Often when women think of perimenopause, they envisage changes to their menstrual cycle, lack of sleep and the dreaded hot flushes. What’s less known is the changes to mental health that a woman can experience during this stage of life. As a transition state, the amount of neurological change is similar to the changes that occur during puberty. When looked at in this way, it’s easy to understand the massive changes a woman’s brain undergoes.
Perimenopause is the transitional phase leading to menopause. It’s when the levels of reproductive hormones in a woman’s body start to change, and she experiences changes in her menstrual cycle. Menopause refers to the point in time when a woman hasn’t had a period for 12 months. The essential point to understand at this time of life is that although the clinical definition of perimenopause focuses on functional changes in the reproductive system, the symptoms of perimenopause are largely neurological in nature. Many women experience mood changes such as depression or anxiety at this time, but don’t recognise it as being driven by hormonal changes.
Biology of perimenopause mood changes
Changing oestrogen levels
Hormones don’t only impact the menstrual cycle, they also influence numerous neurotransmitters and processes within the brain. Oestrogen and progesterone (our main reproductive hormones) modulate neurotransmitters such as dopamine and serotonin. A woman’s brain has a vast oestrogen receptor network. This network of receptors has been used to detect a certain pattern of oestrogen levels across the menstrual cycle. When the hormonal levels start to fluctuate in perimenopause, our receptors have to try to adapt to changing levels of oestrogen, whereas previously it was predictable.
It’s not uncommon for a woman to be profoundly depressed or anxious for days, then feel totally well for a week, only to plunge back into poor mental health. This is due to the underlying fluctuations in the female reproductive hormones and their effect on the brain’s neurotransmitters. For some women, the brain is less able to successfully adapt to the changes in levels of oestrogen, leading to the development of mood changes.
Decline in glucose metabolism in the brain
Oestrogen also contributes to the brain’s ability to transport and metabolise glucose for energy production. The decline in oestrogen results in less glucose being available to the brain, meaning it has to shift its energetic response and means of obtaining fuel. The decline in brain glucose metabolism may be a causative factor in the development of neurological symptoms.
Societal factors
Societal factors which coincide with the menopausal years may contribute to the development of anxiety and depression. Common factors include the stress of caring for elderly parents, adolescent children, financial pressures, relationship stress, and job stress. This is coupled with societal and individual perspective on age, such as the tendency to value youth more than the elderly.
Menopausal depression
Studies have shown that perimenopausal women are at an increased risk of developing depression and anxiety compared to pre or post-menopausal women. Depression during perimenopause has now been identified as a unique subtype of depression with a particular set of symptoms. Lack of knowledge about how this depression can present differently can unfortunately mean perimenopausal depression is often overlooked or left undiagnosed.
Although some of the symptoms of perimenopause depression overlap with major depressive symptoms, some key characteristics differentiate perimenopausal depression. In particular, the mood symptom profile comprises anger, irritability and paranoia, rather than just low mood. Other symptoms include muscle pain, decreased self-esteem, feelings of isolation, cognitive impairment and decreased libido. It’s important that the differences between menopausal depression and clinical depression be recognised, otherwise, women will not be diagnosed, and the diagnosis will be missed.
A questionnaire called Meno-D has been developed by a Melbourne psychiatrist as a validated screening questionnaire to rate the severity of symptoms related to depression in perimenopause. The questionnaire includes a set of sub-scales including:
- Self (self-esteem, isolation, paranoid thinking and anxiety)
- Sexual (changes in libido)
- Somatic (physical pain and weight changes)
- Cognitive (changes in memory and concentration)
This tool is a game-changer in helping us identify women in our clinic with menopausal depression. It can be quickly filled out by either the woman herself, or her practitioner.
Other possible diagnoses
It’s important to consider and either rule in or out other possible conditions that can occur during perimenopause such as:
- Thyroid disorders: A thyroid function test is necessary to determine the thyroid’s involvement in symptoms. An overactive thyroid, or hyperthyroidism can mimic the symptoms of anxiety, whereas an underactive thyroid or hypothyroidism can present with depressive symptoms
- Iron deficiency: Symptoms of iron deficiency anaemia include heart palpitations and shortness of breath, both of which are symptoms of anxiety
- Vitamin D and B12 deficiency: Both are associated with depressive symptoms
Treatment – the conventional approach
Conventional medical treatment for mood changes during perimenopause includes antidepressant medications and psychotherapy. It’s important to consider that antidepressants may not be the ideal choice if the driver of the woman’s perimenopausal mood changes are hormonally driven.
Menopausal hormone treatment (MHT) may be appropriate if there are no contraindications (current or recent hormone-dependent cancer, or history of venous thromboembolism). It’s important though that the prescribing doctor chooses the right form of MHT, as not all forms of synthetic oestrogen cross the blood brain barrier.
The functional medicine approach
The functional medicine approach to thriving through perimenopause considers all factors that can impact a person’s health, and in the case of perimenopause, they include:
- Mediterranean diet: The Mediterranean diet shows the most benefit for this stage of life, both for support of mood and to decrease risk factors for cardiovascular disease and poor bone health
- Soy isoflavones: The inclusion of soy isoflavones can be beneficial as they act  on the oestrogen receptors in the brain and the reproductive system, lessening the impact of the declining and erratic oestrogen levels
- Herbal support: Herbal medicine can be used to help attenuate the effects of oestrogen fluctuations on the brain, in particular Black cohosh (Actaea racemosa) and Chaste Tree berry (Vitex agnus-castus). There’s a long tradition of herbal medicines supporting women through times of hormonal change. Other classes of herbs can be used to help to either elevate mood or to decrease anxiety
- Stress management: The importance of lifestyle modifications at this stage of life cannot be overstated. Management of stress is particularly important as it has been identified as a major contributing cause to many perimenopausal symptoms. It’s imperative a woman learns some stress management strategies she can into her daily life
- Exercise: Exercise is important for its mood-elevating effects, as well as being necessary for bone density and preservation of lean muscle mass.
- Diet and lifestyle changes and using targeted supplementation can help manage and reduce perimenopausal mood changes. This can be done either alongside or without MHT
Perimenopausal mood changes represent a significant yet often under-recognised part of this transitional phase in a woman’s life. While the physical symptoms of perimenopause are more commonly acknowledged, the neurological and mental health impacts, driven by fluctuating hormone levels, are equally critical.
Understanding the biological basis of these mood changes, alongside the influence of societal stressors, highlights the multifaceted nature of this condition. The distinction between perimenopausal depression and other forms of mood disorders is vital for women’s mental health and wellbeing with appropriate diagnosis and treatment.
With the right knowledge, women can be empowered to navigate this life stage with better mental wellbeing and overall health.
