Depression And Menopause

Are you nearing menopause? If so, be aware that depression is a risk.

We say that our hormone levels get disturbed when we grow old. But the body’s logic is that we grow old because our hormones go out of whack.

It’s difficult to believe, but your hormones have that great a role to play in ageing or in regulating countless other body processes. This is because hormones help the trillions of cells in your body to communicate. And by hormones, I don’t just mean just the sex hormones estrogen, progesterone, and testosterone, but also the thyroxine, cortisol, adrenaline, ghrelin, and insulin.

But, let’s talk about the queen female sex hormone- estrogen. Usually, as we women enter our 40s our sex hormones like estrogen taper off and consequently, our bodies undergo a sea of changes and low-and-behold we are in ‘perimenopause’. This stage lasts for anywhere between 10 to 15 years before our periods cease and we are officially in menopause. By this time we are usually in our early 50s. The circle of shedding blood monthly is now defunct and you cannot become pregnant anymore as your body ceases to produce a fertile egg like it used to.

But that’s not all, female sex hormone surges and dips throughout the process of menopause affect your brain as well as the rest of your body. Just imagine that!

This happens because there are receptors for both estrogen and progesterone throughout your body. When the levels of sex hormones begin to decline, every system in your body that has these hormone receptors registers the change, and that includes your brain. When the hormone receptors in your brain begin running on empty it causes a lowering of the key neurotransmitters such as serotonin, dopamine and norepinephrine.

So, this is why you get those unexplained mood swings, crying spells, feelings of emptiness and other debilitating symptoms before your period.

Science and depression

The scientific verdict is divided on whether mood disorders like depression spike when you are in menopause because of the hormone dance.

There are several researchers who don’t agree that there is an absolute, irrevocable link between hormonal fluctuations during menopause and mood disorders. But, more recent studies have highlighted an increased incidence of depression in women during the menopausal transition. These studies red flag the imbalance in brain neurotransmitters, especially serotonin and the mood-regulating chemicals called endorphins in depression (Amin, Z. , Canli, T. & Epperson, C.N. (2005). Effects of Estrogen-Serotonin Interactions on Mood and Cognition. Behavioral and Cognitive Neuroscience Reviews, 4 (1), 43–58. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15886402).

Two other studies published in the journal Archives of General Psychiatry Studies offer some of the strongest evidence yet that hormonal changes may be at least partially to blame in depression.

Both studies followed a sample of women through perimenopause. These were normal women with no history of depression prior to this in their lives.

In one study, the authors, Cohen and colleagues followed 460 Boston women between the ages of 36 and 45 for up to six years. All of them were premenopausal when they enrolled and still had regular periods and none of them had ever been diagnosed with major depression. But, what the researchers found was striking.

They observed that the women who entered perimenopause during the study period were almost twice as likely as those who didn’t to develop significant symptoms of depression.

In the second study, University of Pennsylvania School of Medicine researchers followed 231 women between the ages of 35 and 47 for eight years. Here too, the subjects were premenopausal at entry and had no prior history of major depression.

This study too confirmed that a woman was more than four times as likely to have symptoms of depression during perimenopause due to changes in hormonal levels. What’s more, a diagnosis of clinical depression was also found to be two-and-a-half times more likely during perimenopause according to these two seminal studies.

Scientists have also found that women who enter the menopausal transition early are at higher risk of developing depression.

Predictors of menopausal depression

Hormones are not the only cause of depression during menopause. Other important independent predictors for menopausal depression are previous episodes of depression in your childbearing years, premenstrual syndrome or PMS, post-partum depression and having menopausal symptoms like hot flashes and insomnia, obesity, poor social status, and ethnicity (Bromberger JT, Harlow S, Avis N et al. Racial/ethnic differences in the prevalence of depressive symptoms among middle-aged women: the Study of Women’s Health Across the Nation (SWAN). Am J Public Health 2004;94:1378- 1385).

Another important predictor is a low level of folate, which affects the neurotransmitters that control moods and we do know that women over 50 have a decreased ability to absorb this form of vitamin B.

Another factor which has emerged as a significant risk for menopausal depression is smoking apart from an increased, usually genetic, sensitivity to hormone fluctuation amongst women.

There are too many other factors that can lead to depression during menopause, like the environment which includes cataclysmic life events. Menopausal symptoms may thus exacerbate depressive symptoms and vice versa (Soares CN. Menopausal transition and depression: who is at risk and how to treat it? Expert Rev Neurotherapeutics 2007;7:1285–1293).

What are the available treatment options for menopausal depression?

A number of psychiatrists treat depression, including menopausal depression by prescribing antidepressants. Research, however, supports the use of HRT or hormone replacement therapy along with antidepressants because of estrogen’s role in balancing neurotransmitters in the brain.

But, the link between falling estrogen levels and reduction in neurotransmitters is controversial and many Indian clinical psychologists I spoke to claim that even though biological changes during menopause are known to lead to neurotransmitter imbalances, meditations that restore this balance are the only treatment for depression of any kind including menopausal depression and not HRT therapy.

Kamna Chhibber, Clinical psychologist and Head — Mental Health at Department of Mental Health and Behavioral Sciences, Fortis Healthcare, New Delhi is a case in point as she says, “As depression occurs due to neurotransmitter imbalance in the brain, it can be treated through the use of psychiatric medication that helps neurotransmitter imbalances as well as utilizing psychotherapeutic interventions like cognitive behaviour therapy, mindfulness-based therapy and RBT, to name a few which help in managing the symptoms, changing negative cognition and modifying dysfunctional beliefs and developing better- coping strategies.”

Curing menopausal depression: What can you do?

Even though the symptoms of depression are treatable and this disease is manageable, it is usually left undiagnosed in women old or young. What makes menopausal depression even more difficult to diagnose is because it has atypical manifestations, which means the patient may not show classical symptoms of depression. This makes a diagnosis of menopausal depression even more challenging.

But, you can change this. As a woman in perimenopause or after menopause, you should know that help is available. Talk to your gynaecologist about your emotional health apart from any other physical symptoms related to menopause, you may be facing like hot flashes, and ask her about HRT.

Supplementing estrogen, studies show can sometimes help in managing at least low-grade depression by itself, without anti-depressants.

There are other ways toward healing too, like Dr Chandni Tugnait, a psychotherapist, life coach, and the founder of “Gateway of Healing” elaborates. She says, “ There’s a disconnect between scientific knowledge and clinical treatment when it comes to women with menopausal depression. The treatments that appear to be the most successful for this disease frequently incorporate body psychotherapies that put you in touch with your body and emotions and help you manage them better.”

And finally, be aware that though there is a tendency to dismiss your symptoms of depression amongst doctors as a part and parcel of the menopausal transition, never let them discount your symptoms. Find a doctor or psychotherapist who listens to you and don’t stop till you get a treatment that works.