The Menopause Transition and Mental Health: What Clinicians Need to Know

Perimenopause is often considered a predominantly gynecologic or endocrine event. For many women, though, it is also a time of psychiatric vulnerability. Mood, anxiety, sleep, and cognitive symptoms can manifest alongside vasomotor changes, often while patients are also dealing with a lot of social and professional stress.

Psychiatric Times sat down with women’s mental health psychiatrist Marlee Madora, MD, to discuss how the menopause transition affects mental health. She also covers how clinicians can separate menopause-related mood changes from primary psychiatric disorders, and when to consider hormone therapy vs psychiatric treatment.

Psychiatric Times: How does the menopause transition affect mental health?

Marlee Madora, MD: The menopause transition is a time of extreme psychiatric vulnerability. This time holds a 2-fold increased risk of depression compared with other times in the female lifespan. It can bring on someone's first episode of depression or a recurrence of depression that has happened before.

Perimenopause can lead to vasomotor symptoms, like hot flashes and night sweats, and these can affect someone's sleep and emotional well-being. It is also happening when women are stretched really thin. They might be caring for children and aging parents at the same time, as part of the sandwich generation. They may be holding new roles at work, going through relationship changes, or getting diagnosed with new medical conditions. So it is a time of extreme biological change, and it is also vulnerable because of these other sociocultural stressors.

Menopause is specifically when the period ends. Perimenopause is when there is extreme hormonal fluctuation. Perimenopause lasts 4 years on average, but it can last as long as 10 years. That is when women experience the most vasomotor symptoms, sleep changes, and mood changes, so it is much longer than many patients expect.

It is important to understand what is going on with your patient biologically and medically. Ask about their menstrual cycles and the hormonal changes they are experiencing. It is also important to understand what else is going on in their life and what other triggers there might be. Is this someone's first episode of depression, or is this a recurrence? And what came first? Did vasomotor symptoms disrupt sleep and then affect mood, or did the depression start well before any perimenopausal symptoms? That can help guide treatment.

PT: What psychiatric symptoms are most commonly associated with perimenopause and menopause?

Madora: Common symptoms are low mood, irritability, increased anxiety, and especially sleep problems, both trouble falling asleep and staying asleep. Women often say, "All of a sudden, I do not feel like myself. I am not enjoying anything. I am unmotivated." There are also a lot of cognitive symptoms: low energy, poor concentration, and often difficulty with executive functioning.

PT: How can primary care clinicians distinguish menopause-related mood changes from primary psychiatric disorders?

Madora: I like to think about perimenopause and psychiatric disorders as a Venn diagram. On one side are the physical symptoms of perimenopause, like vasomotor changes (hot flashes, night sweats) and urogenital changes. On the other side are depressive symptoms, like low mood, hopelessness, and worthlessness. In the middle is a large area of overlap, which includes low energy, fatigue, and sleep problems.

All of these symptoms can fluctuate and overlap. Just because someone is in perimenopause does not mean they are not also meeting criteria for a major depressive episode.

PT: When should clinicians consider hormone therapy vs psychiatric treatment approaches?

Madora: Hormone therapy is a wonderful first-line treatment if someone does not meet full criteria for a major depressive episode. Some patients describe low mood, irritability, anxiety, and sleep problems but not low self-esteem, hopelessness, or worthlessness. That may be more in line with an adjustment disorder to this difficult medical time, and that is when hormone replacement therapy can be really helpful. It can improve vasomotor symptoms and sleep, and that can eventually improve someone's emotional well-being.

If the symptoms are more severe, with low mood, hopelessness, worthlessness, or thoughts of death, you should do a full suicide screening and safety assessment. Make sure the depression is treated appropriately with evidence-based therapy, medication, or both if the patient is open to it.

PT: What are some common misconceptions patients have about menopause and mental health?

Madora: The most common misconception is, "I am still getting my period, so there is no way I am in perimenopause." But when someone is still getting their period, that is exactly when they are in perimenopause. Menopause is when periods have stopped completely. It is the rate of hormonal change that drives many of these emotional symptoms, and that happens while patients are still menstruating.

Another common misconception involves cognitive symptoms like brain fog and forgetfulness. Patients may worry that they have a chronic, debilitating neurodegenerative disorder. When you look more closely, it often looks more like perimenopausal cognitive change. Verbal recall declines and word-finding gets harder during this period. Women might say, "I could not think of the word I needed during that presentation," or, "I went to the kitchen and did not know what I was looking for." That can be really distressing.

I like to do a comprehensive assessment. I often start with the Montreal Cognitive Assessment (MoCA), which does a good job of looking at verbal memory. When needed, I refer patients for a full neuropsychological assessment. You can also consider whether the patient may have attention-deficit/hyperactivity disorder (ADHD). Maybe they have had ADHD their whole life and compensated until now, when they are dealing with more emotional strain, sleep difficulties, more demands, and the cognitive changes that are common in perimenopause.

Offering patients a diagnosis gives them so much hope. They need to know there are treatments that work for these cognitive symptoms, such as cognitive behavioral therapy for ADHD, nonstimulant medications, and stimulant medications. This can be life-changing for patients who are anxious about their cognitive symptoms.

PT: How can clinicians better screen for mental health concerns during midlife transitions?

Madora: Screen for mood changes across reproductive transitions. Ask questions like, "When you were getting your period regularly, were there times right before your period when you felt more anxious, depressed, or irritable, to the point that other people noticed?" Ask, "How was pregnancy for you? How was the postpartum period?" Ask about the menstrual cycle and any changes they are noticing now, and about urogenital changes.

Ask about sex, too. It is hard to ask patients about their sex lives, but if you do not, they are not going to bring it up. Ask in a normalizing way, for example: "A lot of women notice that hormone changes can really affect their sex lives. Is that happening to you?" Patients need to hear that they have a place to talk about it, because it affects their self-esteem and relationships, and addressing it can really improve how they feel about themselves.

My favorite tool during perimenopause is the Menopause Rating Scale. It covers 3 domains: somatic, psychological, and urogenital symptoms. It captures the full range of perimenopausal symptoms, so you know where to focus treatment.

PT: What practical advice do you have for clinicians discussing emotional health with patients in menopause?

Madora: The most important thing is to help your patients feel comfortable talking about it. Validate that this can be an emotionally difficult time, that these hormone changes are really challenging, and that there is hope. Ask how their hormones are affecting their sleep, mood, urogenital symptoms, and sex lives. Come at it with curiosity rather than just labeling the patient as perimenopausal and prescribing X, Y, and Z. Really try to hear their particular story, so they feel like you are a partner in this at a time when many women feel alone.

Dr Madora is a women’s mental health psychiatrist and assistant professor of Obstetrics, Gynecology, Women’s Health and Psychiatry at Montefiore Medical Center with Albert Einstein College of Medicine.