Is menopause bad for your mental health?

It’s widely accepted that menopause is associated with poor mental health. News headlines around the world claim that the menopause increases the risk of depression, can “destroy” mental health, or even lead to risk of suicide.

Similarly, the scales of menopause symptoms used in clinical practice typically include mental health issues – like mood changes, anxiety and irritability.

All of this information feeds into the assumption that mental health issues are ‘normal’ during menopause, and that menopause is a time of poor mental health.

But it also contributes to furthering the unhelpful stereotype of the ‘moody menopausal woman’.

Our new Lancet paper on menopause and mental health casts doubt on the idea that menopause transition leads to an inevitable decline in mental health.

HORMONES AND MENTAL HEALTH

The menopause transition, also known as perimenopause, usually starts around age 47 and involves a phase of irregular menstrual cycles culminating in the final menstrual period.

It’s driven by underlying hormonal changes associated with ovarian aging and comes with a range physical symptoms – the most well-known are probably the hot flushes.

Many argue that these hormonal changes and their symptoms (or a combination of these factors) can contribute to a decline in mental health.

Our team reviewed evidence from prospective studies (these kinds of studies look at outcomes, like the development of a disease, during the study period) that tracked changes in women’s mental health symptoms across the menopause transition.

Specifically, we considered studies that investigated the risk of depressive symptoms and disorders, as well as risk of anxiety, bipolar, psychosis and suicide.

Overall, we found no consistent evidence that menopause is associated with a universal or uniform increase in risk for any of these conditions.

But we also found a relative lack of prospective studies investigating menopause and mental health.

While this research is limited, we know the most about the relationship between menopause and depressive symptoms or disorders, so this was our area of focus.

NOT ALL WOMEN ARE AT RISK

Our work found that only two prospective studies have investigated the risk of developing Major Depressive Disorder (or MDD), assessed uniformly by a clinician.

Neither study found that the menopause increased the risk of developing new-onset MDD – although the more robust study found that women with a personal history of MDD were at elevated risk during the transition.

Twelve studies examined the risk of developing clinically depressive symptoms (this has a lower threshold than MDD) over menopause – and findings from these studies were mixed.

While high-impact prior papers found that menopause can double or even quadruple the risk of developing depressive symptoms – our findings offer a more nuanced picture.

We did not find consistent evidence for a universal or uniform increase in depressive symptoms during the menopause transition, but instead found subgroups of women who may be at elevated risk.

THE DIFFERENCE BETWEEN CONSEQUENCES AND SYMPTOMS

We need more longitudinal studies to improve our understanding of exactly who is at risk of mental health symptoms or disorders over the menopause transition, but our findings indicate that a combination of menopause-specific and general risk factors for depression are at play.

When menopause-related risk factors and other triggers (like stressful life events, financial difficulties or a lack of social support) happen at the same time – then a woman may be especially vulnerable.

We found that severe hot flushes, sleep disturbance, surgical menopause (caused by the removal of both ovaries) and a transition that lasts for a long time can elevate risk of depressive symptoms.

On top of this, some women may be more mood-sensitive to menopausal hormonal changes than others – and this also might help explain why subgroups of women are at greater risk.

To me, it comes as no surprise that severe hot flushes can contribute to mood disturbance – especially when they interfere with sleep.

Disruptive physical symptoms of any kind can impact our mood.

For example, if you have a bad cold you might feel frustrated or grumpy (especially if it disrupts your sleep), but this doesn’t mean that this frustration is a symptom of having a cold, rather, it’s a consequence.

A DIVERSITY OF EXPERIENCES

A recent survey of more than 7,000 Australians and Europeans found that around 60 per cent of people self-reported psychological symptoms associated with their menopause – which the study authors defined as mood changes, depression or concentration/memory loss.

So, how can this high reporting of mental symptoms fit with our findings from prospective studies on mental health?

Firstly, mood symptoms are different from a clinical measure of depressive symptoms. The mood symptoms used in menopause scales or checklists are typically assessed with a single ‘yes/no’ answer.

In contrast, depressive symptoms are assessed using validated scales that are designed to measure the mental health condition of depression.

Also, it is important to consider role of history and culture in shaping the views that we hold about menopause.

Beliefs that menopause is associated with poor mental health are longstanding. The first modern menopause symptom rating scale was developed in the 1950s, setting a precedent that psychological symptoms are a core part of the menopause experience.

Midlife is a stressful time of life associated with relatively low levels of mental wellbeing, regardless of gender. So, it could be that other life-stage factors, combined with menopause-specific factors like hot flushes or poor sleep, are at play.

We must also challenge the idea of the ‘moody menopausal woman’ by better training doctors and healthcare professionals to support women to manage the menopause while acknowledging the diversity in symptoms and experiences.

Currently, both here in Australia and around the world, many GPs do not feel confident treating the physical symptoms of menopause but instead refer patients on to a ‘specialist’ which can delay treatment.

In my clinical work as a psychologist, I have witnessed this problem countless times.

Unfortunately, GP confusion around menopause and lack of confidence in treating its symptoms can lead to additional mental health burden for some women, who endure untreated severe symptoms totally unnecessarily.

Just as no woman is exactly the same as another, menopause transition experiences differ – and it’s important to be aware of that rather than assuming menopause itself can impact the mental health of all women in the same way.

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