What women need to know about menopause and mental health

Here, Dr Deborah Lee, Dr Fox Online Pharmacy, discusses everything that women need to know about menopause and the effects it can have on your mental health

It’s estimated that 20% of women experience depression at some point as they pass through the perimenopausal transition. This is the time period, which starts when menopausal symptoms begin, and continues until the last menstrual period. The perimenopausal transition can last anything from 2 to 5 years. During this time as the ovaries are failing, and estrogen levels fall dramatically. After the last period, a woman is postmenopausal, and hormone levels become more stable.

What causes depression at menopause?

The precise role that estrogen and other female hormones play in the onset of depression at menopause, is not entirely clear. No correlation has been found with low estrogen levels, for example. It is more likely that women with risk factors for depression find their mood disturbance is triggered, by the rise and fall in their hormone levels. Hormone levels fluctuate dramatically during this time.

Some women are more susceptible to depression at menopause. These women, tend to get premenstrual syndrome, and postpartum depression – and then may well develop depression around the time of menopause. A personal history or a close family history of depression, also make depression around menopause more likely.

Estrogen and the brain

The hypothalamus and the amygdala are specific areas of the brain involved in regulating mood. These structures are rich in estrogen receptors. Experimental work with rats has shown that the neural connections in these areas of the rat brain increase and decrease with the ebb and flow of the monthly hormonal cycle. Also, scientists have discovered that if estrogen is injected into these parts of the rat brain, the rats exhibit less in the way of depressive behaviour.

Estrogen also has a positive effect on another part of the brain – the hippocampus. The size of the hippocampus is increased in women on HRT. Blood flow to the hippocampus is also increased while taking estrogen. Other studies have demonstrated increased activity in brain neurons in HRT users.

Brain function relies heavily on the action of neurotransmitters. These are chemical messengers which signal cells to get on and perform a specific function.

Serotonin, for example, is a neurotransmitter which has a key role in mood, depression, social behaviour, sexual desire and sleep.

Estrogen is known to promote serotonin. It does this by facilitating serotonin synthesis and increasing the number of serotonin receptors in the brain as well as increasing serotonin uptake.

Estrogen also upregulates the adrenergic and dopaminergic pathways. Dopamine and noradrenaline are also important hormones in terms of mood and wellbeing.

Treating depression at menopause

Leading authorities now advocate the use of HT at menopause to depression as a first-line option. Antidepressants are now generally regarded as second-line. Although, some women will require both.

Studies on the effectiveness of HRT to alleviate depression have shown conflicting results. However, the studies which did not show benefit, have received criticism. They either used groups of women with very severe depression and on anti-psychotic medication, and/or tended to use either oral (tablet form) HRT, or E1 (oestrone) only.

Other studies have shown estrogen to be extremely effective at alleviating depression in menopausal women. For example, a 2001 randomised, placebo-controlled trial of 50 perimenopausal women with depression, 68% of those on HRT experienced remission of their depressive symptoms compared to 20% on placebo. This was highly statistically significant. 

Which type of HRT?

Transdermal (skin patch) HRT has definite advantages for treating depression. This is because depressive symptoms seem to be triggered by fluctuating hormone levels. Transdermal estrogen gives stabilizes hormone levels as opposed to oral HRT which involves a daily dose of estrogen. Transdermal preparations contain E2 (17 beta-estradiol).

There are several different transdermal brands available. Moreover, transdermal HRT does not affect blood clotting and has been shown to have some clinical advantages in terms of safety.

Progesterone and HRT

The type of progesterone in HRT may also influence mood disturbance. There are several different HRT progesterones to choose from. There is no hard and fast rule which one is preferable, they are all equally effective, but some women respond better to one type than to another other in terms of side effects.

Norethisterone and levonorgestrel are testosterone derivatives, whereas medroxyprogesterone acetate (MPA) and duphaston are more closely related to progesterone. If one of these doesn’t suit, try one from the other group.  Satisfaction has been reported with Utrogestan, which is a type of natural progesterone.

Other factors

Research suggests estrogen is most effective at treating peri-menopausal depression. In the postmenopausal period, estrogen may be ineffective. As with many of the other HRT benefits, the best effects of estrogen on depression are seen if it is used through the window of opportunity – that is for 5-10 years from the time symptoms are first noted and through the perimenopausal transition. This generally means use between the ages of 50-60. 

Final thoughts

After years of negative publicity about HRT, the pendulum is now firmly swinging the other way. In 2015 the National Institute for Health and Care Excellence (NICE) reviewed the evidence and endorsed the use of HRT. The British Menopause Society have declared ‘HRT is safe after all!’

Women need to understand the potential benefits of HRT on many of their menopausal symptoms, including their mental health, and be able to disc this with their healthcare providers.

For more information

• Women’s Health Concern – The Menopause
• Royal College of Obstetrics and Gynaecology – Mood Changes and Depression
• Menopause Matters