Having taken a strong interest in how the menopause affects women in recent years, it was encouraging and sobering in equal measure to hear a recent episode of Women’s Hour on Radio 4. Presenter Anita Rani led a discussion about how menopausal, or hormonal, depression affects women and how the medical profession is starting to acknowledge the link between high suicide rates in women over 45 and the menopause.

I have long been aware that sadly, between the ages of 45-55, a woman is most likely to take her life (Source: ONS). When investigating possible reasons for this increase, it is only recently that the link has been made between hormonal depression and suicide in women over 40.

As Stef, the guest on Women’s Hour shared, when her mother, Jill, sadly died by suicide in 1991, at the age of 41, there was no mention of the possibility that her changing hormone levels may have been responsible for her sudden and continued low mood. It is now thought that it was these changing hormone levels which eventually led Stef’s mother to be so desperate that she took her life. Stef said that she herself had experienced a similar ‘depression’ during her 40s, which led to a suicide attempt. She explained that the change in mood, energy and motivation had been sudden and unexpected and she had felt so desperate that she didn’t see another way.

Professor Pooja Saini, professor of suicide and self harm prevention at Liverpool John Moores University has done pioneering work in this area and told the programme that she has heard more and more stories like Stef’s and would encourage psychiatrists and gynaecologists to start working together in order to treat women in a more holistic way when noticing severe depression over the age of 40.

No Previous Mental Health Concerns

What is striking is that many of the women who experience what is termed ‘hormonal depression’ may never have suffered with adverse mental health before. They are not known to their GPs as patients who have experienced depression or self harm in the past and this is what differentiates them from many women who have a history of mental illness.

As such, there is a call for GPs and other mental health professionals to have an awareness of this group of women and take serious note when they start to experience low mood or unusual symptoms such as despair, fatigue, lack of motivation and severe anxiety.

The Science

The science behind this change in mood is really quite simple. As a woman’s oestrogen and progesterone levels decline, they move into what we call peri-menopause, which is the time (sometimes years) before her periods stop. Menopause itself is just one day – the date when a woman has not had a period for one calendar year.

The reason this is significant in terms of low mood, depression and anxiety, is that the declining hormones also govern levels of the endorphins serotonin and dopamine. It is these endorphins that are responsible for mood and anxiety. As serotonin and dopamine decrease, a woman can naturally feel low, anxious, tired and depression can set in.

Is There Anything Anyone Can Do?

If you are a woman experiencing unusually low mood or severe despair, or you are a concerned friend or family member, what can you do?

Well, the reason I found the programme as encouraging as well as sobering is that our increased knowledge and awareness means that there are many more opportunities to have an open conversation once we have recognised what might be going on.

Information is more readily available than ever before and my hope is that this continues so that every woman has the informed knowledge that she needs to recognise her symptoms and to be empowered to seek help.

The Traditional GP Route

The recommended first line of treatment remains a visit to the GP to explore what might be the cause of symptoms and what treatment might be available. It is no secret that a huge number of GPs are still ill-informed about the perimenopause and do not recognise the risk factors around a woman’s mental health. Some GPs prescribe anti-depressants as initial treatment; some patients report being told that they are too young to be experiencing perimenopause; some GPs are still running a single set of blood tests, rather than a few spaced out to get a true reflection of what might be going on as hormones fluctuate throughout the month. Patients report that they feel unheard and invalidated in many cases. There are, however, many GPs who have become much better informed and take the time to explore all options with their patients. If you feel that you have been dismissed, you are entitled to ask for a second opinion.

As well as anti-depressants, HRT (hormone replacement therapy) is often prescribed. This is often reported to be the best treatment but it can take time to find the right doses and combinations of hormones. Traditionally, just oestrogen and progesterone are used but there are growing calls for the replacement of testosterone at crucial intervals and this may be something to explore with your GP.

It is also recommended to go in having done some research about what you might be experiencing. Of course, anyone who is feeling tired, low, lacking self-esteem and feeling desperate might not be strong enough to go in and ‘fight’ for what is right for them. In such cases, the best scenario might be to take an advocate along who can speak up with you can’t. If that is not possible, remember that you have options and you can seek alternative care, even if you realise after the appointment that you didn’t get what you needed from the appointment. Never feel pressurised into taking medication that you do not feel comfortable with.

For women who can afford it, specialist menopause clinics are increasingly popular. Women can see doctors who are familiar with all the latest research and treatments and some experiences suggest that the care is tailored and empathic, with patients going on to live a more happy & fulfilled life.

Self-Care Benefits Everyone

As well as exploring the medical route, there are other ways that women can improve their outcomes by exploring self-care and learning about how important it is to put themselves and their needs first.

As women we tend to put others first, including partners, children and parents, as well as work and colleagues. It can be hard to change the mindset and learn that putting ourselves first isn’t selfish; if anything, it benefits everyone around us. Improving our self-care improves our sense of self-worth and self-esteem, both critical to improved mental health and a reduction in low mood.

Becoming aware of how we can look after ourselves in a way that improves our mental health outcomes benefits not just ourselves, but everyone around us.

*Please note here that in terms of hormonal depression, this is a serious physiological and psychological illness and that if you experience suicidal thoughts, please seek medical treatment and put that need before trying to ‘cope’ with self-care methods.*

There are links to support that anyone with suicidal thoughts & ideation can access at the end of this article.

 

What Can I Do?

When thinking about self-care, the main areas I think about include enjoying time with friends & peers, getting outside, connecting with new or existing hobbies, making time for meditation, journalling, sleep health, moving your body; and getting optimal nutrition.

 

Enjoying Time with Friends & Peers	During the Woman’s Hour programme, presenter Anita Rani read out a contribution from a lady in her 70s who referred to her long-time friendship group. She highlighted the importance of connecting with other women who are experiencing the same or similar feelings. Just sharing your experiences and realising that you are not alone in what you are feeling can be validating and can release any shame or guilt that you might be feeling as a result of the negative thought patterns. We’re all in it together!
Getting Outside	Connecting with the outdoors and being part of something bigger and more powerful that sleeps, thrives, flourishes and rests can be humbling. It can also serve to provide a reflection to our lives. Just as I have times when I flourish and times when I need rest, seasons in nature shows me that those periods of rest are essential to the continuation of life. As well as the bigger metaphor, just being in fresh air can be invigorating. As I always say, you’ll never come home from a walk feeling worse than when you left!
Connecting with New or Existing Hobbies	Hobbies can mean different things to different people. They can be social, competitive, display progression, relaxation or achievement. Whatever your hobby brings you, it will rarely make you feel worse. It could be your opportunity to socialise with like-minded people or familiar faces that make you feel comfortable. It may be that you bake or cook, which makes you happy. Maybe the achievements in the garden, which include fresh air, noticing seasons (see above), creating colour & beauty, feeding yourself or your family, or just welcoming birds & bugs into your environment. These all improve our mental health and give us a sense of purpose, achievement and relaxation. Whatever your hobby, make time for it during this difficult period in your life.
Practice Meditation & Mindfulness	Although steeped in tradition for centuries, this is a new one for many people. According to the UK’s Mental Health Foundation, mindfulness allows us to notice our thoughts, feelings, physical sensations and surroundings by paying attention to the present moment, not the past or future. Just by noticing something as simple as the smell of a cup of coffee, we can learn to live more in the moment and let distractions go. This is a very simplified explanation but I would recommend anyone to take time to do some research and learn how to incorporate mindful behaviours into every day life in order to help alleviate stress & anxiety. Meditation is different in that you need to set time aside for it and it is usually time-limited. It also involves a point of focus, such as your breath or a spot on the wall. I really enjoy doing a ‘body scan’, which slowly focusses the mind on every part of my body from forehead to the soles of my feet. To help get you started, there are several apps that provide guided meditation to help you on your way. Learning to meditate effectively can take time and patience but with practice, it creates a state of mindfulness and the rewards are great. The Calm App and website has some great information and resources that can get you started with both mindfulness and meditation, including guided meditations:   https://www.calm.com/blog/mindfulness-vs-meditation Many people have found the app Headspace to be very useful for daily meditation as well: https://www.headspace.com/
Journalling	Getting our thoughts and feelings down can be the most powerful action we take when trying to understand ourselves and our feelings. This is not about a diary of events. Journalling is about writing about how something made us feel. What it reminded you of. Writing it down can help let it go; it’s no surprise that therapists sometimes suggest it might be helpful to write a letter to a loved one detailing how we feel, before destroying it. It is the act of writing it down that helps us understand before we can let it go.
Sleep Health	I’m aware of the irony of talking about getting enough sleep when one of the main symptoms of perimenopause is poor sleep. However, maintaining a healthy sleep pattern is one of the most important factors in mental, emotional and hormonal balance. There is hope. Despite being a symptom of perimenopause, there are a few actions that women can take to reduce the amount of sleep interruptions, increase sleep duration and ease the common night sweats and aid a better (if not perfect) night’s sleep. Elimination of caffeine and alcohol from your lifestyle could turn around nocturnal problems, literally overnight. The stimulation and anxiety-inducing effects, as well as increasing the need to pee in the night, are major factors contributing to a higher night-time temperature and likelihood of waking several times during the night. Wearing light clothing (or nothing at all) also reduces night-time temperatures, as will swapping out a duvet for a sheet, or in my case, just the duvet cover. Research and anecdotal evidence suggests that taking a magnesium citrate supplement (I’m a big fan of this for many reasons, not just sleep health) makes a significant difference to sleep duration and quality. Sleep and magnesium both play a part in balancing hormone levels, so using both together to combat hormonal depression can lead to better outcomes. I’ve explored meditation above, but in essence, if we fall asleep at peace and with a calm mind, sleep quality can be improved. Exercise - Again, when you’re dog-tired and feeling low, exercise is probably the last thing on your mind. However, exercising during the day (not too late or you might still be buzzing) will make you physically, rather than mentally tired. This may improve your sleep quality and duration.
Exercise	Not just for sleep health! As explained earlier, as our oestrogen and progesterone levels decline, so do our serotonin and dopamine levels. These endorphins are essential for helping us to feel more positive and they contribute to our mood so it is no surprise that when our hormones decrease, so does our mood, which can lead to severe hormonal depression. We can’t replace these completely but we can reduce the rate of decline by introducing physical movement into our daily lives. Exercise, particularly exercise that makes us breathless (raises our heart rate) releases these endorphins and contributes to feeling lighter. Additionally, exercise often leads to a sense of achievement and progression, which can affect how we view ourselves, our self-esteem and self-worth.
Nutrition	As a Nutritionist, I can’t ignore the role of what we eat and drink when thinking about improving our mental health. There are undisputedly foods that are better for us and those (readily available) that contribute to poor mental health. Our consumption of ultra-processed foods and particularly sugar has increased exponentially over the past 40 years and there is speculation that this intake of nutrient-poor food has contributed to poor mental health outcomes across all sectors of society. So eating a healthy balanced diet of unprocessed fruit, vegetables, meat and starch, while reducing or ideally eliminating sugary foods is optimum for healthy brain function, hormones and physical health at all times of life. As our bodies change, a nutrient-rich diet high in protein, fat and vegetables is desirable for mental wellness.
Alcohol	It is so easy to reach for that glass of wine (or two!) when we’re feeling low. At a time when we don’t feel like ourselves and find it hard to understand what is happening to our body, a little bit of self-help in the form of the foggy haze that alcohol gives us is so welcome. Unfortunately, alcohol just makes things worse; it is a depressant. We are more likely to suffer from poor sleep, night sweats, heightened anxiety, low mood and poor diet choices if we have been drinking and whilst the initial relief is palpable, it isn’t long before depression sets in again. It is very hard to stay healthy, motivated and energetic after drinking so unfortunately, it is best to lay off the booze for a better outcome in the long term.
Talking Therapies	And finally, of course, I have to mention talking therapy, or counselling. Talking to someone about what you’re experiencing can be incredibly powerful. A good therapeutic counsellor or psychotherapist will hear you, validate your feelings and help you understand how you are feeling. Hormonal depression can be impacted by lifestyle and life changes that often come when a woman hits her 40s. This is the most common age for marriage breakdowns and for many women, they are coming to terms with older children becoming adults and leaving home, while parents become more frail. It may be a time when a woman’s career peaks and she is juggling her personal and professional lives. Conversely, she may be looking to return to the workplace or making a career change that can seem daunting while her confidence is low and her body is changing. Counselling can help a woman make sense of how she is feeling and help her work on her self-esteem in order to build confidence to tackle this new era in her life. It may help her understand when the right time to seek help from the GP will be and encourage self-care. A good, empathic counsellor will help a woman find her voice in this difficult time of change and hopefully allow her to feel her best self.

 

We don’t know how many women have died by suicide due to hormonal depression during the perimenopausal years. The only thing that we can be sure of is that TOO many women have found it too hard to carry on while feeling so bad. TOO many women were not aware of what was happening to their minds and bodies so didn’t know that they could ask for help. TOO many families have been left without their mother, grandmother, sister, daughter, wife because their battle raged silently and went unnoticed.

I am grateful that I live in a time that recognises what women are going through and as more professionals become educated, I hope that more women will be informed about what is happening and how they can be heard and treated for the absolute best outcomes.

 

Support & Helplines

The Samaritans: Call: 116 123, www.samaritans.org

Suicide Prevention UK: Call: 0800 587 0800, www.spuk.org.uk

SOS Silence of Suicide: https://sossilenceofsuicide.org/

Shout: Text SHOUT to 85258 – this is a text service; you do not need to speak with anyone.