
Transformations
The mental health issues that can accompany menopause often go unaddressed
Vanessa Haygood, MD ’78, remembers when the referrals started rolling in to her obstetrics and gynecology practice in Greensboro, North Carolina. What gave her pause wasn’t that primary care physicians would send women in their forties and fifties to her with complaints of anxiety or depression. It was how often the accompanying notes indicated that the cause boiled down to “just menopause” and that the women simply “needed some hormones.”
Thirty years of clinical experience taught Haygood what more clinicians and researchers appreciate with each passing year: that changes in mental health can indeed accompany the transition into menopause, sometimes with such intensity that they damage physical health, quality of life, relationships, and work, and that the causes are complex and the treatments many.
Yet the reductionist, even dismissive, tone of the referrals reflected broader trends in mainstream U.S. culture and in the medical profession about which populations and conditions deserve attention. Attempts to address changes in mood and mental health around the time of menopause suffer from an unholy trinity of neglect: the patients affected are mostly women and women’s health isn’t studied or treated as thoroughly as men’s, the women are typically heading into older adulthood in a society that clings to youth, and the problems are psychological in a health care system disposed to prioritizing the physical.
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As a result, many women and their care providers don’t fully appreciate the risk of developing new, relapsed, or worsened mental health conditions as menopause approaches. Those who are aware may not know how best to treat the symptoms. And researchers have barely begun to quantify menopause-associated mood changes and mental illnesses, pinpoint their causes, and compare the effectiveness of treatments.
“More attention should be given to the mental health aspects of menopause,” says obstetrician-gynecologist Laurie Green, MD ’76. “Women are suffering in silence.”
Haygood, who retired last year, appreciated the referrals because she felt she could legitimize patients’ concerns and discuss options. She only wishes more women enjoyed such support. “I’d like to see this attitude that it’s ‘just menopause’ change. It would be a real advancement in care.”
Signs and signifiers
Clinicians, such as Laura Payne, an HMS assistant professor of psychology in the Department of Psychiatry at McLean Hospital, offer a quantitative way to understand the problem when they explain that the menopausal transition “is a vulnerable time for women in terms of mental health struggles.”
Patients, such as British journalist Rose George, paint the qualitative picture. “I am one of the women of menopause, who struggle to understand why we feel such despair, why now we cry when before we didn’t, why understanding what is left and what is right takes a fraction longer than it used to … I miss myself, the woman who didn’t feel like this,” George wrote in The New York Review of Books in 2018. For her, as for a subset of women, terms like “low mood” and “brain fog” fail to capture the extent to which natural menopause “doesn’t feel natural. It feels like a derangement.”
Menopause, defined as having had no periods for one year, represents one of life’s rites of passage: a bookend to the onset of menstruation in adolescence, marking the end of fertility and the beginning of a new stage of life. It can be a source of joy, relief, pride, or darker sentiments. While some sail through the gradual winding down of the reproductive system known as perimenopause with no trouble other than missed periods, most must navigate stormy waters for anywhere from a few months to more than a decade, often without a compass—or even a raincoat. Clinicians have no way to predict how long an individual’s journey will take or how smoothly it will go.
Physical hallmarks such as hot flashes and night sweats, which strike about three-quarters of perimenopausal women, don’t tell the whole story.
Mood swings turn familiar emotional rhythms into a pinball game. Risks of depression, anxiety, and alcohol and substance use rise. So may those for psychiatric illnesses: Many women with bipolar disorder or schizophrenia find that their symptoms intensify during perimenopause, and schizophrenia, most often diagnosed in young adulthood, has a second, smaller peak of onset in women around menopause. Cognitive troubles commonly include having difficulty concentrating, experiencing short-term memory failures, and losing motivation. These can be frustrating or downright frightening. The North American Menopause Society, or NAMS, reports that many perimenopausal women who struggle to think clearly or remember obvious words fear that their symptoms herald not menopause but dementia.