MENOPAUSE DEPRESSION: Under Recognized and Poorly Treated
By Professor Jayashri KULKARNI & Dr Louise Newson, on behalf of all authors on article
Menopause affects 51% of global population yet is still shrouded in mystery and unfounded concerns and confusion. Menopause has so much media attention, yet few people can accurately describe what it is.
Menopause is a hormone deficiency which affects all women yet globally only around 5% of menopausal women receive evidence-based treatment – hormones – which will improve symptoms as well as future health. The majority of menopausal women experience mental health issues, such as anxiety, depression, irritability, low motivation, mood swings, tearfulness, memory problems and brain fog – caused by hormone (oestrogen, progesterone and testosterone) levels in the brain fluctuating and reducing.
Symptoms of menopause can last for many years and the low hormone levels last for ever. Most women start to experience symptoms in their 40s but one in 30 women will be menopausal under the age of 40.
In the past and even now, many people simply perceive menopause as being a few symptoms predominated by hot flushes and sweats. However, the mental health impacts of menopause, which have not received much attention, can cause major problems that impair the quality of life for many women. In our recently published article, a large and diverse group of authors focused on menopausal depression.
Menopausal depression is different to other depressions. The key mental health symptoms include anxiety and panic, rage, exhaustion, sleep disturbance, decreased libido, poor concentration, poor memory, and tearfulness. Physical symptoms such as muscle aches, joint pains, cystitis, palpitations, painful sex, and headaches are also common. Symptoms can fluctuate in intensity or even disappear and then return days or weeks later. This fluctuation can be very challenging for women and can make an accurate diagnosis of menopausal depression difficult. To add to the diagnostic difficulty, there are no specific, objective tests for menopausal mental ill health.
The key to diagnosing menopausal depression and to distinguish it from other mental health conditions is to listen carefully to the woman who often knows her own self very well and may suspect some or all of her symptoms are due to her changing hormone levels. Women need to be involved in both making the correct diagnosis and also deciding on the treatment options most suited for them.
Too frequently, menopausal women are offered or prescribed antidepressants for their menopause depression or mental health symptoms which have no evidence to support their use. These women are not prescribed hormones which are likely to improve symptoms as they are treating the underlying cause. This can lead to poor outcomes for menopausal women and their families.
Over recent decades, we have gained more knowledge about the brain effects of menopause. The key hormones that fluctuate and reduce during perimenopause and menopause include oestrogen, progesterone, testosterone and the precursors to these important brain steroids. These hormones have multiple, crucial roles throughout the brain which is often overlooked or misunderstood. For many years, there has been the false belief that these hormones only impact ovaries, uterus and breast tissue.
In the brain, oestrogen functions as both a hormone and a neurotransmitter - allowing signals to pass to different areas of the brain and altering the production of other neurotransmitters such as serotonin and dopamine, which can improve mood and wellbeing. Oestrogen protects the brain by reducing inflammation, improving brain cell function, improving and maintaining brain circuits and connections and also increasing blood supply to the brain. Progesterone has ‘anti-anxiety’ and protective effects by modulating particular brain chemistry, and testosterone also has multiple beneficial effects in the brain. All three hormones work on areas of the brain that determine various important functions including mood, personality, cognition, memory, behavior and sleep.
It is obvious that a hormone caused depression would respond best to a hormone treatment. This has been seen in clinical practice where hormone therapy has been prescribed for menopause symptoms, and incidentally, improvements are frequently seen in mental health.
Hormone treatment – replacing oestrogen, progesterone and testosterone - is still not approved for menopausal depression in many menopause guidelines, which reflects the poor understanding of menopause depression and the effects of hormones on the brain by so many people.
Older studies of hormone therapy (the Women’s Health Initiative study in 2002) wrongly sensationalised concerns about the safety of hormone treatment. These concerns have been dispelled, particularly regarding the current, safer hormone treatment. Hence it is now time to consider hormone treatments more frequently for menopausal depression – particularly as we now have more knowledge about the brain hormone changes in menopause.
We need to innovate and optimise the treatment for all women with menopause-related mental health issues. To do this, we need to conduct different types of research including relevant clinical trials, to involve industry groups and corporate workplaces, to include diverse health and mental health professionals and primary healthcare practitioners and to educate all our communities about menopause using multimedia channels. The diversity of input needed for a new approach to menopausal mental health is reflected in the large, diverse group of authors listed on this viewpoint article. Improving investment for research needs to be a priority.
Above all, true innovation is only possible when the woman with lived experience of menopause is front and center of this debate.
Article Details
Menopause depression: Under recognised and poorly treated
Jayashri Kulkarni, Caroline Gurvich, Eveline Mu, et al.
First published May 18, 2024 Research article
DOI: 10.1177/00048674241253944
Australian & New Zealand Journal of Psychiatry
About the Authors
