the confusion. There isn’t and wasn’t any intentional lack of care out there but, simply put, some doctors have been de-skilled in menopause and made to be sceptical of HRT.

Hence even today we know of midlife women who’ve seen their doctor with low mood and been immediately prescribed antidepressants. We know women who’ve presented with palpitations and been investigated for heart conditions. We know women with brain fog who’ve been screened for dementia …

In all these cases symptoms were menopause-related.

Mental health? Mention menopause

Of course, anxiety and depression can coexist alongside menopause – no-one’s saying all depressed women are menopausal!

But whenever a woman of any age presents to me with mental health symptoms, I always want to know about her hormones, her periods and other physical symptoms that may be linked. If I suspect menopause, I know that the HRT benefits on mind and mental health can be profound.

As said earlier, the brain – and all the functioning, decision-making and emotional balance that it presides over – has gotten used to a regular and consistent supply of hormone, so replacing that hormone can quickly make a difference to one’s mental health.

It’s also important to say that, while we’re now aware of the benefits of HRT, it’s not for everyone. Not all women want to take HRT, not all women need to take HRT and not all women CAN take HRT. It is prescribed based on the individual, taking into account risk, benefit and symptoms.

Also, lifestyle remains fundamentally important in managing hormone health and mental health so, with or without HRT, it’s vital to focus on those pillars of health: diet, exercise and sleep.

Comfort in menopause

It might sound perverse or counter-intuitive, but hearing the word menopause – and tying it into what’s going on – can bring about significant relief, especially if a woman has previously been clamouring for answers about her mental health.

Specifically, burnout in midlife is often a prelude to menopause that gets downplayed, gets missed, and gets worse.

I’ve seen dozens of successful and career-orientated women who start to notice they’re falling behind or unable to keep up the work rate of old. They sense something’s wrong with their mental health but instead of reducing their workload or taking some down time, the temptation is to work harder! Very often they’re on a path to burnout as the individual works harder; sacrifices more personal time; misses more sleep; skips more meals …

This burnout spiral can lead women to feel like they’re losing control of who they are, what they do and their place in the world. If it’s not identified early, it can lead to crisis. It can lead to worse.

For these women, fast-forwarding to the menopause part can be such a relief because it explains what’s been happening and gives them permission to seek help.

It also tends to speed up her acceptance that the old way and previous working patterns will have to take a back seat while she shifts priorities to concentrate on her – and calmly guiding her body through its change. There’s psychological comfort in that.

A final word

If you’re in midlife, or someone you know is, and mental health is becoming an issue please see it as a red flag. It’s time to see a doctor and it’s time to insert the word menopause into the conversation.

If it’s not menopause you’ve lost nothing. If it is or may be, you can bypass the trial and error and head for the first-line treatment.