The Intersection of Menopause and Mental Health

As with all transitions from one life stage to the next, menopause can impact mental health in a variety of ways.

This article looks at how hormonal changes during menopause can influence mood and mental health, as well as outlining some of the treatment options available.

What is menopause?

Menopause is a natural biological transition characterized by a decline in estrogen levels and is officially identified as the moment when menstruation has been absent for a full year. After menopause, pregnancy is not possible. Menopause, as a life stage, significantly affects health and overall wellness.

Symptoms manifest in the period leading up to this milestone, known as perimenopause. This stage can last up to 8-10 years.

The phase following menopause is referred to as postmenopause, and this can last up to a decade. Again, symptoms may persist into postmenopause.

When does menopause take place?

Although menopause typically occurs between the ages of 45 and 55, experiences are not solely tied to age.

The average age at which menopause is reached is 51. However, a significant number (11%) reach menopause before 45 years of age. Menopause affects 10% of 40- to 45-year-olds, while 1% of individuals will undergo early menopause (defined as menopause occurring before the age of 40).

The perimenopause phase can begin as early as one’s twenties. Similarly, surgical procedures, illnesses, or treatments for other medical conditions, such as chemotherapy, have the potential to initiate early menopause.

How many people are affected by menopause?

In the United States, there are around 57 million women who are over the age of 45. This means approximately 6,000 women enter menopause every day.

However, this number is actually much higher when we consider the time spent in perimenopause and postmenopause. Since the duration of menopausal symptoms can vary from person to person (typically lasting for about four years, sometimes extending up to 14 years), the true number of women impacted by menopause is significantly greater than the 6,000 mentioned earlier.

Likewise, menopause doesn’t just affect those it directly happens to. Family, friends, and colleagues of those going through menopause can also be impacted, depending on the severity of symptoms experienced and any possible treatment sought.

What are the symptoms of menopause, and how long do they persist?

Roughly one out of every four individuals will encounter incapacitating symptoms, including:

• Sleep difficulties: Challenges falling asleep or staying asleep, and night sweats.
• Cognitive changes: Issues with memory or concentration commonly referred to as “brain fog.”
• Muscular and joint discomfort: Aches and pains in the muscles and joints.
• Palpitations: Irregular or heightened heartbeat sensations.
• Headaches and migraines: Recurring head pain or recurrent migraines.
• Weight fluctuations: Gaining weight and struggling to lose it.
• Skin changes: Dry, itchy skin.
• Decreased libido: Reduced interest in sexual activity.
• Changes to menstruation: Periods can become irregular, changing in duration and flow.
• Vaginal discomfort: Dryness, pain, itching, or discomfort during sexual intercourse.
• Urinary issues: Frequent urinary tract infections; incontinence.
• Hot flushes/flashes: Sudden sensations of heat or cold in the facial, neck, and chest areas, often accompanied by dizziness, skin reddening, sweating, palpitations, and a brief but intense period of physical unease, which can endure for several minutes.
• Emotional changes: Low mood, anxiety, mood swings, and diminished self-esteem.

These symptoms affect all aspects of well-being: physical, emotional, mental, and social.

According to a 2013 study^[1], symptoms can be a significant personal and economic burden on women in middle age. Equally, menopausal symptoms have been found to correlate directly with diminished health-related and menopause-specific quality of life.

Broader social issues relating to menopause and mental health

Menopause is a universal experience for women across the world. Despite being a natural phase of life, there persists a stigma, lack of understanding, and stereotypes surrounding it.

Menopause is not just a significant biological change, but it also has social implications that are exacerbated by psychosocial stressors, role changes, losses, and the experience of aging.

Experiences of menopause can also be impacted by gender expectations, familial dynamics, and broader sociocultural elements, specifically including general perceptions of female aging within cultural contexts.

In certain cultures, including the United States, the decline in fertility can be associated with a perceived decrease in sexual vitality. As women transition into midlife, many express feelings of becoming “invisible,” perceiving a diminished value placed on them by society. Often, they experience embarrassment about their symptoms and try to conceal them, fearing they might be labeled as “aged”.

The combination of this stigma with the physical symptoms of menopause can intensify the challenges of this transitional period, making women more vulnerable to mental health issues, particularly anxiety and depression.

How do hormonal changes during menopause influence mood and mental health?

Many going through menopause experience low mood, anxiety, mood swings, and diminished self-esteem. These symptoms can significantly affect their overall mood and mental health.

A 2022 study^[2] found menopause symptom severity was significantly associated with depression, sleep difficulties, binge eating severity, and most quality of life measures.

One of the main issues experienced by those going through menopause is when the hormonal fluctuations that begin in perimenopause are misdiagnosed as a mental health issue by both patients and medical professionals alike.

Unfortunately, this means patients may believe that what they are experiencing is purely psychological rather than a combination of hormonal, physiological, physical, and psychological symptoms. As well as the impact on self-esteem, this misdiagnosis may mean patients are prescribed antidepressants rather than hormone treatments.

Complicating the issue even further is that certain antidepressants (ie. those related to the class of drugs called SSRIs/selective serotonin reuptake inhibitors) may decrease menopausal hot flashes, as well as improve mood. Nevertheless, understanding the cause of a patient’s symptoms is key.

Menopause and depression

The North American Menopause Society^[3] reports that pre-existing depressive symptoms tend to exacerbate during the course of menopause, although there is a mix of evidence regarding whether depressive disorders are more prevalent during the menopausal transition compared to the perimenopausal phase.

A significant proportion of women who exhibit depressive disorders while undergoing the menopause transition have previously experienced depression before this stage. Women with a history of depression face an increased likelihood of this depression recurring during the menopause transition.

As a result, clinical guidelines advise healthcare professionals should assess for depression in women with a history of depression and to prioritize the utilization of antidepressants or established psychotherapies (such as cognitive-behavior therapy, interpersonal therapy, and mindfulness-based cognitive therapy) as the primary interventions for managing recurrent major depressive episodes.

Are there any treatments for menopausal symptoms?

Yes. A range of non-hormonal and hormonal approaches exist to mitigate menopausal symptoms.

Symptoms that affect health and well-being should always be discussed with a healthcare professional, enabling the exploration of potential management strategies based on medical history, personal values, and preferences.

1 – Hormone therapy

According to the North American Menopause Society’s 2022 statement^[4], hormone therapy is the most effective treatment for hot flashes/flushes and night sweats (vasomotor symptoms or VMS) and genitourinary syndrome of menopause (GSM) and has been shown to prevent bone loss and fracture.

The risks associated with hormone therapy can vary for women, depending on factors like the type of hormone, the dose, how long it’s used, the method of administration, when it’s started, and whether progestogen is required. To make the most of the benefits and minimize risks, treatment should be tailored to each individual using the best available evidence, with regular reassessment.

For women under 60 years old or within 10 years of starting menopause and without any conditions that prohibit hormone therapy, the balance between benefits and risks seems positive for managing bothersome vasomotor symptoms, preventing bone loss, and reducing the risk of fractures.

On the other hand, women who start hormone therapy more than 10 or 20 years after beginning menopause or when they’re 60 years old or older might have a less favorable balance of benefits and risks compared to younger women. This is because the absolute risks of conditions like coronary heart disease (CHD), stroke, venous thromboembolism (VTE), and dementia become higher.

For relieving genitourinary symptoms of menopause (GSM) that don’t respond to non-hormonal treatments, it’s recommended to consider low-dose vaginal estrogen therapy or other therapies that are approved by government authorities, like vaginal DHEA or oral ospemifene.

1b. A note on hormone therapy and depression

Estrogen therapy doesn’t seem to be effective in treating depressive disorders in postmenopausal women. However, evidence suggests that estrogen therapy can have antidepressant effects similar in strength to antidepressant medications when given to perimenopausal women dealing with depression. There’s also an indication that estrogen therapy could improve mood and overall well-being in perimenopausal women without depression.

Relatedly, using transdermal estradiol (estrogen delivered through the skin) with intermittent progestin (progesterone) might have a preventive effect against the onset of depressive symptoms in perimenopausal women with stable moods. However, evaluating the risks and benefits is crucial to any treatment, and right now, the available evidence isn’t strong.

Estrogen-based therapies could also potentially enhance the effectiveness of antidepressants in midlife and older women, particularly when these therapies are also meant to address other menopause symptoms like such vasomotor symptoms (VMS) as hot flushes/flashes and/or night sweats.

Research in this area continues. However, it’s important to note that estrogen is not approved by the government for treating mood disturbances.

2 – Non-hormone therapies

Non-hormone treatments for menopause offer a range of options for managing the diverse array of symptoms that can accompany this transitional phase in a woman’s life. These treatments aim to provide relief without relying on hormonal interventions and are particularly relevant for women who cannot or choose not to undergo hormone therapy.

For managing vasomotor symptoms such as hot flashes/flushes and night sweats, several approaches have shown promise. Behavioral strategies such as maintaining a cool environment and wearing breathable clothing can help mitigate discomfort.

A low-dose antidepressant for the management of hot flashes may also be useful for women who can’t take estrogen for health reasons or for women who require an antidepressant for a mood disorder.

Cognitive-behavioral therapy (CBT) and mindfulness techniques offer non-pharmacological avenues for reducing the frequency and intensity of hot flashes.

Genitourinary symptoms of menopause, like vaginal dryness and painful intercourse, can be effectively addressed through non-hormonal methods. Over-the-counter vaginal moisturizers and lubricants provide immediate relief.

What other interventions improve mental health during menopause?

Lifestyle modifications can be a helpful way to approach non-hormone treatments for menopause symptoms.

Regular exercise not only contributes to overall well-being but can also alleviate mood disturbances (including depression^[5]) and sleep disturbances.

A balanced diet rich in phytoestrogens, plant-based compounds with estrogen-like properties, may contribute to symptom relief.

Psychological symptoms like mood swings and anxiety can benefit from psychotherapy and counseling. Cognitive-behavioral therapy, in particular, equips women with effective coping mechanisms to navigate emotional changes.

The effectiveness of all menopause treatments can vary from person to person. Consultation with a healthcare provider is crucial to tailor these treatments to individual needs and preferences.

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1. Whitely J, DiBonaventura MC, Wagner J-S, Alvir J, Shah S. The impact of menopausal symptoms on quality of life, productivity, and economic outcomes. J Womens Health. (2013) 2:983–90. 10.1089/jwh.2012.3719
2. Hooper, Savannah C. BA; Marshall, Victoria B. BA; Becker, Carolyn B. PhD; LaCroix, Andrea Z. PhD; Keel, Pamela K. PhD; Kilpela, Lisa S. PhD. Mental health and quality of life in postmenopausal women as a function of retrospective menopause symptom severity. Menopause 29(6):p 707-713, June 2022. | DOI: 10.1097/GME.0000000000001961
3. & 4. Menopause: The Journal of The North American Menopause Society
5. Fausto, D.Y. et al. (2022) ‘An umbrella systematic review of the effect of physical exercise on mental health of women in Menopause’, Menopause, 30(2), pp. 225–234. doi:10.1097/gme.0000000000002105.