Perimenopause, or the stage in your life before your body officially enters menopause, can be a tumultuous time of change, ups and downs. I’m there, right now. Still working things out and experimenting with what helps me. As I’m reading around it, I’ve noticed that there are very different perspectives and approaches to managing it. On one end of the spectrum there is a largely medical view that symptoms resulting from hormonal depletion is the main issue and that these cause distress and are linked to later life disease risk, but thankfully can be helped by HRT. This is a hugely important angle and many are fighting for peri/menopause to be recognised as a worthy medical issue so that funding towards research can be achieved. For many years woman have been branded neurotic or depressed, with lack of appreciation of the impact that depleting hormones are having on women’s bodies and the link between this and cardiovascular disease, dementia and osteoporosis risk. Similarly, although foundationally different, there are advocates of alternative remedies, diet and lifestyle approaches that also suggest that symptoms should be reduced in order to feel okay, with some claiming symptoms can be erased. At the other end of the spectrum there are those that are more philosophical suggesting that this is an essential life stage that should be accepted and embraced (or put up with). Where you place yourself on this spectrum is of course very individual and this should be each woman’s right. I’m pretty clear that I’m somewhere in the middle. I think we need to both accept our life stage and the changes but also do what we can to reduce the pain, bodily discomfort and psychological distress. I don’t think it’s helpful to profess that one approach will remedy or eradicate difficulties because this only leads to disappointment and perpetuates the idea that we should try to get rid of problems. Generally, I’ve discovered during my career, that those who seek solutions and struggle to accept that what they’re going through is part of being in the flow of life, are very dissatisfied with life and will experience resentment and depression. There needs to be some acceptance that as humans we all suffer at various stages in our life. This might be the first step in the process that moves you towards recovery. Learning how to respond to this suffering is key and is linked to well being. Anger and fighting against the situation you’re in will perpetuate and heighten distress. Once we have accepted what we’re going through, we can then consider what might ease this suffering and boost our coping and this is likely to be multifaceted because we are complicated beings.
Whilst attention has been paid to mental health symptoms during Perimenopause, this has again been from a medical perspective, whereby mental health changes are thought to be symptoms consequential to hormone changes, but the processes involved haven’t been unpacked. Mental health is much more complex than this. Mental health has been defined in many different ways but I like the following suggestion by Galderisi et al 2015. It’s acknowledged that mental health is not the absence of mental distress, nor the presence of happiness and instead recognises that part of human existence is to experience real emotions of sadness, anger, guilt etc. They say that, “Mental health is a dynamic state of internal equilibrium. Harmonious relationship between body and mind represent important components of mental health which contribute, to varying degrees, to the state of internal equilibrium. They highlight that mind, brain, organism and environment are heavily interconnected, and the overall experience of being in the world cannot be separated from the way in which one’s body feels in its environment. As a Clinical Psychologist this fits well as I prefer to look at situations through a Biopsychosocial lens. Going through Perimenopause will affect all parts of our mental health because we are part of it, exposed to it, influenced by it, living it as a breathing organism. We all arrive at Perimenopause with different stories and perspectives on life, we also arrive with different cognitive and social abilities and different emotion regulation skills which affect our functioning and stress tolerance. It’s the combination of all of this that determines our equilibrium.
So mental health during the Perimenopause will be an individual experience. Despite this, this definition also accepts, that whilst there will be cultural differences in defining mental health, there are some universal concepts that will be true for all. Galderisi et al give the example of different cultural eating habits, but the agreement that certain vitamins are important as are the basic food groups. For perimenopause, the universal acknowledgement at the centre, is that hormones fluctuate and reduce, which can effect different women in different ways. Another central truth is that this reduction in hormones is linked to late life diseases. A final universal concept during Perimenopause is that fluctuating hormones do impact on the systems in the body that regulate emotion. For example, the reduction of progesterone early in Perimenopause can heighten physical anxiety symptoms as can increased levels of the stress hormone cortisol.
If we start to look at this in more depth, i.e. the bidirectional nature of mind and body, the interaction between this and our environment, plus what each woman uniquely brings to the Perimenopause, but centred on the universal truths, this might enable us to help women with their mental health during Perimenopause in a more real and meaningful way. Let’s use a fictional case study to do this. Note: This in no way replaces medical or psychological advise and I’d advise you to see your GP, to consider your own picture.
Autumn (See what I did there? No? Don’t worry) is 45, and married with three kids. She has recently started to wonder whether she has ADHD, has a history of depression, stemming from an unhappy childhood, where she was often blamed for things going wrong. Her oldest is an emotional teen and she spends many nights awake with her youngest, just 4 or worrying about her middle child who is struggling at school. She has a 90 year old mother, and Autumn was the youngest, and a mistake as she was told. She is the only sibling who lives near Mum so she ends up shouldering the responsibility of looking after her although they don’t have the best relationship. Lately she has been feeling even more excessively tired than usual and when she does get to sleep sometimes wakes up in a panic or a hot flush. She is worried this is effecting her concentration at work as she has slipped up a couple of times and keeps forgetting her colleagues’ names. It’s not that she doesn’t know their names but in the moment it slips away from her memory like some sort of elusive fish. She’s thinking about asking for some time off work, but she knows if she does that Mum will expect her to help her sort the flat out. Autumn feels a bit lost. She looks at her peers and thinks they all seem to be able to manage, the kids, the parents, the job and she blames herself for not being able to cope better. She tries to talk to her husband about it but he just says, “You’ll work it out, you always do”, but he doesn’t get it, with his golf friends and nights out, he seems to have it figured out. She doesn’t resent him enjoying himself, as he has a stressful job and is a good father.
Okay let’s try to make sense of this and at least come up with a set of follow up questions that we might (should) be interested in, if we are to properly support her mental health.
- What is the most difficult part of this for you? What are you hoping for at the end of our meeting? Rationale – establishing her priorities and getting to her hopes and expectations.
- You mentioned that you have always struggled with your mood and think this links back to when you were younger. Is this something that I could ask you a bit more about? Rationale – we know that trauma in early life predicts mental health and women can be especially vulnerable during stress and life transitions. We’d want to know about her past coping, what has helped, whether she has had any therapy or thinks this would be helpful or relevant now. We’d also want to know a bit more about her current symptoms and whether she feels it’s similar to before or different. For example is she bursting into tears frequently, but actually mood is not too bad? We’d maybe want to use a BDI (Beck Depression Inventory) or a CORE questionnaire, to see what the symptoms are and how bad.
- As you are 45, would it be okay if I asked you to complete a questionnaire / asked you about some other symptoms that sometimes come up at this age? Rationale – obviously we’re hopefully keeping Perimenopause very much on our radar. We must be very careful not to jump onto the fact that she has had depression before and has a certain amount of life stress – if we do this we are in danger of completely missing the role of hormones and consequently not being able to offer her hormone replacement therapy which might be a very valid treatment option for her, as part of an overall package of care.
- Do you feel like you have enough support? Rationale – she sounds like she might be isolated and perceiving that everyone else is okay, without receiving any social feedback. Engaging in peer support of many different kinds could be beneficial as part of her plan.
- Do you feel you have enough support as carer for your Mum and children? Rationale – As before but she might benefit from support from services or charities.
- You mentioned being a bit forgetful, could I ask a bit more about this? Rationale – It’s highly likely that the forgetfulness is linked to Perimenopause but she mentioned that she wonders if she has ADHD so following up and taking a history around this would be important. It can massively help stress levels and self blame to know that this is a normal part of Perimenopause and not something else.
- What do you think is going on? Rationale- she is the expert on her own health, ie does she think she’s depressed again, does she thinks it’s Perimenopause or ADHD? Discussing the potential reasons will help her see it’s not her fault. It’s also important to understand her beliefs about her situation as this will be effecting her mood and could be easily remedied once you identify a way forward.
From the small amount of information we have we can pick out the social, biological and psychological factors that are affecting Autumn’s mental health. We can then start to think about the interaction between these. Just one part of this is as follows. Autumn has maybe internalised a sense of self blame. She lacked someone to soothe and respond to her emotions empathically and so struggles with this herself now. Because of her age, it is possible / likely that she is experiencing hormonal fluctuations (universal truth) which will be a) heightening her emotions at times or bringing up old wounds and b) creating new physiological stress on her body (the panic and hot flushes in the middle of the night). Given that she already struggles with sleep due to her worry about her children and one of them regularly needing her through the night, this is probably leaving her even more exhausted than usual. Exhaustion perpetuates low mood and is linked cognitive difficulties, plus her life stage means that hormones can be influencing the areas of the brain involved in cognition and mood (ie no one thing causing the other but all are linked). We have identified some hypotheses and routes to follow up. It’s important to keep an open mind and be honest about this and engage her in discussion about intervention options.
Hugely important take home points for Autumn: –
- It is not your fault that you are struggling with all of these different things. Hormones, plus sleepless nights and being a parent, plus experiences when you were younger, are providing a perfect storm for you to feel overwhelmed, and you didn’t ask for any of this! You are trying so hard. You have done the right thing coming to ask for help.
- It is possible that you are in Perimenopause and Hormone Replacement Therapy might be an option – especially related to the hot flushes during the night – so you might get a better night sleep. Otherwise there might be other sleep remedies. It might turn out that you feel generally better in yourself and mood too just by targeting your hormones, enabling you to have the energy to look at other things that might help. If you’re unsure about Perimenopause, maybe you could start to monitor your symptoms using the Balance app or similar to help you work this out.
- Would you like some help with looking at the fact that you are blaming yourself and with your mood? Therapy could help you to look at the way your beliefs affect your coping under stress. It could also help if you think old wounds are resurfacing. If you’re unsure, then get the referral and the Psychologist could help you figure it out during an assessment. Sometimes a Psychology assessment is all that is needed to develop clarity and goals. They might also help with the ADHD part that you’re worrying about.
- Is there a way that you can find some time for yourself even if it’s just for an hour? It’s important to look after yourself plus find ways to stay healthy at this age because everything is interconnected – your body and your brain and how you feel.
- Is there someone you could reach out to or meet up with, who might be at the same life stage? It’s really important to connect with others to support your mental health.
As I’m writing this I’m thinking why shouldn’t it be the case that any woman presenting at her GP age 35-50 ish be asked about the common perimenopausal changes? In addition, a trauma screening questionnaire where someone presents with mental health concerns? Whilst there are some great GPs and frontline practitioners, training is needed and not just for new doctors. More could be done though to alleviate GPs, such as informational care sent out at timely points in women’s lives and education at school. The Menopause Mandate is a year old this week. This is a group of campaigners trying to instigate change for women, including education before Perimenopause starts so that women are informed and can make choices before they’re in the thick of it. This would make such a difference keeping women well and in work.
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Sea change 