by Jo Farren

Depression during Menopause

The perimenopause includes a wide variety of symptoms, some that we hear a lot about and some that we don’t speak about so freely. I feel like depression is one of the latter: we hear about the hot flushes and the night sweats, but do we know about the mood changes that can accompany it, too?

As with all things, our individual experience of menopause can differ wildly, and so just because this is *one* of the symptoms, it doesn’t mean that everyone will find themselves feeling this way, but in our survey of 122 people, 54% said they struggled with depression during their perimenopause. In my research, figures range from 20 - 40% of menopausal folks will have feelings of depression, so its absolutely something we need to be highlighting and talking about, in order to provide holistic and person centred care.

It is thought that depression in menopause is brought on by the declining levels of our sex hormones, oestrogen and progestorone, which decrease during the perinemopausal years (1). Not just this, but the complicated relationship between these hormones, and neurotransmitters such as dopamine (2), and serotonin (3) can impact our mood during the perimenopause. In truth, there are more factors to our mood than simply just hormone levels - and there’s more impacting our hormone levels than just the menopause.

We know that stress can influence and impact our sex hormone status (ref), and that doesn’t stop here, so we do absolutelty need to consider the impact that social issues have on our perimenopause experience (4). One study in Korea (5) showed that as well as stress being a major factor in how a person experiences the menopause, lack of sleep and smoking also seemed to contribute to struggling more. Whether smoking was the cause, or whether smoking happened to be a coping mechanism for those who are more susceptible to stress, remains to be seen. Other research identifies ‘sociodemographic, physical, psychological, cultural and sexual risk factors for depressive symtpoms’ (6) - so factors like education, physical activity, emotional support and diet are also important (7)

Depression in menopause can be a difficult one to formally diagnose and identify: partly because we are often looking through a retrospective lens: that is, that some of the emotional and mental symptoms start occuirng prior to physical symptoms and they can vary from more ‘traditional’ depressiion. Symptoms include (but are not limited to), low energy, paranoia, anxiety, reduced self esteem, feeling isolated or lonely, sleep disturbance and reduced libido (4).

It’s now understood that as well as a functional shift in our hormone levels, we also may struggle with the transition in an emotional sense: menopause for some can be a significant milestone in ones life, and that can be one that is met with some resistance. Sometimes that resistance is due to menopause coming into our lives much earlier than we expected: perhaps we haven’t completed our family? Perhaps it signifies ageing, and we aren’t ready for that? Society seems to favour and celebrate youth in all things, and moving into that third stage of our lives can be a difficult one to accept. With cartoon villains often being crones, our early exposure to post menopausal women is a negative one, and so for us to now be moving into that stage means we start to identify as this character, and pushes us to challenge some of those old stereotypes.

Who's most likely to get depressed during the menopause?

If we consider that these stereotypes impact our experience of menopause, it’s interesting to know that Chinese Americans are the least likely in American culture to experience depression during menopause (Bromberger,2002). It’s theorised this may be because they have a positive role for their ageing population and therefore more positive attitudes to ageing. Our western view on ageing, really needs a rethink, if we consider how much less of an impact this has on the Chinese American population.

It seems as if there are specific groups of people who are more at risk of suffering with depression: I’ve already mentioned the idea that socioeconomic factors can be strongly linked, so it may not be a surprise to hear that folk who live on their own, or are isolated from support networks are also thought to be more vulnerable to suffering with depression. The idea of this ‘village’ of support which we hear about so often in early parenting, seems like it would really come into its own here too (8). There may also be a correlation between when you get your first period, and when you start going through the menopause on whether depression will have an impact (9)

Why do people get it?

Research shows that poverty, stressful life events, and negative attitudes contribute to meno-depression more than ethnicity does (Muir, 2022). We may also find that people who already have neurological conditions or have been previously diagnosed with depression, may be more susceptible during the perimenopausal years (10), as also women and people who experience the perimenopause prior to the age of 40 (11) either through biological or surgical menopause.

What can we do about it?

So, what can we do about it? Some of my favourite herbs for depression in menopause include: lemon balm, st Johns Wort and Black Cohosh.

The Herbs

Lemon Balm (Melissa officinalis) - is one that I find incredibly helpful were there’s an anxious element to the mood, too: where your mood needs lifting.

St John’s Wort (Hypericum perforatum) - is a super popular herb for mood: and it can be really helpful for some people during the menopause - but it doesn’t suit everyone. It would be remiss of me not to mention it here, because it absolutely plays a role in many of my treatment plans.

Black Cohosh (Cimicifuga racemosa) - often used for it’s impact on hot flushes, this is one that I find really helpful when we have menopause specific mood disturbance: Black Cohosh seems to help ease the transition into menopause in not just a physiological way, but in an emotional way, too. One study found Black Cohosh to be more effective than Prozac in dealing with some of the physical symtpoms of menopause, and that it was thought that it was comparable in dealing with menopausal depression (12).

Korean Ginseng (Panax ginseng) -can be a particularly stimulating tonic: it’s not suitable for everyone, but it can be really helpful in helping support energy levels. Siberian ginseng (Eleutherococcus senticosus) is one that I consider slightly less stimulating: that is it’s more slow burning energy-wise, and doesn’t have such a dramatic effect, which can be really useful if you’re particularly burnt out.

Ashwagandha (Withania somnifera) - is one of my favourite tonic herbs: it tends to be nourishing and supportive, a much more quietly burning energy! And Shatavari similarly is a quieter and more nourishing herb, but don’t be fooled, it is really powerful and can be incredibly supportive with libido. 

Top Lifestyle tips

Pytoestrogenic foods such as soy beans, flax seeds, dried fruits and more, can really help to support the declining oestrogen levels in our bodies.

Essential fatty acids are key for the functioning of our neurotransmitters (13)

Leafy greens, pretty much for anyone who tolerates them - but specifically because they’re jam packed full of b vitamins (important for the nervous system again), can be really helpful at keeping your bowels in tip top condition (which again, can really help with our hormone levels and mood!).

Proteins in the diet, as the amino acids found in proteins are another building block for our neurotransmitters: for example phenylalanine is a precursor for dopamine, and tryptophan is a building block for serotonin. If we can include these things in our diets, then it’s definitely worth considering.

Support groups I know that local to me there’s a support group, and given that the research suggest that support is a key factor in how we experience the menopause, that’s definitely something I’d consider. If big groups aren’t your thing, then how about a trusted friend or family member with whom you could mutually share and support? A professional may also be worth considering, particularly if none of these options feel comfortable to you. Lots of counsellors and therapists will list their specialist areas on their websites, and you would be absolutely encouraged to reach out and ask if someone has specific experience with supporting people going through a similar experience to you.

Rest I would also really encourage making sure that you have enough down time and rest: in a perfect world I’d say we should all reduce stress levels but that feels like it’s been said many times - so whatever is going on in your life, whatever your stress levels are - making sure you have some decent rest, is going to be really important. It doesn’t need to be sleep - it can just be time when you’re in a calming state: going for a walk, swimming, yoga, reading a book… it looks different for different people.

When should you see a doctor or herbalist?

Of course there are times when I feel like having some extra support on your side can be incredibly powerful: in my mind, it can be tricky to be objective with your own health, and so if you’re feeling overwhelmed with choice, and knowing which herb to try, or which supplement to include, it might be wise to speak to a herbalist. They can provide expert, bespoke support and work with you to make sure that their recommendations suit you and your lifestyle: it can be difficult to implement a regime which doesn’t fit into your life, and so that 1:1 care can be really helpful and make all the difference. If you’re feeling very bleak, or that you might harm yourself or someone else, then I would reach out to a doctor, as a case of urgency.

Final Thoughts

There is such a tremendous amount of pressure put onto women and menstruating people throughout their lives: menopause is no exception. In fact, by the time we get to menopause, we have had a lifetime of it already. I feel that can make our transition all the more challenging. Throw into that the rejoicing of youth and this fear of growing old (particularly women!) and it can be a wild ride: needing support around you, whether that be physical, emotional or social, can be incredibly helpful. But more than that, talking about it, making sure we are heard and seen in the bigger social picture, means that it’ll be easier for future generations to make that transition: we don’t disappear when we stop bleeding, and some of us spend 50% of our lives in the menopause so we need more representation, and perhaps even a bit of celebration?! It would be nice to have my worth based on my worth, not my appearance, age, gender… and I’m sure many of you share this sentiment. Perhaps if we could recognise the importance of the changes that happen in the menopause, and make allowances for them, rather than trying to hide the fact that it’s happening, and then celebrate being the other side of monthly bleeds, might help us all. In short, we need to be talking more about all aspects of our periods, period.

References

1: Shors & Leuner, 2003. Estrogen-mediated effects on depression and memory formation in females.Journal of Affective Disorders. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3374589/

2: Pablo et.al., 2018. Steroid Hormones and Their Action in Women's Brains: The Importance of Hormonal Balance. Frontiers in Public Health. Vol 6. https://www.frontiersin.org/article/10.3389/fpubh.2018.00141

3: Barth, C., Villringer, A., & Sacher, J. (2015). Sex hormones affect neurotransmitters and shape the adult female brain during hormonal transition periods. Frontiers in neuroscience, 9, 37. https://doi.org/10.3389/fnins.2015.00037

4: Kulkarni J. (2018). Perimenopausal depression - an under-recognised entity. Australian prescriber, 41(6), 183–185. https://doi.org/10.18773/austprescr.2018.060

5: Kim K. (2020). Identifying the Factors That Affect Depressive Symptoms in Middle-Aged Menopausal Women: A Nationwide Study in Korea. International journal of environmental research and public health, 17(22), 8505. https://doi.org/10.3390/ijerph17228505

6: Azizi M, Fooladi E, Masoumi M, Orimi TG, Elyasi F, Davis SR. Depressive symptoms and their risk factors in midlife women in the Middle East: a systematic review. Climacteric. 2018 Feb;21(1):13-21. doi: 10.1080/13697137.2017.1406908. Epub 2017 Nov 30. PMID: 29189084.

7: Gujski, M., Raczkiewicz, D., Humeniuk, E., Sarecka-Hujar, B., Wdowiak, A., & Bojar, I. (2021). Depressive Symptoms and Healthy Behavior Frequency in Polish Postmenopausal Women from Urban and Rural Areas. International journal of environmental research and public health, 18(6), 2967. https://doi.org/10.3390/ijerph18062967

8: Wariso BA, Guerrieri GM, Thompson K, Koziol DE, Haq N, Martinez PE, Rubinow DR, Schmidt PJ. Depression during the menopause transition: impact on quality of life, social adjustment, and disability. Arch Womens Ment Health. 2017 Apr;20(2):273-282. doi: 10.1007/s00737-016-0701-x. Epub 2016 Dec 21. PMID: 28000061; PMCID: PMC6309889.

9:https://pubmed.ncbi.nlm.nih.gov/20531231/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2882813/ Sassarini DJ. Depression in midlife women. Maturitas. 2016 Dec;94:149-154. doi: 10.1016/j.maturitas.2016.09.004. Epub 2016 Sep 16. PMID: 27823736.

10: A. Unsal, M. Tozun & U. Ayranci (2011) Prevalence of depression among postmenopausal women and related characteristics, Climacteric, 14:2, 244-251, DOI: 10.3109/13697137.2010.510912

11: Padda J, Khalid K, Hitawala G, Batra N, Pokhriyal S, Mohan A, Zubair U, Cooper AC, Jean-Charles G. Depression and Its Effect on the Menstrual Cycle. Cureus. 2021 Jul 21;13(7):e16532. doi: 10.7759/cureus.16532. PMID: 34430141; PMCID: PMC8378322.

12: Oktem M, Eroglu D, Karahan HB, Taskintuna N, Kuscu E, Zeyneloglu HB. Black cohosh and fluoxetine in the treatment of postmenopausal symptoms: a prospective, randomized trial. Adv Ther. 2007 Mar-Apr;24(2):448-61. doi: 10.1007/BF02849914. PMID: 17565936.

13: Chang CY, Ke DS, Chen JY. Essential fatty acids and human brain. Acta Neurol Taiwan. 2009 Dec;18(4):231-41. PMID: 20329590.