Life for 48-year-old Rachel got “a bit wild” a year ago. She started to feel out of control of her emotions, depressed and anxious.
She describes a recent incident. “I started crying in the car park at Countdown for no reason; that overwhelming feeling of ‘oh my God, I can’t stop crying. And this is outside of my control,’” she says.
The feelings confused her: “Nothing’s going wrong. On the grand scale of things in my life – which can often be a little bit complicated – things are really calm. There really is nothing to cry about.”
Rachel’s low mood coincided with the time of hormonal change known as perimenopause, the time leading up to menopause (the end of menstruation), when reproductive hormones start to fluctuate and can cause a wide range of symptoms. It’s part of the overall menopause transition which can start in the early 40s, and go on for anything between two and 10 years. Women’s experiences of it are very individual, and aren’t always what we might think of when menopause comes to mind.
Rachel, for example, hasn’t had any hot flushes, a symptom many recognise as being a classic of perimenopause. But alongside her menstrual cycle taking unpredictable turns, she has experienced some debilitating mental health symptoms.
She describes what she calls “a darkness”.
“It’s a feeling of waking up and thinking, ‘this does not feel great’. And then thinking, ‘okay, how am I going to do this? How am I going to get out of bed?’”
Normally a person who feels capable and on top of things, Rachel says she also feels frustrated and angry more often.
“Everything’s a big deal. Frustration and rage and overwhelm, you know? And you know that you’re making a fuss out of nothing.”
Rachel lives with her husband and two teenage sons, one of whom is on the Autism spectrum. That’s challenging, but the barely controlled rage she sometimes feels at home is new and unexpected.
“Teenagers are teenagers… but there are some days I just cannot tolerate it. I know my reaction is unreasonable, and I’m thinking, I didn’t need to get that angry about that! But it almost it feels like wild horses couldn’t stop it.”
Like many GenX women, Rachel describes herself as a problem solver, “but everything just feels insurmountable and hard. That’s not something I’m used to.”
Work stresses “that would be water off a duck’s back usually to me” feel overwhelming.
“It’s a kind of fragility and anxiety. You feel like something’s pressing on your head and you’re on the verge of tears, but you just have no idea why.”
“It affects everything,” she says. “It’s so hard. I just wonder how many other women are out there, trying to hold it together.”
The answer to that is: quite a lot.
I’ve heard stories like Rachel’s over and over again in my work on menopause, both in researching my book on the topic and in subsequently speaking to groups around the country. Now we have recent data to back up these stories, which shows mental health struggles in perimenopause are real – and very common.
A survey, conducted by Tauranga GP and menopause practitioner Dr Linda Dear, looks at more than 4000 Kiwi women’s experiences of this life stage. Among the results: 69% of respondents said they experienced low mood, and 64% had symptoms of anxiety.
More concerning: 18% of the women in the survey said they had thought about ending their lives, and 23% had experienced thinking life was not worth living.
Perimenopause and menopause can, Dear says, cause profound psychological symptoms, and this is often not well recognised.
“That’s probably one of the big reasons perimenopause is misdiagnosed or missed,” she says. “It’s when it hides itself as a mental health problem, because it really does mimic that quite closely. It can be hard to say, ‘well, is this depression? Is this anxiety? Or is this perimenopause?’ Because they all have the same disguise on a lot of the time.”
In a woman’s brain in perimenopause – because of fluctuating levels of oestrogen, the powerful hormone that drives many functions in the body – there are changes going on that can lead to mental health and mood symptoms, even for women who’ve never experienced these things before.
“There are a lot of women who are having mental health symptoms purely because of hormonal changes,” explains Dear. “But because that’s not recognised, women are getting labelled with mental health disorders and treated with antidepressants. Or they’re seeing a psychiatrist. That’s not always such a bad thing… but hormones are being ignored.”
Doctors frequently miss perimenopause symptoms, or fail to take into account a woman’s life stage when she presents with mood issues and fatigue. And the lack of awareness is true of women themselves, too. In the survey, 64% of women didn’t know their symptoms were due to menopause.
“Everyone’s looking for that first hot flush,” Dear points out. “But it doesn’t have to come. It can be the woman’s mental state that shows up first. I say it all the time: our hormones mess with our heads.”
The consequences can be serious. Dear was surprised by the high number of women in the survey reporting suicidal thoughts. Though, she says, she sees women in distress every day.
“The mental health stuff can be really, really hard and sad and serious. Women lose themselves and feel like they’ve lost their minds for a while. They are genuinely not stable. They’re not being nice to themselves; not thinking nice things at all about themselves.”
When they front up to see her in practice, women often put on a brave face at first.
“I think with hormonal mental health – more so than with non-hormonal mental health problems – there is this mask; there is this trying to cover it up, trying to push on. And then when the woman gets into that room with the doctor, as long as it’s a doctor they trust and get on with… it all just comes flooding out.
“A lot of these women are in a crisis. They are so down, so anxious. They often say, ‘I feel like I’ve lost myself. I don’t know who this is.’ And they do get on quite a downward spiral. So they can be really tearful in the consultations. They can be inconsolable.”
Dear says while there are some women who are genuinely suffering from clinical depression rather than hormone-driven change, there’s usually some insight and perspective in menopausal women that’s different from someone with depression.
“Sometimes you lose all perspective with clinical depression. But when it’s in menopause and perimenopause… they know they shouldn’t be this unhappy.”
This is something Christchurch gynaecologist Dr Olivia Smart has also seen many times. By the time women come to see her, they have often had less than satisfactory experiences with their GPs in seeking to ease their symptoms.
“Women can often feel unheard. People don’t recognise the symptoms, and then they’re not being offered a range of treatment options appropriately. And the impacts are huge. The consequences on self-esteem, career and relationship are enormous,” she says.
For those women whose mood issues are hormone-driven, Dear says hormone treatment is a far more effective solution than antidepressants.
“If they go onto something for their hormones, their mental health is almost magically improved – much quicker than antidepressant can do it.”
The state of GP-land
The fact that women are being offered antidepressants over hormone treatment is perhaps a symptom of the patchy state of knowledge and confidence among GPs when it comes to treating women in perimenopause and menopause.
Women I’ve talked to have reported feeling dismissed by GPs, or having their symptoms minimised. Women in Dear’s survey – of whom 74% had sought help from their GPS - reported the same thing, with one commenter saying, “My doctor told me that ‘at this practice we do not medicalise menopause.’” Another said, “My GP basically said, ‘it’s menopause and there’s not a lot we can do for you.’”
On the other hand, other women reported being incredibly well supported by their GPs. And many have up-skilled themselves. Rachel tells the story of a friend who went to another doctor at the practice she uses, who prescribed her HRT.
“He said, ‘If we’d been having this conversation maybe a year and a half ago, I might not have done this.’ He admitted having educated himself more.”
The uneven nature of the GP experience is also reflected in the survey data, where GPs emerged as both the most helpful and the least helpful health professionals among respondents.
Smart can understand this. “I do think there are probably are a proportion of GPs who are doing great work in this space,” she says. “But I think it’s fair to say that training and updating around menopause is not happening. And so doctors are still peddling the messages that they may have picked up 15 years ago, around the WHI study. Which is not what we should be telling women now.”
She’s referring to the Women’s Health Initiative study, a large trial of HRT (hormone replacement therapy) conducted in the late 1990s, and prematurely halted in 2002 when researchers said they identified an increased risk of breast cancer from hormone treatment.
The result of the communication (and the ensuing panic) about this was that a generation of women threw away their HRT, and a generation or more of doctors stopped learning about how to prescribe and manage for menopause and perimenopause.
A recent increase in awareness and conversation around menopause has driven greater knowledge – it’s now acknowledged that HRT is a low-risk and highly effective treatment for most women – and demand for it is increasing. But GPs are not always keeping up. The survey data showed 31% of women had taken HRT, and of those, 48% felt they should have been offered it sooner. The most common reason given for not taking it was the belief HRT was too risky or dangerous.
Smart points out another unfortunate – and most likely unexpected – consequence of the 20-year under-use of HRT, which can also preserve bone density and potentially heart health: a possible impending crisis in women’s health.
“I think the heartbreaking thing that’s happened as a result of the Women’s Health Initiative and that two decades of not prescribing oestrogen, is that group of women is now in their mid to late sixties. And they’re falling over and breaking bones tripping over a curb, and then someone’s going, ‘well you’ve got osteoporosis, because you’ve been oestrogen deplete for the past 15 years.’”
“And then backtracking like we do with so much of medicine… we wait till things have got so bad, we wait till your coronary arteries are occluded. We wait until your diabetes is off the chart. We wait till your bones are so thin they’re going to snap like a twig. And then we initiate management without acknowledging why that decline has happened.”
Treating women differently
So what’s the solution for preventing this in future?
Smart and Dear agree it’s not fair or even useful to mandate compulsory menopause training for GPs. But those who are interested should have resources made available to them.
Smart says there’s a real demand now from interested GPs for up-skilling on menopause. This was reflected in the sold-out conference of the Australasian Menopause Society in Queenstown.
“That probably reflects women coming to their GPs and being informed, and I think that’s the right way to create the noise,” she says. “I don’t think you can necessarily say to the GPs: you have to do this. We have to create the demand from the women so that they go armed with the questions and knowledge, and don’t get what we hear all the time: ‘here’s a prescription for antidepressants.’”
There’s currently no standardised post-graduate training course in menopause for doctors in New Zealand. Trainee GPs get some education on it, but it’s bundled into the 36 core areas of health in the GP curriculum, which is hugely demanding.
Dear says things in GP-land are “dire”, with many GPs on the verge of collapse, feeling over-worked and under-resourced. Last year’s workforce survey from the Royal NZ College of GPs found 96% of practitioners felt overburdened. Piling another thing on their to-do list seems unfair.
“The GPs out there are all about to have nervous breakdowns,” Dear says. “It’s bad.”
She believes the answer lies instead in menopause-focused clinics, as has been done in the UK. Her own practice now focuses solely on menopause.
“I think menopause and a lot of women’s health should just be scooped out of general practice and out of hospitals – because it’s true, we’re not ill. And it should be done in a different way. You know, this whole medical model of everything just thrown in there – every type of problem a human being can have in the brain or the body; GPs see it – the world’s too complicated now and it doesn’t work for women’s health. It never did. And this is why you’ve got such a variety of responses when women book that appointment and sit in front of that doctor.”
For Rachel, still very much on the perimenopause journey, progress towards finding herself again is slow but steady.
“I think it’s really important that you get help and keep trying to find solutions, because this can really take you down. There are so many women out there probably in similar positions to me. When you are the person who’s used to fixing everything... you don’t really necessarily know how to fix yourself sometimes, you know?”
After trying “all manner of natural stuff”, Rachel is now on HRT – the standard regimen of a patch of oestrogen and oral progesterone – which she thinks is helping. She also has an un-filled prescription for antidepressants. She will take these if she needs them, she says. But “I’d really like to solve the root problem, if we can.”
She also takes heart from women she talks to who are out the other side of the menopause transition. She recounts a recent conversation with an older work colleague. “She said, ‘hang in there, honey. Because there’s a bit just after you go through this, and it’s wonderful.’”
This article was originally published on 7 August 2023.
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