Hormone changes, life stresses, sleep problems, worries about body image, infertility, and aging are all factors linked to menopause that can contribute to mood swings, stress, anxiety, and a decreased sense of well-being in women. Perimenopause is the phase before the final menstrual period during which the body undergoes many physical changes. These changes in the body lead to the factors mentioned above that can lead to anxiety.

Menopause occurs when periods have ended for 12 months. Symptoms of perimenopause may continue in menopause but usually occur less often. Studies report that 23 percent of women experience symptoms of anxiety during perimenopause and that these symptoms of anxiety are not necessarily linked to depression. It is normal to feel anxious or depressed when perimenopause begins, but frequent, severe feelings of anxiety or panic attacks are not typical symptoms of menopause.

Psychological effects of menopause

Some women may feel sad or troubled during menopause, because of the changes to the body that occur, such as the loss of fertility. Other women may feel relieved to no longer fear pregnancy.

In addition to this, women may undergo many significant life changes during the menopausal years. Their children may leave home, and their parents or partner may become unwell related to aging. These factors can all contribute to heightened feelings of anxiety.

The hormonal changes that happen during menopause can also drive feelings of anxiety. Changes in levels of hormones called estrogen and progesterone, in particular, can have an impact. These symptoms may go away when perimenopause ends, and women enter the postmenopausal period when hormones become more balanced.

Does this sound vaguely familiar?

“Crippling anxiety, sleep issues, panic attacks, lack of energy, weight gain, intense sweating, no sex drive, dry hair and brittle nails.” Just a few of the 219 comments expressed by women from around the globe in response to a 2011 blog I wrote titled, “Menopause and Anxiety: What’s the Connection?” for HealthyWomen.org.

It turns out anxiety is not the only thing about menopause plaguing the 6,000 U.S. women who reach menopause each day.

The Story

I’ve been blogging since 2009 (that’s a long time, in blogging years). Never has any one blog post ever gathered so many comments (and the comments continue to roll in four-plus years later).

So, What Do All These Comments Mean?

Women need other women.

Women need a sense of community.

Women need commiseration.

Women need to feel heard.

Women need to share and express themselves.

What Women Are Saying

Basically, that menopause has ruined their lives. Or if not ruined them, changed them (and not for the better).

” I need help.”

“I have no patience.”

“I have crippling anxiety.”

“I get awful panic attacks.”

“I have sleep issues.”

“I feel sooo old.”

“I used to be energetic.”

“I’ve gained so much weight.”

“I have brittle nails and dry hair.”

“This is so much worse than PMS.”

“Who is the menopause expert?”

“Will it ever stop so I can be my old self again?”

“I’m tearful and afraid.”

“Brain fog mood swings.. I’m worried about driving.”

What the Experts Say

Hot flashes:

You may not be able to eliminate them, but you can get enough relief to make a difference in things like sleep and your sex drive. The North American Menopause Society suggests trying things like lifestyle changes, nonprescription remedies, hormone therapy (estrogen alone if you’ve had your uterusremoved; if not, then estrogen plus progesterone is suggested) and non-hormonal prescription drugs.

Mental health:

Indeed, menopause can wreak havoc on your psyche, confirms the brain and spine team at the Cleveland Clinic. It may start out as sleepless nights, feeling more tired than normal and moody and short-tempered (or what I like to call “prickly”). Oh, I almost forgot: there can also be  problems with concentration and memory.

Many women go on to experience anxiety or depression, which can be especially crippling if they can’t find relief. Read more about that.

(Yes, changing estrogen levels could affect your mental state. And no, it’s not all your imagination. That calls for a toast.)

Who Else You Can Turn To

Many women complain that their health care professionals are either poorly educated about menopause or uninterested in the subject and, as a result, are ill-equipped to offer helpful advice.

Look for someone who is a NAMS Certified Menopause Practitioner (NCMP). These are licensed health care practitioners who pass a competency exam created by the North American Menopause Society (NAMS) to certify that they skilled at providing health care for women in perimennopause and beyond.

What Else?

Having personally been privy to a host of these discomforts, I’ll add my two cents. I MADE IT OUT ALIVE!

Because I’m a breast cancer survivor, taking hormones was a no-no. Fluoxetine, an antidepressant prescribed by my gynecologist, helped with my irritability. My hot flashes gradually subsided after a very long seven years.

My Non-Drug Drug of Choice

Exercise. Yeah, I know, I think it can cure all ills. Well, not all, but many.

Whether it truly helped with my menopausal symptoms or just took my mind off them matters not. And it’s good for things that midlife puts you more at risk for, like osteoporosis, diabetes, heart disease, weakening bones and insomnia.

Think I’m wrong? Just look at this study published in Archives of Internal Medicine. Even if you never exercised before, it’s not too late: being fit in midlife may make you a healthier older adult.

Treatments for coping with anxiety related to menopause

It is not uncommon for women undergoing menopause to receive hormone replacement therapy (HRT) and other treatments for menopause symptoms. Some women are not good candidates for HRT and should make these decisions with their doctor.

If a woman is going through perimenopause and is experiencing high levels of anxiety, she may also be prescribed medication to treat the anxiety. A doctor may also recommend counseling. Women with moderate-to-severe anxiety may be prescribed a popular type of antidepressants known as selective serotonin reuptake inhibitors (SSRIs).

SSRIs are often effective in improving symptoms of anxiety. According to the North American Menopause Society, however, about half of people who use these medicines experience side effects that affect their sex lives. These side effects can include reduced libido and difficulty maintaining arousal or achieving orgasm.

Other types of antidepressants are available for women who experience sexual side effects from SSRIs. These include newer types of antidepressants, such as bupropion and duloxetine. Older types of antidepressants, such as tricyclic antidepressants and monoamine oxidase (MAO) inhibitors, are not linked to sexual dysfunction. However, they may cause other side effects.

Decreasing the dose may reduce the side effects for some people who experience sexual dysfunction from taking antidepressants. However, it is important for anyone considering lowering their dose of medicine to consult their doctor first, as stopping medication can have severe consequences.

Lifestyle tips

Doctors believe that following a healthful lifestyle both helps with menopause symptoms and reduces panic attacks. A healthful lifestyle, which includes some gentle exercise, may significantly reduce anxiety.

Regular, gentle exercise can significantly reduce anxiety. Women who are going through perimenopause should pick their favorite form of exercise and try to make it part of a daily routine. Whether it is walking, running, swimming, or yoga, regular exercise can help to burn off nervous energy and improve symptoms of anxiety.

People should try not to drink too much caffeine or alcohol. Caffeine can trigger anxiety and nervousness. Alcohol is a depressant that can also make the underlying causes of anxiety worse. Acupuncture may be effective in reducing anxiety and treating other symptoms of menopause.

Getting good-quality sleep is important for reducing anxiety. However, women going through menopause often sleep poorly due to night sweats caused by hormone surges. Some people with anxiety find keeping a “pre-sleep journal” can help improve sleep. In a pre-sleep diary, people write out any nervous thoughts they might have so that their mind can rest easier.

There are support groups for women going through menopause, and these can be helpful. In a support group, people with the same issues get together to discuss the problems they are facing. Sharing their experiences together can help them to overcome their anxiety. If a woman is going through menopause and is experiencing anxiety but does not want to attend a support group, just talking to friends about what she is going through can also be very helpful.

Importantly, women should make sure that they take time out for themselves. Certain activities, such as gardening, reading, meditating, practicing mindfulness, or yoga, are all good ways to focus on oneself and create feelings of well-being and relaxation.

Dealing with a panic attack

Many women experience panic attacks during the menopause. Because people that have had panic attacks before are more likely to experience panic attacks during perimenopause, doctors think that panic attacks are a reaction to rather than a symptom of menopause.

When someone has a panic attack, they experience intense feelings of anxiety or “doom.” These feelings may be accompanied by physical symptoms, such as:

• heart palpitations
• shortness of breath
• dizziness
• weakness
• sweating
• nausea
• tingling sensations

Panic attacks most commonly last for 10-30 minutes, but they can also recur in a series of episodes that can last for hours.

Many people experiencing a panic attack for the first time worry that they are having a heart attack or a nervous breakdown. Panic attacks can be among the most terrifying experiences of a person’s life. If someone has panic attacks, they should speak to their doctor. They may either prescribe some medication or refer the person for a mental therapy that may be able to help.

Some people find that practicing mindfulness techniques can help prevent panic attacks. In mindfulness, practitioners focus on the thoughts and physical symptoms that accompany a panic attack and learn how to manage them. Irregular breathing can cause panic attacks. For example, trying to breathe in more than your body can let you, or breathing too quickly. Learning to control breathing when experiencing high levels of anxiety can help people to control panic attacks.

Having someone with you during a panic attack is helpful. This person can reassure you, gently encourage you to slow your breathing down, and stay with you until the attack has passed.

As with anxiety more generally, some lifestyle changes are known to help reduce panic attacks. These include:

• eating a healthful, balanced diet with lots of fresh fruit and vegetables
• avoiding alcohol
• reducing consumption of caffeine
• learning self-relaxation techniques
• getting plenty of fresh air

Menopausal Symptoms and Their Management

The menopause transition is experienced by 1.5 million women each year and often involves troublesome symptoms, including vasomotor symptoms, vaginal dryness, decreased libido, insomnia, fatigue, and joint pain.

In one population-based assessment of 386 Australian women, 86% consulted a clinician at least once to discuss menopausal symptoms. Several symptoms bear an obvious relationship to the changing hormonal milieu associated with menopause, and most women make direct linkages between menopause and the common symptoms of hot flashes, vaginal dryness, and disrupted sleep (with or without associated night sweats).

 In addition, during menopause, women may develop depressive symptoms and cognitive difficulties, which are more subtly and inconsistently linked to hormones. Depression and cognitive impairment can be burdensome for women and also compound the burden of medical illness for the aging female population. As postmenopausal women are already at risk for osteoporosis and cardiovascular disease, it is important to address potentially changeable psychiatric issues that may make medical issues more difficult to treat. An understanding of the risk factors, clinical presentation, and management of these common menopausal symptoms allows for improved patient care and health outcomes for older female patients.

The Core 4 Sympttoms: Vasomotor, Vaginal, Insomnia, and Mood

Epidemiology

Population-based, epidemiologic studies of menopausal women have recently been conducted and are yielding reliable and consistent information about the incidence, prevalence, and severity of several menopausal symptoms. However, the field is relatively new, and it is likely that there are subsets of women who are more or less vulnerable to particular symptoms or sets of symptoms. In 2005, a state-of-the-science conference on menopausal symptoms was convened, with a worldwide panel of expert evaluators who were tasked with determining which among the large set of midlife symptoms are most likely to be due to menopause.

Symptoms were evaluated for their proximity to menopause, apart from the aging process, and the likelihood that estrogen is effective in relieving symptoms. Based on this evidence review, 3 symptoms emerged as having good evidence for linkage to menopause: vasomotor symptoms, vaginal dryness/dyspareunia, and difficulty sleeping/insomnia. After this conference and based on 3 seminal studies adverse mood/depression was added to the list. Adequate longitudinal studies on cognitive function during the menopause were not yet available but have also become subsequently widely reported.

It is clear that there are many other symptoms that are reported by menopausal women. These include joint and muscle aches, changes in body contour, and increased skin wrinkling. Several studies have examined the associations between these symptoms and menopause.

Given the methods of ascertainment, the subjective nature of the complaints, the likelihood that there is publication bias (wherein positive studies demonstrating linkage to menopause are more likely to be published than negative studies), and their variation over time, it has been difficult to establish a true relationship between these symptoms and menopause. Other symptoms, such as urinary incontinence (UI) and sexual function, have mixed data for efficacy of estrogen treatment and linkage to menopause, apart from the aging process. For these reasons, this article addresses the core 4 symptoms and includes cognitive issues because they are of great importance and concern to aging women.

Vasomotor symptoms

Vasomotor symptoms afflict most women during the menopausal transition, although their severity, frequency, and duration vary widely between women. Hot flashes are reported by up to 85% of menopausal women. Hot flashes are present in as many as 55% of women even before the onset of the menstrual irregularity that defines entry into the menopausal transition and their incidence and severity increases as women traverse the menopause, peaking in the late transition and tapering off within the next several years.

The average duration of hot flashes is about 5.2 years, based on an analysis of the Melbourne Women’s Health Project, a longitudinal study that included 438 women. However, symptoms of lesser intensity may be present for a longer period. Approximately 25% of women continue to have hot flashes up to 5 or more years after menopause. A meta-analysis of 35,445 women taken from 10 different studies confirmed a 4-year duration of hot flashes, with the most bothersome symptoms beginning about 1 year before the final menstrual period and declining thereafter.

The exact cause of the hot flash has not been elucidated. The most accessible theory purports that there is a resetting and narrowing of the thermoregulatory system in association with fluctuations in or loss of estrogen production. In the past, hot flashes were thought to be related solely to a withdrawal of estrogen; however, there is no acute change in serum estradiol during a hot flash.

Others have related hot flashes to variability in both estradiol and follicle-stimulating hormone (FSH) levels. It is thought that decreased estrogen levels may reduce serotonin levels and thus upregulate the 5-hydroxytryptamine (serotonin) (5-HT_2A) receptor in the hypothalamus. As such, additional serotonin is then released, which can cause activation of the 5-HT_2A receptor itself. This activation changes the set point temperature and results in hot flashes. Regardless of the exact cause of the hot flash, both hormone therapy and non hormonal regimens can help to relieve vasomotor symptoms.

Vulvovaginal atrophy

Urogenital tissues are exquisitely sensitive to estrogen, and the fluctuations in estrogen that occur during the menopausal transition, followed by sustained low levels after menopause, can render these tissues fragile and cause distressing symptoms. Multiple population– and community-based studies confirm that about 27% to 60% of women report moderate to severe symptoms of vaginal dryness or dyspareunia in association with menopause.

In addition to vaginal atrophy, narrowing and shortening of the vagina and uterine prolapse can also occur, leading to high rates of dyspareunia. Furthermore, the urinary tract contains estrogen receptors in the urethra and bladder, and as the loss of estrogen becomes evident, patients may experience UI. Unlike vasomotor symptoms, vulvovaginal atrophy does not improve over time without treatment.

Menopausal hormone therapy (MHT) is an effective treatment of vaginal atrophy and dryness. For this purpose, systemic or vaginal estrogen can be used, although locally applied estrogen is recommended and can be administered in very low doses .These low doses are believed to be safe for the uterus, even without concomitant use of a progestin. Data are currently insufficient to define the minimum effective dose, but vaginal rings, creams, and tablets have all been tested and demonstrated to reduce vaginal symptoms.

Sleep disturbances and insomnia

Sleep quality generally deteriorates with aging, and menopause seems to add an additional, acute layer of complexity to this gradual process. Women report more trouble sleeping as they enter into the menopausal transition, and sleep has been shown to be worse around the time of menses, both by self-report as well as by actigraphy. Actigraphy studies indicate that as much as 25 minutes of sleep per night can be lost when a woman is premenstrual in her late reproductive years.

Women report sleep difficulties approximately twice as much as do men. Further compromise in sleep quality is associated with the hormonal changes associated with the menopausal transition and with aging, apart from hormones. Over time, reports of sleep difficulties increase in women such that by the postmenopause more than 50% of women report sleep disturbance. Women seem to experience more detrimental effects on sleep in association with aging, when compared with men.

Hormonal changes alone are not likely to provide the complete explanation for the relationship between sleep difficulty and menopause. Consistent with this concept is the fact that hormones are not always successful in treating sleep problems in midlife and beyond. Chronic poor sleep hygiene habits and mood disorders contribute further to sleep problems.

Adverse mood

One-fifth of the US population will have an episode of depression in their lifetime, and women are twice as likely to be affected. Although depression is more likely to occur in young adults, with peak onset in the fourth decade of life, there is evidence that the perimenopause represents another period of vulnerability for women. Several large prospective cohort studies have shown an increased risk of depressed mood during the menopause transition and an approximately 3-fold risk for the development of a major depressive episode during perimenopause compared with premenopause.

Although a previous episode of depression has been shown to confer an increased risk, women with no previous episode of depression are still 2 to 4 times more likely to experience a depressive episode during the menopause transition compared with the premenopause. Anxiety symptoms have been found to precede depression in some instances, and anxiety may also be viewed as increasing a woman’s vulnerability to a midlife depressive episode.

Menopause and cognition

Many women complain of changes in their cognitive function during the menopause transition, with the majority reporting worsening of memory. Verbal memory (word list learning and recall), which women generally excel at when compared with men, is often the type of complaint noted. Women may notice difficulty remembering names and other verbally told information.

In addition, they may report other cognitive challenges, with more trouble organizing and planning or possibly with concentration. In one study of 205 menopausal women, 72% reported some subjective memory impairment. Symptoms were more likely to be associated with perceived stress or depressive symptoms than peri-menopausal stage, but overall, cognitive symptoms were more prevalent early in the menopause transition. Aside from being bothersome, these symptoms raise women’s concerns regarding their risk for dementia; however, it remains unclear whether these symptoms correspond to an increased risk for more serious chronic issues.

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