Two leading experts in the field provide the answers.
Treating menopausal women with mental health symptoms can be challenging for health professionals. Hormonal changes at this life stage can have a debilitating and complicated impact. To help you best support your patients in this space, we’ve collated our top five GP questions and invited two experts to answer.
Jayashri Kulkarni AM is a psychiatry professor at The Alfred Hospital and Monash University, Victoria, plus director at the Monash Alfred Psychiatry Research Centre and director of HER Centre Australia.
Rodney Baber AM is a clinical obstetrics and gynaecology professor at the University of Sydney, and past president of the International Menopause Society.
Here’s what they had to say…
Prof Kulkarni: Yes! Menopause starts in the brain. From around age 45, depression, anxiety or brain fog are often the first indication that perimenopause is underway. Everybody thinks of hot flushes but depression around this time is common – and debilitating.
Prof Baber: Absolutely. Women who have had PMS, premenstrual dysphoric disorder or postnatal depression – which are associated with low levels of oestrogen – are more likely to experience perimenopausal and menopausal mood changes. Mental health issues, including depression, are also more common in those who have had a hysterectomy or their ovaries removed.
Key message: Some patients don’t know that menopause can involve mental health symptoms, or they’re too embarrassed to bring them up. It’s important to initiate these conversations.
Prof Baber: Yes, but in my experience this isn’t common. Or, the patient will come to me and say ‘I have the odd hot flush but it doesn’t bother me’, or ‘I’m not sleeping as well as I used to but I generally sleep okay’. The key is to make sure your patient fits the category of perimenopause or postmenopause, in other words, menstrual irregularities that are persistent or no periods at all. Use a validated screening tool when assessing your patient – the MENQOL and Jayashri Kulkarni’s Meno- D are very useful.
Prof Kulkarni: Some women can present first with mental health symptoms and then hot flushes five or six years later. When investigating whether the mental health symptoms are tied to perimenopause, it’s important to take a good mental health history. Mental health symptoms that come on suddenly towards midlife and fluctuate could indicate a hormonal process and therefore, potentially, perimenopause.
Key message: Using validated tools, get a good understanding of your patient’s medical (including mental and menstrual health) history.
Prof Baber: Brain fog, depression and anxiety are the big ones. We tend to see less sadness. Instead, they might experience more anger, irritability, a loss of energy and libido, memory and concentration problems, and symptoms that fluctuate with the changing hormone levels. Remember, midlife brain fog is not a forewarning of dementia in almost all cases.
Key message: Brain fog, depression and anxiety are three key mental health presentations in midlife women.
Prof Baber: We know there are hormone receptors for oestrogen and progesterone in parts of the brain, including the frontal cortex, thalamus, amygdala, hypothalamus, cerebellum and hippocampus. During reproductive life, these receptors have a substantial supply of hormones. But in perimenopause oestrogen levels fluctuate and after menopause they decline. What this means is there’s a lack of hormones stimulating the receptors. These changing hormones also affect levels of neurotransmitters, including dopamine and serotonin. Put simply, in some women, these shifts in hormone levels and brain chemistry can affect mood and cognition.
Key message: Increasingly, research is showing that menopause can impact mood and cognition, and this can affect a woman’s quality of life, including her work and relationships.
Prof Kulkarni: For perimenopausal depression, I use a holistic model that includes psychotherapy and a look at any contributing social issues. When going down the biological path, think about menopausal hormone therapy (MHT) rather than antidepressants first. If the patient doesn’t have a history of mental illness and the issue is likely hormonal, MHT might be better suited if there are no contraindications. You can add antidepressants later if necessary.
Prof Baber: Adopt a biopsychosocial approach that includes healthy lifestyle measures. If introducing MHT, give it a reasonable trial – for most that’s about six to eight weeks. Avoid conjugated oestrogens – they’re terrific for hot flushes but don’t cross the blood-brain barrier so aren’t much good for mood. Body-identical estradiol given transdermally and progesterone (rather than synthetic progestogens) are preferred in this situation, provided the patient can tolerate them. Later, you might wish to add an antidepressant. A caveat: If you fear there’s any suicidal ideation, intervene immediately with antidepressants. Then, once things are under control, take a more holistic path. Also, reassure your patient that menopausal symptoms tend to settle once hormone levels stabilise.
Key message: In most cases, MHT should be considered first-line medication for perimenopausal or recently postmenopausal patients with symptoms including hot flushes and mood changes. (MHT may also be appropriate when the only symptoms are mood disorders). First, ensure careful evaluation of mental health history and any contraindications.