‘Am I going mad?’
‘I don’t recognise myself’
‘I don’t understand what is happening to me’
These are comments I often hear from women in perimenopause. Some feel like they are having a personality change – where previously they enjoyed reasonable levels of resilience and confidence, their moods swing, their memory is unreliable and they feel confused, anxious, angry or overwhelmed.
Once they are made aware these changes can be attributable to perimenopause and that help is available they generally breathe a sigh of relief. Whilst hot flushes, joint pain and other physical symptoms of perimenopause can be challenging many women report that their greatest struggle in perimenopause is with the psychological symptoms.
Awareness of what to expect and ways to help can make a significant difference. Here is an overview of how our mental health can be affected during perimenopause and suggestions to help you to manage. There are many ideas so that you can choose what is right for you. It is important to stress that every woman has her own unique experience of peri and menopause and symptoms will vary from person to person. What works for one woman may be different to another.
What causes Psychological Symptoms in Perimenopause
Mental health issues such as depression and anxiety can have complex causes and debates have raged over the years as to how much is due to circumstance and how much is biological. The reality is that it is a combination of both. Yet when we enter perimenopause we undergo numerous changes within the body, particularly hormonal, which influence on our moods and affect our ability to regulate emotions.
Consequently, women who have enjoyed relatively good mental health throughout their lives may be surprised by the degree to which they struggle during perimenopause. Women who have experienced difficulties previously may find that they become heightened at this time.
And we must remember that peri and menopause do not happen in isolation. Whilst women’s bodies undergo substantial changes we continue to deal with the usual life issues - bereavement, job pressures, relationship issues, relocation, family responsibilities, financial worries, health concerns and much more. These events are challenging at the best of times, let alone in the midst of perimenopause.
The Psychological Challenges in Perimenopause
Here are some of the many challenges that we may face:
· fluctuating hormone levels can cause mood swings, making it harder to regulate our emotions. Things that we previously would have brushed off as minor issues can take on great importance, leading to emotionally charged reactions - anger, guilt, tears, overwhelm.
· physical symptoms can have a knock-on effect on our moods e.g. persistent fatigue can prevent us doing what we enjoy and leave us feeling low; and fear and embarrassment around hot flushes can raise anxiety levels.
· sleep disruption – many women experience sleep difficulties and this affects our ability to cope and function well.
· everyday stress - caring for families (children, partners, step families, elders), career pressures, new health concerns, financial worries and little time to slow down.
· anti-ageing culture – negative social attitudes towards ageing can leave women suddenly feeling invisible, undesirable, redundant and worthless, we may grieve the loss of youthfulness.
· unfinished business – it is not unusual for past issues to arise during perimenopause, feelings that we have buried long ago may resurface and be harder to supress.
· existential questions arise with the realisation that we may be halfway through our lives, the sense of time passing invites us to live more purposefully.
One of the first psychological symptoms of perimenopause is often anxiety. This is because one of the first hormonal changes is a significant drop in progesterone. Progesterone has been shown to have a calming effect on the nervous system and so, the lack of it can lead to heightened anxiety levels or even panic attacks.
Oestrogen acts in many parts of the body including the parts of the brain that control mood. It increases serotonin and the number of serotonin receptors in the brain as well as modifying the production and effects of endorphins, often referred to as ‘feel-good’ chemicals. Levels of oestrogen can fluctuate dramatically throughout perimenopause, at times we will have very low levels, and this can lead to swings in mood and emotions.
Common Mental Health Issues during Perimenopause
Anxiety is an uncomfortable feeling of worry or unease about something with an uncertain outcome. It is generally concerned with events that may or may not unfold in the future, it could be a fear of doing a bad job, worry about all the things we feel we ought to be doing but aren’t managing, health-related fears, relationship worries or a belief that the worst will happen.
Feelings of anxiety are a normal part of human experience and can help us by drawing our attention to something that needs to be taken seriously. Used well it can motivate us to take action and make positive decisions but when it becomes overwhelming it can be distressing or even paralysing, affecting us physically, mentally and emotionally.
Below are some of the signs of anxiety:
Emotional signs of anxiety are:
· Irritability or persistent bad mood.
· Low, depressive or hopeless feelings.
· A pessimistic outlook.
· Ruminating on mistakes, personal failures, fear of things going wrong.
· Seeking frequent reassurance.
· Unable to priortise.
Physical signs are:
· Sleep disruption – difficulty falling asleep, night waking, early waking or nightmares.
· Difficulty concentrating.
· Muscle tension and headaches.
· Rapid heart rate and breathing.
· Panic attacks.
· Digestive issues.
· Low libido.
· Dry mouth, difficulty swallowing.
· Sweating or trembling.
“Depression is the most unpleasant thing I have ever experienced. . . . It is that absence of being able to envisage that you will ever be cheerful again. The absence of hope. That very deadened feeling, which is so very different from feeling sad. Sad hurts but it's a healthy feeling. It is a necessary thing to feel. Depression is very different.”
― J.K. Rowling
Feeling hopeless or that life isn’t worth living
Unable to enjoy life
No motivation or interest in things
Persistent anxiety or worry
Continuous low mood or sadness, feeling tearful
Feeling numb and empty
Irritability and intolerance of others
Wanting to withdraw and isolate yourself
Suicidal thoughts or thoughts of harming yourself
Lack of energy
Loss of libido
Disturbed sleep – difficulty falling asleep or staying asleep
Change in appetite
Unexplained aches and pains
Increased reliance on alcohol or other substances to soothe difficult feelings
Oestrogen and testosterone have an important role to play in cognition and memory. Brain fog is a common symptom which can be affected by changing hormone levels as well as the stressors of our busy lives. It can feel like your brain is ‘cotton wool’ or in a fog.
Common examples are tip of the tongue syndrome (inability to find the right word), going to another room to find something but forgetting what is was once you arrive, forgetting appointments, difficulty absorbing information and concentrating. This can have an impact on relationships and in the workplace. Some women fear it is the onset of dementure but it is quite common during perimenopause.
Anger and Rage
Although all emotions can be affected during this time one that many women report is intense feelings of anger and rage. This anger can burst forth suddenly, triggered by seemingly minor infractions. Things that we may have previously shrugged off as unimportant may lead to shouting and violent thoughts. This can lead to a cycle of angry outbursts, shock at our behaviour followed by guilt.
How to Look After your Mental Health
If all this seems worrying the good news is that there are many things we can do to help improve our emotional wellbeing. Below are some suggestions.
· Acceptance - it is normal to have heightened feelings during perimenopause, treat yourself with compassion. This phase of life will pass. However if you are persistently overwhelmed and struggling then accept you are struggling and reach out for help.
· Remove stress where possible. Take time to reflect on your life and what is causing you worry. Even small changes to your routines or asking for help can make a difference.
· Exercise can do wonders for emotional wellbeing. If you are unused to exercise start slowly with something gentle like walking, cycling or swimming. Keep it regular and try to find something you enjoy, it will make it easier to stick to.
· Eat nutritious food. Try to incorporate plenty of fresh fruit and vegetables, a balance of carbohydrates, proteins and fibre.
· Minimise sugar and alcohol intake. These have been shown to have an adverse effect on mood.
· Avoid negative self-talk. Learn to speak to yourself in a kind way. Catch yourself in the act of criticising yourself and instead speak to yourself with compassion.
· Ask yourself what you need. If you feel down or anxious ask what would help you to feel better.
· Spend time with friends and loved ones. Stay connected with the people that matter, the ones that make you feel good about yourself. Avoid peole who are critical or leave you feeling drained.
· Deal with unfinished business. If you find yourself thinking about unresolved issues and feelings take some time to figure out what you need for resolution. We can’t change the past but we can find ways to heal, and respond in the present. Journaling, talking about it and being honest with yourself are a good place to start.
· Be curious about your feelings. It is tempting to dismiss how we feel as ‘just hormones’ but if we do we may miss out on vital information. Whilst they may lead to strong reactions pay attention to what is upsetting or angering you. For example, if you fly into a rage because you don’t feel appreciated by your family it may be time to deal with some long held resentment and make some changes.
· Breathe - if you feel anxious or overwhelmed stop and take a few deep breaths. Count your breath in for four counts and out for four counts. This simple act can begin to restore a sense of calm.
· Speak to a professional. A counsellor or psychotherapist can support and encourage you to make sense of what is going on and respond to your needs.
· CBT has been shown to be effective in managing anxiety, especially related to symptoms such as hot flushes.
· Practice gratitude - in positive psychology gratitude is strongly associated with greater happiness. Our brains are hard-wired to register threats and notice problems so we need to consciously train ourselves to notice what is good and positive. Choose to notice what you appreciate and you may be surprised at the results.
· Mindfulness and meditation. These practices can help to calm the mind, and promote better wellbeing. Popular apps like Headspace, Calm and Buddihify can help you to learn the technique. If sitting meditation is not for you try a moving mediation, an activity that has the effect of relaxing and grounding you such as walking, gardening, pottering, colouring. The key is to find an enjoyable activity that allows you to switch off your thinking, often they make you lose track of time.
· HRT can make a significant difference to mental health during perimenopause. It is advisable to do some research to help you make an informed decision about if it is right for you, and be aware it may take some trial and error to find what is best for you personally. Before approaching your GP familiarise yourself with the NICE guidelines which advise that HRT is the first line of treatment rather than anti-depressants for moderate levels of depression.
· Herbal medicine – herbal remedies such as St John’s Wort and Black Cohosh are not as well supported by research but many women find them helpful. If you take them make sure you check for any contra-indications. Alternatively you can book an appointment with a registered herbal practitioner for tailored advice.
· Acupuncture – there is some evidence that acupuncture can help to promote relaxation, reduce anxiety and promote general wellbeing.
· Massage – any treatments that help you to relax are well worth including in your self-care management.
· Learn what helps you. Whether it is reading a book, a soak in the bath, a coffee with friends or a walk with the dog learn what grounds you, relaxes you and makes you feel good and ensure you build it into your life.
If you are struggling there are many methods of supporting yourself. Perimenopause and menopause are a transition to another phase of life, one which many women describe as a time with many gifts and much to look forward to. In the words of actress Kim Cattrall:
"I see menopause as the start of the next fabulous phase of life as a woman. Now is a time to "tune in" to our bodies and embrace this new chapter. If anything, I feel more myself and love my body more now, at 58 years old, than ever before."