Prepared by:
Dr. Bharathi Vengadasalam

From menopause blues to midlife wellness

Menopause is a natural transition of life for most women . Some women may enter menopause more abruptly after surgical removal of ovaries. Whether natural or induced, the menopausal transition is accompanied by various physical and emotional changes.

Menopause and Mood

While hormone fluctuations in the perimenopause period can have a direct effect on mood, one cannot undermine the role of other stressors of midlife. Midlife years for women coincide with other stressors such as “empty nest syndromes”, caregiving towards aging parents, health problems of women and their partners, marital changes, their own confrontation with ageing, sexuality and body image . These stressors can impact on mood and emotional wellbeing more than the menopausal transition affects mood. For example, the Melbourne Women’s Midlife Health Project, reported that depressed mood was not directly related to menopausal phase or hormone levels but women were more susceptible to become depressed in response to stressors occurring while they were in the menopausal transition. It is interesting to note that depression may be related to hot flashes. Hot flashes can cause sleep disturbances which in turn contribute to depressed mood. Some other studies have shown that the late stage of menopausal transition may be related to depressive symptoms.

While mood swings during menopausal transition are not unusual, research findings also indicate that majority of women do not become depressed during this period. However some women, in particular those with past history of depression or problematic premenstrual mood symptoms, are rendered vulnerable to depression by the hormonal fluctuations. For perimenopausal women whose depression coincide with altered hormone levels and menstrual irregularities, estradiol may benefit mood. Estradiol has also shown some positive effect on sexual functioning. However there are attendant risks of hormone therapy as seen in the Women’s Health Initiative (WHI) study, which was carried out in older, asymptomatic women. The WHI study assessed the effect of continuous combined estrogen-progestin hormone therapy and reported an increase in coronary heart disease, stroke, cancer, pulmonary embolism and dementia. The results of this trial may not necessarily pertain to other forms of estrogen therapy or mode of administration, especially in younger perimenopausal women. Considering all this, each women considering hormone therapy needs to discuss her unique risk-benefit ratio with her gynaecologist. Usually hormone therapy is effectively prescribed only for short-term relief of menopausal symptoms. Sometimes collaborative care between the gynaecologist and psychiatrist may be required to address the multiple symptoms and to determine the cause and extent of menopausal blues. In other words, assessing depressive symptoms and determining if they constitute a clinical depression or part of menopausal symptoms. Antidepressants such as selective serotonin reuptake inhibitors still remain the medications of choice for major depression. Some antidepressants have been found to relieve hot flashes concurrently in depressed women. For the management of depression, antidepressants are most effective when combined with counselling or psychotherapy.

Menopause and memory

Some women relate forgetfulness or “brain freeze” as part of their menopausal changes and fear that they are suffering from dementia or Alzheimer’s disease. Common examples are forgetting where belongings were placed, struggling with names and trouble finding the right words. There may be a temporary dip in ability to learn and retain information during the perimenopausal period.

Most of the time, such forgetfulness actually arises in the context of anxiety, worry, stress or depression. Many research studies show that memory problems of menopausal women may be due less to hormonal changes and are attributed more to stress, such as that of dealing with aging parents, teenage children and the conflicting responsibilities of home and work. Managing stress, anxiety and depression can often improve memory troubles. Another factor affecting memory may be hot-flash induced sleep deprivation or night sweats. In other words, when hot flashes interrupt sleep at night, it can contribute to attention and concentration difficulties which in turn influence memory.

Estrogen and cognitive function

Our natural estrogen has a small protective effect on cognition ( cognition is the total human information processing which includes attention, learning and memory, problem-solving skills and other processing abilities of our mind). Estrogen affects our cognitive functions through a sum of interacting influences on various regions or structures in our brain. The exact neuroprotective role of estrogen has not yet been worked out and its influences on cognition are not major . Estrogen therapy can cause harm to women over the age 65 including increasing the risk of cognitive impairment and dementia as seen in the Women Health Initiative Memory Study WHIMS. Yet, there appears to be a critical age period in less older women where estrogen treatment can protect aspects of cognition if treatment is started soon after menopause. In the use of estrogen therapy or hormone therapy, there are many factors that have yet to be worked out - differences in the type of estrogen compounds, route of administration, types of regimes and combination with progestins. In summary, postmenopausal hormone therapy should not be prescribed for preservation of cognitive function in older postmenopausal women. Strong evidence of cognitive benefits for women taking postmenopausal hormone therapy at younger ages (eg, near menopause) is also lacking.

Treatment options for memory problems will depend on the cause. As mentioned earlier, many other issues can co-exist during this time of a woman’s life including depression, and low thyroid hormone levels. A careful history and a thorough examination are needed to sort through symptoms and rule out other conditions.

What should I do if I am really concerned about my memory? Talk to your physician. It is important to write down examples of the problems you are having. Take a family member or a friend with you to the appointment to help provide information that you may not remember. Your physician may do a cognitive assessment or refer you to a consultant trained in memory and cognitive disorders for a proper evaluation.

Menopause, whether natural or induced, has some challenges which we need to overcome. Learning some useful strategies can help us weather these changes, including mood and memory issues.

Here are some useful coping strategies:

Helpful hints for remembering (Source: Thompson RL. Menopause and Brain Function. Neurology 2003;61:E9-E10, patient page)

Menopause and sleep

Insomnia is very common in the perimenopausal period. This can be due to hot flashes at night or can be a direct effect of circadian hormone shifts that makes a person wakeful at the same time each night. Here are some techniques to try: