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The menopausal transition is a normal part of a woman’s life, but it can be unsettling. In my clinical practice in Providence, R.I., I find that symptoms of depression in women between the ages of 40 and 60 are among the most misunderstood and misdiagnosed. Too often, midlife women and their doctors minimize the problem with the statement, “It’s probably just menopause.” This is an inaccurate and potentially harmful belief. Midlife depression is rarely the result of declining hormones alone—usually there are many other factors involved.
If you are experiencing changes in mood, schedule an appointment with your primary care doctor. She will probably consider medical explanations for your depression, including thyroid disorders, which are common in midlife, chronic dieting and side effects to medications, such as those prescribed to control high blood pressure. She may also ask about your alcohol intake, because many women turn to drinking to relieve their depressed or anxious mood. But drinking is counterproductive—alcohol is a depressant and causes insomnia, which exacerbates depression.
You and your doctor should also evaluate the severity and duration of your depressed mood. Do your sad feelings or irritability pass in an hour or last for weeks? Are your symptoms new, or have you had them for many months, or even years? Have they disrupted your sleep, appetite or ability to concentrate? A major depressive episode (MDE) is diagnosed when your feelings of sadness, irritability or loss of interest and other symptoms are severe and interfere with your daily activities for more than two weeks. The expression “clinical depression” also refers to an MDE. This is a serious diagnosis, one that is twice as common in women than men.
For less severe depressive symptoms, regular exercise, which may boost the feel-good hormone serotonin, can be an accessible and inexpensive mood management strategy. Women who exercise at least 20 to 30 minutes a day report improved mood immediately after exercise and beyond. Social support helps, too. In studies of women who are under severe stress, those who have a close confidant are less likely to become depressed. If you exercise with a friend, you will gain two benefits from one activity.
Three groups of women are more likely to become clinically depressed at midlife: women with severe, untreated hot flashes; women experiencing high levels of stress; and those with previous histories of depression, including premenstrual dysphoric disorder, postpartum depression or MDE.
Some refer to hot flashes as the “calling card” of menopause, as 75 percent of American women report them. In reality, it is not menopause, the permanent end of menstrual periods, but perimenopause, when hot flashes—and associated mood problems—begin. Perimenopause is the time just before menopause when menstrual periods become erratic. The stage can last for up to five years before the last menstrual period occurs. Women who have had their ovaries surgically removed experience more severe hot flashes than women going through natural menopause. Hot flashes that occur at night disrupt sleep by causing a sudden increase in core body temperature. As many as 40 percent of women in midlife who experience sleep disturbances also report psychological distress, in contrast to 15 percent of women without sleep problems. That’s no surprise—everyone feels better if they get uninterrupted, restorative sleep.
Many women find the following strategies to be helpful in dealing with night sweats: wearing cotton pajamas or night gowns, keeping ice water at their bedside, avoiding foods or beverages that trigger sweats and using layers of sheets or lightweight blankets that can be easily tossed off. For severe perimenopausal hot flashes, your doctor may prescribe low-dose oral contraceptives.
The most effective treatment for reducing hot flashes during menopause is hormone therapy, specifically estrogen, which is usually prescribed alongside progesterone. Unfortunately, the results of the Women’s Health Initiative, a landmark 15-year study of 161,808 postmenopausal women, indicate that hormone therapy (estrogen plus a progesterone) puts women at increased risk for heart attacks, stroke, blood clots and breast cancer. Therefore, you should try a nonhormonal treatment for hot flashes first.
These include the antidepressants paroxetine (Paxil) and venlafaxine (Effexor), which are effective for reducing hot flashes and improving mood. Given the overlap between depression and hot flashes, this is good news. Other medications for reducing hot flashes include the antiseizure medication gabapentin (Neurontin) and progesterone. If your doctor prescribes estrogen or combined hormone therapy, it should be at the lowest dosage for the shortest amount of time.
Many women turn to botanical preparations to alleviate hot flashes. These include dong quai, black cohosh and plant-derived estrogens such as red clover and soy protein. St. John’s wort has been shown to be useful for treating mild and moderate depression, but not MDE. Overall, the results of large, controlled studies on these remedies have been mixed. A major issue with all herbal remedies is that the Food and Drug Administration does not regulate them, so some may contain harmful contaminants or multiple unknown ingredients. Acupuncture is another treatment that some women find helpful for taming hot flashes, but it has not been shown to be effective in larger controlled studies.
There are two new areas of research on the treatment of hot flashes to watch in the future. In one small yet promising study, omega-3 fatty acids reduced hot flashes and improved mood. Another small study showed that eight weeks of mindfulness meditation helped women feel less distressed by hot flashes. This technique trains you to stretch, breathe deeply and be aware of the feelings in your body rather than immediately react to them.
Stress is another risk factor for midlife mood changes. Studies of midlife women reveal that those with high levels of social stress are most likely to become clinically depressed, regardless of their hormone levels. The midlife years can be associated with the onset of health problems, caretaking of aging parents and in-laws, divorce or separation, problems with teenage or adult children and, now more than ever, financial worries. Note that missing from the list is “empty nest syndrome.” More women actually worry about the refilled or revolving-door nest as grown children return home in growing numbers. Many hospitals now offer stress management programs that may be covered by health insurance.
Perhaps the most isolating issue in midlife is the unhappy marriage or relationship suffered in silence. Silence leads to separation from friends, family and the support they provide, and this continues the cycle of stress. If you are experiencing major conflicts in your relationship, consider couples or individual counseling. Or at least confide in a close friend or relative.
Women with previous histories of depression, especially those associated with hormonal changes, such as premenstrual dysphoric disorder or postpartum depression, are more vulnerable to clinical depression during the menopausal years. A growing body of work suggests that there may be a “reproductive subtype” of depression, which links the condition with our bodies’ premenstrual, postpartum and perimenopausal phases. If you have a history of previous depressive episodes, you should to be alert for any depressive symptoms starting in perimenopause so that you can receive appropriate treatment quickly.
If you are diagnosed with an MDE, consult with a mental health professional. Your employer may have an Employee Assistance Program to help you identify a psychologist, clinical social worker, psychiatrist or clinical nurse specialist. Treatments for an MDE include psychotherapy, antidepressant medication or a combination of both. The psychotherapies shown to be most effective in treating depression include cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). Cognitive-behavioral therapy focuses on pessimistic beliefs and challenges negativism to discover new patterns of behavior. Interpersonal therapy analyzes past and current relationships as the key to understanding and overcoming depression. The goals of IPT are improved communication skills and increased feelings of self-confidence.
Remember: Midlife mood instability is usually not simply a result of declining hormones. Persistent depressed mood requires a medical assessment, consideration of causes and relief of symptoms through a variety of treatments. Ask for help, find a provider experienced in the evaluation of perimenopausal women, educate yourself online and seek support, and you will be able to enjoy the next phase of your life. Click through this slideshow for more tips on how to manage your mood.
Carol Landau, Clinical Professor of Psychiatry and Medicine at Brown University's Alpert Medical School, is a co-author of The New Truth About Menopause: Straight Talk About Treatments and Choices from Two Leading Women Doctors.
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