Chapter 10

Mental and Emotional Issues

In This Chapter

Differentiating between menopausal symptoms and emotional or mental changes

Recognizing depression during menopause

Remembering to read this chapter

Connecting hormones to mental and emotional stress

Dealing with life changes

Many of us have “senior moments” even before menopause. You know — those brain hiccup moments when you’re about to introduce a friend you’ve known for years and her name suddenly escapes you. Or maybe you find yourself spending more time thinking about the hereafter as you walk through the house — as in, “What am I here after?”

You’re not alone. Many women experience these mental lapses during perimenopause or menopause. Some women even experience this type of forgetfulness long before menopause — during their menstrual cycle when estrogen levels are at their lowest. Estrogen plays a major role in memory and emotional functions.

Some perimenopausal and menopausal women also fall prey to emotional rollercoaster rides (and sometimes your friends and family are taken along for the ride). Fluctuating hormone levels prompt some emotional moments (remember being a moody adolescent?); others can come as a response to life events that — coincidentally — are more likely to occur at about the same stage of life as menopause.

Then again, you may simply not experience many mental and emotional problems at all during perimenopause or menopause. Like PMS (premenstrual syndrome), these symptoms are more severe in some women than others. Some women just seem to be more sensitive to hormonal changes. In fact, if you had memory lapses and heightened emotions in connection with your menstrual cycle in the past, they may be part of your perimenopausal and menopausal experience too.

In this chapter, we cover some of the symptoms you may be experiencing, how they’re related to your hormones, and how you can tell if a symptom is hormonal or psychological.

Understanding the Mental and Emotional Stresses of Menopause

Fortunately, with 40 or 50 years of emotional experience behind you, you’re most likely quite prepared to cope with the challenges life throws your way. Midlife changes present you with plenty of new opportunities, but also with a boatload of things that may be tough to handle.

If emotional issues or serious concerns about possible mental illness bother you during these years, visit your medical advisor. Life events may certainly trigger temporary mental or emotional issues, but there’s a difference between a temporary mental state and a debilitating condition. If your emotional state severely interferes with your daily life for a prolonged period of time, ask your doctor for a referral to a therapist or counselor.

Finding the link to menopause

You have estrogen receptors all over your brain, particularly in areas associated with memory and mood, because your brain needs estrogen to function properly. So, a dip in your estrogen levels can affect your mental and emotional health. But medications, illness, and physical conditions other than menopause can lead to mental and emotional problems. Ask your doctor to help you tease out what’s going on.

The medical establishment didn’t recognize hot flashes as an actual physical condition (as opposed to whining) until the late 1970s. If going to the doctor makes you feel as if you’ve stepped through a time warp into the 1950s (“It’s all in your head. It’s just stress, dear. Go out and buy yourself something pretty.”), then you, the patient, must take that bull by the horns (or by the hormones), and make it clear to your medical advisor that you want him or her to take the subject seriously. The symptoms caused by estrogen fluctuations are at least as common in perimenopause as they are during menopause itself. You may have to insist on a test to check your hormone levels. And if you meet resistance, ask your friends for the name of a more receptive doctor.

We’re sure you’ll be delighted to know that you can have perimenopausal symptoms and PMS at the same time! Because so many of the symptoms are the same, especially for women who have a hard time with PMS, it can be difficult to tell whether your moodiness, fatigue, headaches, and weight gain are from your PMS or your perimenopause. Keeping a diary can help you tell — PMS symptoms will be more regularly cyclical, occurring in the days or weeks before your period. Perimenopausal symptoms are more unpredictable and can occur at any point in your cycle.

Separating menopausal symptoms from psychological disorders

The mental and emotional changes that you experience because of hormonal changes shouldn’t interfere with your daily life — cause damage to friendships or relationships with the folks at work, make it impossible to manage your normal schedule of activities, or prompt you to abuse alcohol or drugs to help you feel better. If your symptoms do provoke these changes, talk to your doctor, seek out psychological help, or talk to your spiritual advisor.

You typically experience symptoms of menopause over a limited period of time, in episodes that come and go as your hormone levels fluctuate. Although your loved ones may disagree, these symptoms don’t completely alter your everyday life. They may make you occasionally unpleasant to be around for a while, but they’re not debilitating or irreversible. On the other hand, mental disorders do alter your everyday life.

Deciding Whether You’re Depressed

When we talk about the mental and emotional changes you may experience during perimenopause and menopause, it’s important to distinguish between these symptoms and the psychological disorders of the same name. For example, some women experience periods of depression during menopause. How do you know if you’re in trouble or if this is just a symptom you have to deal with?

Understanding the differences

During perimenopause and menopause, experiencing episodes of sadness isn’t unusual. During your younger days, you may have felt moody or blue for a few days each month before your period. But most women in their 40s and 50s have to deal with physiological changes (as they did when they were younger) while they’re dealing with one or more items from a menu of life-changing events: aging parents, the death of a loved one, marital problems, empty nests, retirement, job loss, and maybe a few unfulfilled dreams.

A hormonal link between depression and menopause seems to exist. Like a lot of issues that pop up at about the same time that your estrogen begins to decline, however, this may (or may not) be another coincidence of timing. Estrogen therapy, for instance, has not been found to be a good treatment for depression. And after you’re fully into menopause and your fluctuating hormone levels finally settle down, you may find your blues pack up and leave, too.

This does not mean that any depression you’re feeling isn’t completely real. Lots of things can cause depression, among them:

Hormonal imbalances: Shifting levels of estrogen and other hormones can contribute to depression.

Heredity: If you have a parent or other close relative who suffers from depression, you are much more likely to experience it than is someone with no family history of this problem.

Gender: Women are twice as likely as men to have depression.

Prescription medications: Depression can be a side effect of medication.

Seasonal changes: Seasonal affective disorder (SAD) is a common problem, still not fully understood, in which lack of exposure to sunlight during winter months seems to contribute to depression.

Situational events: Depression can be triggered by loss or by major life changes.

We all feel sad, dejected, or blue now and then. You may become upset when you look in the mirror and see that your face has a few more wrinkles today than it did last year. Or perhaps you haven’t yet won the Nobel Prize or published that novel or climbed Mt. Everest. Or you may be in the midst of profound mourning after the death of a loved one. Such sorrow may last for several months. This is a completely normal response to a deeply felt emotional loss. The major difference between sad feelings and a true major depression is that sad feelings eventually pass — depression doesn’t.

Knowing the signs

Are you depressed? If you’re even asking yourself the question, it may be time to speak with your doctor, but here are some signs that your sadness is more than just a passing thing:

Favorite things or activities no longer bring you pleasure

Your patterns of eating, sleeping, or sexual activity have changed

Everything seems as though it takes more effort than it used to

You cry more than you used to or you don’t seem to feel much of anything

You have thoughts about harming yourself

If these descriptions apply to you, talk to a doctor about whether you may be suffering from clinical depression. People who seek help for their depression are likely to find relief from medications or other treatments that can help you to get a handle on depression and feel like yourself again.

Dealing with the Head Games

Your memory works because neurons (nerve cells) talk to each other across special connectors in your brain. It’s normal for these cells to wear out over time, but they’re also affected by the decreasing amount of estrogen available in your body. Estrogen keeps your brain — like so many other systems in your body — running smoothly. In the case of your brain, it plays a role in stimulating the growth of new neural connectors, and also helps keep blood vessels in the brain nicely dilated so that blood can flow through them without interference. So, a decrease in estrogen makes your brain run, well, not quite as smoothly as before.

Knowing the symptoms

The mind games associated with menopause are tricky, and they come on gradually — so gradually that you’re not sure whether you’ve always been this way or if this is something new. You think you’re going crazy. Your brain just doesn’t seem to be working the way it used to! Some of the symptoms you may experience include

Fuzzy thinking: Having trouble staying focused at work? Do you feel as though you’re walking around in a fog some days? Many women complain of problems concentrating during perimenopause and menopause. Shortened attention spans also seem to be associated with hormonal change.

Memory lapses: Not everyone experiences memory lapses, but if you do, they can be annoying, even downright scary. Misplacing your purse or temporarily forgetting how to spell a simple word is aggravating, but not recognizing your husband or child is another story altogether. Just because you occasionally experience this can’t-find-my-pencil type of memory loss doesn’t mean that you have Alzheimer’s disease or that you’re going to develop it.

There’s hardly anyone who doesn’t worry about Alzheimer’s when confronted with a frustrating episode of minor memory loss. Remember — losing your car keys, forgetting what you were about to say, or trying to use your office key to unlock your front door at home are all examples of normal forgetfulness. The time to worry is when you can’t remember how to drive your car, suddenly don’t recognize the person you were talking to, or can’t figure out how a key works. The old adage about memory is true, too: if you can remember to worry about your memory, you’re most likely still okay. If those around you are beginning to be concerned, it’s time to speak with your doctor.

Looking at the research

Since the first edition of this book came out in 2003, the women’s health community has almost completely reversed its position on whether hormone replacement therapy (HRT) is effective for maintaining sharp mental functioning and preventing dementia after menopause. Remember how we said that estrogen plays an important role in brain health? It really does, so for years the conventional wisdom was that estrogen replacement would keep your memory sharp and help to ward off Alzheimer’s.

But — go figure — the research findings of the Women’s Health Initiative Memory Study don’t bear this out. Instead, this is what the long-term studies of cognitive functioning and HRT have found so far:

HRT (neither estrogen-alone nor combination therapy using estrogen plus progestin) does not protect women from cognitive impairment associated with aging.

In fact, hormone therapy actually seems to increase the likelihood of both general cognitive decline and the development of dementia.

As with any longitudinal study, research will continue and long-term findings may be different. Findings may not apply in the same way to all women in all groups, either — the WHI memory study, for instance, only looked at women 65 and over, so we can’t say with certainty what the findings mean for younger women. For now, however, it doesn’t look as if seeking protection from dementia or cognitive decline is a good reason to go on HRT. If you’re already taking HRT, talk to your doctor about whether this is still the best choice for you, and how long you ought to continue taking hormones.

Beating the memory game

The least invasive (and very effective) ways to improve your memory during and after menopause are also good for the rest of your health: Stick to a balanced diet and exercise regularly. Also remember (no pun intended; well, okay, it was intended) that your brain needs exercise too. Throughout your life, you need to challenge and exercise your brain to keep those neurons firing and to keep your memory from getting flabby and weak. Here are some things you can do to help manage your memory:

Check your thyroid and ovarian hormone levels. Checking your hormone levels can help determine whether your symptoms are related to menopause or whether you may have a more serious condition.

Don’t smoke. As if you needed yet another reason to quit smoking, those gray clouds suffocate the nerve cells as they restrict the amount of oxygen that gets to your brain.

Exercise your mental muscle. Do crossword puzzles or sudoku, read, take a class, or try memorizing poems or recipes. Even just traveling, trying new foods, or keeping interesting company helps to build new neural connections and protect existing ones.

Exercise your body. Get going! Walk or swim, climb mountains or do yoga — just find something you love to do, and do it! Brisk aerobic activity three to five times a week for 30 minutes to an hour keeps the oxygen flowing to your brain, which improves your memory and your mood.

Get enough sleep. A loss of estrogen can cause disruptions in your sleep. Whether your particular brand of sleep deprivation is due to stress, urinary problems, low levels of estrogen, or your partner’s snoring, it can do a number on your memory.

Be careful about using sleeping pills; they interrupt your normal sleep patterns, which in turn, has a negative impact on your memory. You should never use sleeping pills for more than two weeks in a row.

Limit your alcohol consumption. Consumed in excess, alcohol damages nerve cells in the brain and depletes your body of vitamins necessary for building neural connections. Ironically, though, a number of studies show that moderate use of alcohol may actually help protect you from dementia and senility.

Take your vitamins. Certain vitamins help build nerve cells and the neural connectors that you need to remember things (or to just plain think). Some of the more important vitamins include

• B vitamins: This group includes vitamins B1, B2, B6, and B12, and the lack of these can cause memory problems. You can find vitamin B in meat, milk, and eggs, but if you’re vegan or vegetarian, you can also find them in enriched flour, cereals, and wheat germ, and in some enriched soy products. If you have a serious B vitamin deficiency, your doctor may even prescribe vitamin B injections.

• Folic acid: Good news for veggie lovers, this B vitamin relative is found primarily in vegetables rather than flour and meat. Green, leafy vegetables, such as spinach, collard greens, kale, and broccoli, are rich in folic acid (but it’s also often added to enriched breads and cereals, for those of you who still don’t like green foods).

• Antioxidants: The antioxidants serve as rust protection for your cells. Oxidation of your cells has a similar effect as oxidation of metal (called rust) — it damages and eventually kills your cells. Antioxidants include vitamins E and C, beta-carotene, and selenium.

Take a look at Chapter 18 to find out more about the importance of vitamins during and after menopause. Most women require a multivitamin to get sufficient dosages of these vitamins.

Straightening Out the Commotions with Your Emotions

As a woman, if you’re going to develop depression or an anxiety disorder in your lifetime, it will most likely happen when you’re in your late 30s or early 40s. Is there a link between depression and menopause-related hormone changes? More than likely. Aside from this fairly obvious coincidence in timing, some physical characteristics of women with depression point to lower levels of estrogen as a factor: Women with depression tend to have lower estrogen levels, and their estrogen levels go up after they pull out of the depression. Also, women with depression have lower bone density than non-depressed women. Low bone density is another common byproduct of low estrogen levels. Estrogen therapy, however, has not been found to be an effective treatment for depression, so the exact nature of the link between hormonal changes and an increase in emotional upsets, if one exists, still isn’t well understood.

Connecting mental changes and thyroid function

The thyroid is a butterfly shaped gland in your throat right in front of your larynx. It produces the hormone thyroxin, which is responsible for regulating the rate of oxidation in your body, but it also has a profound effect on your moods and your mental functioning. There are two basic forms of thyroid disease: you can be hyperthyroid (in which the thyroid gland produces too much thyroxin) or — and this is more common in women, particularly as we age — hypothyroid (in which it produces too little). Both disorders result in changes, usually subtle but sometimes dramatic, in your overall health.

The kicker is that the symptoms of a thyroid gland on the blink are remarkably similar to the symptoms of menopause. Thyroid disease also tends to occur, when it does, at about the same point in your life as menopause. It’s understandable, therefore, that you might go through menopause blaming your symptoms on estrogen depletion without ever knowing your thyroid is behind some or all of your discomfort. Both are associated with changes in skin, hair, menstruation, and weight, with depression, insomnia, fatigue, mood swings, and memory problems, and with anxiety, heart palpitations, and loss of libido.

At each checkup your doctor should palpate (feel) your throat to check the size and shape of the thyroid gland, but if you or she have concerns about your symptoms she can also order blood and other tests. She will also look for symptoms that are common to thyroid dysfunction but not to menopause, such as tenderness or pain in the throat, swelling in the arms or legs, or loss of eyebrows and eyelashes. Treatment will depend on whether your thyroid levels are too high or too low, and on what your doctor determines to be the cause of the malfunction. Many thyroid problems are treated easily, effectively, and inexpensively with oral medication.

Feeling your way through the symptoms

Here are the emotional changes you may notice as you approach menopause:

Anxiety: You’re driving along and all of a sudden you feel panicky. With anxiety, you may experience both emotional and physical symptoms. Emotionally you may be irritable or have trouble focusing. Physically, your heart may start beating as though you’ve just sprinted a 50-yard dash. You wonder if you should drive straight to the hospital. Heart palpitations or a racing heart accompanied by butterflies in your stomach are common during perimenopause and menopause.

Depression: If you’re dealing with interrupted sleep, hot flashes, or memory lapses, avoiding the blues is hard. If you experienced depression related to PMS or if you had to deal with postpartum (after-childbirth) depression, you’re more likely to experience depression during the change (see more about depression earlier in this chapter, under “Deciding Whether You’re Depressed”).

Increased sensitivity: You may feel that life isn’t fair or that everything is your fault, or you may find yourself looking for a fight. Performing at any level that falls short of perfection can cause a negative emotional reaction. Or you may experience crying jags — with or without reason.

Mood swings: One minute everything is fine, and the next minute you’re sad and gloomy. You may find it difficult dealing with family situations, relationships at home, or professional relationships.

Understanding the physiology and getting relief

When estrogen levels drop, the hormone serotonin decreases. Serotonin helps decrease anxiety, so when it drops, you tend to get more anxious. When serotonin drops, it also aggravates adrenaline-inspired irritability and heart palpitations in addition to anxiety. Your doctor may prescribe serotonin-enhancing antidepressants to relieve anxiety during perimenopause and menopause. SSRIs (selective serotonin reuptake inhibitors) can balance certain brain chemicals to help relieve the symptoms of depression.

Keep in mind that, though these symptoms can be annoying, they aren’t actually dangerous. Anxiety and depression can also be treated without medication through acupuncture, counseling, biofeedback, yoga, relaxation, herbal remedies, and massage. (See Chapter 17 for more information on alternative therapies.) The decision to take antidepressant medication should be yours, not your doctor’s. If you decide to take them, talk with your doctor about possible side effects, and never stop taking them suddenly or change your dosage without medical supervision.

SSRIs are also used to treat depression triggered by an imbalance between estrogen and progesterone in your body. With estrogen levels lower during perimenopause and menopause, progesterone can temporarily overpower the effects of estrogen and testosterone in your brain. You may feel like crying, or you may feel irritable, grumpy, or downright ugly.

Situational stress (not unfamiliar to women in their 40s and 50s) triggers changes in ovarian function. Hormone production can then drop off, causing even more emotional changes. Life events may start your mental and emotional symptoms, but hormonal changes turn up the volume.

Managing life changes

Going through menopause might be a little easier if you could do it in a social vacuum. You know, maybe take a nice stack of great books, a few bottles of wine, and your favorite comfy clothes and hole up in the mountains (or at the beach or in a luxury big city penthouse apartment — select your favorite scenario) for, oh, say, three or four years. You might still have hot flashes and night sweats and irregular periods, but the aggravation factor in your life would be almost nil.

Instead, though, we all get to go through these life changes in the midst of a crazy, busy world. Menopause seems to get plunked down into your life just at the point at which you still have the concerns of a younger woman but are also beginning to take on the roles of an older one. You might have children still at home when you start taking care of your aging parents or in-laws. Perhaps you’re simultaneously dreading and looking forward to having the nest empty out just a bit. You might be wondering when your periods are going to stop and your preteen daughter’s are going to start. And you may have reached a position of new responsibility in your job — and here your brains seem to be turning to oatmeal.

Whatever’s on your plate, it’s going to bring both stress (and, if you’re lucky) and joy. Ups and downs. Mood swings and stretches of tranquility. In Chapter 20 we’ll talk a lot more about how the changing features of your life affect (and are affected by) your menopause experience.