Is it Menopause? Or is it Mental Health?

It Might Not Be So Obvious

In the past few months I have had a few new patients come see me in my office, all around age 50, with very similar stories. They all told me some version of the following:

“I went to see my primary care doctor, and had my annual check up. I told my doctor that I am having difficulty getting up in the morning, I feel like I have no energy, my periods have changed, I’m waking up at night sweating, and I feel kind of irritable.”

And all three times, the doctor sent them home with a prescription for an anti-depressant/anti-anxiety medication. Two of them also received mental health referrals, in the form of a list of local therapists. None of them were specifically referred to me by their doctors. The stories were uncannily similar, all three women felt that there had been no detailed conversation, no list of effective treatment options that may provide relief, and all three left their primary doctors offices feeling unheard. Their doctors just assumed that a woman ‘of a certain age’ must be suffering from anxiety and/or depression, so why not just treat it as such?

Why not?!

Understanding the physical, emotional, and mental health of women ‘of a certain age’ is a nuanced and complex undertaking. If a primary care physician (or even your gynecologist) is not up to date and aware of how to evaluate these problems and offer various treatments to provide the best relief, then they should probably refer to someone who can. Treating perimenopause and menopause symptoms with only medication aimed at treating anxiety and depression and not offering any alternatives is not digging deeply enough to uncover the reasons that these women may be experiencing these symptoms. Might these medications be a piece of the puzzle? Absolutely. But in order to know that, we need to take a look at the whole picture.

FIRST: The Evaluation:

When I see a new patient in my office, first I ask them to tell me what symptoms are bothering them, and how long they have been present.

I then get a history– a long history, including medical diagnoses, medications and supplements they take, family history, surgical history; and then a detailed history of what their menstrual cycle has been like from their teen years until the present. We talk about how (or if) the bleeding patterns have changed over time, and what they have experienced in the different decades of their reproductive lives.

Have they had irregular periods? Severe cramps? Emotional difficulties with their periods, or any mental health issues connected to their periods (anxiety, depression before or around the time of bleeding? PMS?) We also discuss any pregnancy, delivery and fertility history. All of this will give me clues as to what type of experience this woman will have in her perimenopause years and in her transition to menopause.

SECOND: A Questionnaire:

I have a long questionnaire to ask about symptoms that they may or may not realize that they are/have been experiencing. It also includes a numerical scale, as to how much or how little each of these things are bothersome, and how much they would like to seek relief. It includes questions about what type of exercise they do regularly, what type of diet they follow and what changes have occurred in their general health. This provides a great way to evaluate changes over time, and which changes may or may not be related to their hormonal shifts. We review the answers together, and we discuss which problems may be related to perimenopause and a change in hormones that accompanies this time of life. (And which may not.)

THIRD: The Discussion:

We talk about their history and all the answers in the questionnaire; then I give them some information. We talk about how one of the most common but least understood emotional changes during perimenopause is a noticeable change in moods. How someone may feel calm, with a sense of well-being one minute; and then, seemingly without a trigger, can feel sad, depressed, and gloomy. It may not be uncommon to snap at your spouse or your kids when they ask a simple question, such as, “Are you okay?” These mood swings may happen only occasionally, without impacting your life or your relationships with your family and friends. Or they may start to affect those relationships.

Women at this time in life may feel anxious, irritated, or even angry for what seems like no reason. If these emotional swings happen too often and with regularity, and interfere with the quality of life, we can’t just blame it all on perimenopause. Other problems —real relationship issues, family complications, psychological or medical problems —may cause (or, at least, contribute to) these bouts of emotional upheaval. We discuss all of this.

ARE Your Hormones Responsible?

In perimenopause, hormone levels, especially estrogen, begin to fluctuate wildly, and in menopause, all hormone levels sink to zero. The ovaries are pretty much done. These variations and the eventual absence of hormones can cause a variety of symptoms, including hot flashes, night sweats, irritability, vaginal dryness, lack of energy, low libido and fatigue. Estrogen is strongly connected to serotonin and dopamine, two brain neurotransmitters important for a feeling of well-being, good sleep, calm mood and sharp cognitive function. When estrogen fluctuates and then disappears, so do some of the benefits of adequate dopamine and serotonin. Progesterone, which is the hormone associated with ovulation, is also the ‘calming’ hormone, and very connected to restorative, deep sleep. If a patient tells me that she had a long history of PMS (premenstrual syndrome) and now the period of time feeling those premenstrual symptoms has just gotten longer and more intense, I begin to think that progesterone might be a part of their relief plan.

Deciding how to relieve perimenopausal and menopausal symptoms should take into account all the symptoms a woman is having and how to best relieve them. I believe in a “whole person” approach, that includes healthy eating, regular exercise, relaxation, self-care and good sleep habits. Then deciding if the changing hormones or lack of hormones seem to be connected to symptoms of depression, anxiety and irritability. **Hormones are not the treatment for anxiety or depression** Antidepressants are not the solution for hot flashes and night sweats for women who want to and can use hormone therapy** But some combination of the two may be the solution for women experiencing a variety of perimenopausal and menopausal symptoms. A good evaluation and discussion of the risks and benefits will let us know exactly which combination is likely to help. A list of options and alternatives with an explanation of how these choices can offer relief should be offered to women seeking help for a variety of symptoms. Sometimes it’s hormone therapy. Sometimes it’s mental health medication. And often, it may be some combination of the two, or maybe an entirely different plan!