Jokes about women and their hormones are as old as the hills and generally about as welcome as a sharp object in the eye. Nonetheless, there is a mass of evidence demonstrating the fundamental role that oestrogen has in the neurobiological pathways of mood regulation. Oestrogen has multiple serotoninergic effects, including the up-regulation of receptors, increasing responsivity and promoting transport and uptake.
It is no coincidence then that as women enter a state of oestrogen deficiency, that mood changes are prevalent. Low mood, irritability, anxiety and tearfulness are all commonly reported symptoms of the menopause and may predate the sought after symptoms of amenorrhoea or hot flushes. It is often too easy to assume that these mood problems relate to the stereotyped contexts of mid-life (e.g. problems with marriage, teenagers, work stress or elderly parents) and that the answers lie with CBT and an SSRI, rather than thinking out of the box a bit and of a possible hormonal cause.
And therein lies part of the problem in making the diagnosis; unless someone has had the menopause abruptly thrust upon on them by surgery or chemo, it is a slow process (the old boiling a frog analogy springs to mind here), and women (and their family and work colleagues) can find themselves at a loss to explain why their husband is SO ANNOYING, why they are lying awake at 3am with a drenching anxiety and why their usual happiness and joie de vivre has been replaced by melancholy and tearfulness.
Spotting the connection in a 40-something woman can be utterly life changing – and not just for the patient! In a time when we are all exhausted, it is totally uplifting to hear the phrase ‘Amazing! I have got my old self back’ from a woman after making the diagnosis of perimenopausal mood disorder and starting HRT. They didn’t need sertraline, they needed oestrogen. HRT has come a long way since the bad old days of the WHI study in the mid noughties and after an efficient discussion of risks with context (no increased risk of breast cancer for the first five years of combined HRT using micronised progesterone and a patch or gel, possibly small increase if risk after those 5 years, but reduced risk of CVD), women can then make an informed decision about treatment. If they have contraindications to HRT or opt not to take oestrogen, as with everything in life just knowing and understanding what may be causing the problem can still be helpful.
Mental health symptoms of the perimenopause are a serious issue. They are common, debilitating and potentially fatal - the most common age for suicide in women is 50-54. We are in a brilliant position to support, educate and help the 50% of our patients who will go through this experience, and help to prevent them losing their job, their partner or their mind.
Come and join on Friday 11th March for the Mental Health Webinar, or catch up on demand, where we will be discussing how to manage perimenopausal mood disorder, as well as depression in older adults, ADHD, personality disorders, social anxiety and much more.