By Moryt Milo
Mental illness has never been a one-size-fits-all neurological disorder, and in women’s health the intersection between hormones and mood can further complicate life.
But it doesn’t have to be that way said physician Karen Adams, director at Stanford University School of Medicine for Menopause and Healthy Aging. Understanding major depression, schizophrenia, and bipolar disorder during perimenopause and menopause can help women predisposed or diagnosed with a mental illness get through this transitional phase.
Adams is doubly board-certified in Obstetrics and Gynecology (OB-GYN) and Lifestyle Medicine and is a Menopause Society-certified menopause specialist and expert in sex medicine.
“Perimenopause is a window of vulnerability for both new onset and recurrence of mental health disorders,” Adams said. “During perimenopause, hormonal changes go through unpredictable cycles and hormones are all over the place.”
Perimenopause is when the body is transitioning to menopause and menopause is when reproduction ends. Moods can become erratic during this time, and if the individual experiences depression or anxiety there is menopause hormone therapy (MHT) to help. This can be beneficial to women who experienced postpartum depression after giving birth, mood disorders in college, or had been previously diagnosed with depression.
There is science to back the evidence. In 2018, the first guidelines came out to treat perimenopause depression in Menopause: The Journal of the Menopause Society.
The study reported that 45%–68% of women experience mood symptoms during perimenopause which is more than those experiencing premenstrual syndrome (PMS).
Adams said this is because PMS falls during menstrual cycles, but in perimenopause there is no rhythm to the cycles and mood swings can be erratic.
Data culled from the study enabled doctors to develop guidelines for treating perimenopausal mood disorders with medication and psychological tools like Cognitive Behavioral Therapy (CBT) and mindfulness techniques.
But this is only one piece of the puzzle. Further research is needed. Once a woman transitions to menopause, Adams said hormone therapy does little to improve mood.
More data is needed on hormone therapy for women with schizophrenia and bipolar disorder. During menopause, a second peak incidence of schizophrenia can occur, and antipsychotics may need to be adjusted. For those with bipolar disorder, depression symptoms can increase in late perimenopause and early post menopause.
Adams said, to date, hormone therapy has had minimal effect on those with bipolar disorder and can be controversial for those with schizophrenia. She said individuals with schizophrenia need to work closely with their OB-GYN and psychiatrist.
Focused on Biology
To understand these mood changes means looking at the biology, psychology, and sociology and the way American culture interprets this transitional time in a woman’s life.
In her presentation, Dr. Adams focused on the biology and the effect of hormones—estrogen and progesterone—on mental illness.
‘These impact the brain chemicals,” she said, “which also may be a possible reason why some women are protected from some forms of mental illness like schizophrenia.”
Estrogen impacts the brain’s cognitive and affective processes such as learning, memory, mood regulation, and stress responses, Adams said. Progesterone is similar to anti-anxiety pain and sleep medications. It has a calming effect, she noted.
“It’s the reason why we think women have later onset schizophrenia between ages 20–35 versus men at ages 15–23,” she said.
There are guidelines to help women as they begin to experience random mood swings, especially if there is prior history of postpartum depression or other pre-existing health issues.
Adams said there is a checklist with nine symptoms such as feeling sad, empty, hopeless or have thoughts of death/suicide, fatigue, or loss of energy. If the woman says yes to five out of the nine symptoms over the previous two weeks, this could be an indication of major depression.
“This is important because at some point during perimenopause or menopause, one in four women will have major depression,” Adams said. “Most during the perimenopause phase when hormones are erratic.”
Even women with no prior symptoms are two times as likely to experience major depression during perimenopause and menopause.
What To Do?
When mood swings become dominant, Adams said to meet with a health care provider to determine the severity. If it’s perimenopause, hormone therapy can help. Birth control pills can stabilize mood within two–four weeks. The Food and Drug Administration has approved one specifically for perimenopause. Exercise is another tool, along with therapy treatments.
Adams said antidepressants help with hot flashes, but vitamins such as B6 and E, the supplement St. John’s Wort, and evening primrose oil have not proven to work.
“The key is to be aware that perimenopause is a window of vulnerability for mood disorders even for women without a history,” she said.
Adams said once through all the transitions and into post menopause, women have a zest.
“And the zest is real,” she said. “Their role at work, their friendships, self-fulfillment, once through it they are happier than they’ve ever been,” Adam said.
To watch the presentation, click here.
