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Mental Health in Menopause

Although some women sail through menopause - for others it is a tough time which

causes significant physical health issues and significant mental distress. This may be the first time in their lives they reach out for support for their mental health.


For those of you with primarily female hormones (oestrogen and progesterone) - unless you have experienced early menopause, these hormones begin to decline in your 40s. How much they decline and how this impacts you can depend on a number of things. Testosterone also declines as we age, however, unlike oestrogen and progesterone, post-menopause testosterone levels actually increase - and can revert back to levels that we experienced in our earlier years.


Oestrogen and progesterone don’t only affect our periods and sexual health - these hormones also impact our immune function, inflammatory response, cardiova


scular health and our brain function - the decrease of these hormones can have a significant impact on our overall health and well-being.


Before we continue - to help you understand a bit of terminology. The term menopause or menopausal is often used to describe what is technically called perimenopause (or the menopause transition). This is the time defined as ‘persistent cycle irregularity’, when you may begin noticing changes such as:

  • Irregular periods

  • Hot flushes

  • Increasing aches and pains

  • Increase susceptibility to viruses and infections

  • Poor memory

  • Poor sleep

  • Reduction in libido

  • Vaginal dryness

  • Mood changes, depression, irritability, increased anxiety, decreased resilience.

Perimenopause can last from 4 - 7 or so years (longer for some, shorter for others). Hot flushes and night sweats are the strongest symptoms of those reported by women


affected by the changes experienced during the menopause transition.


As levels of estrogen decrease at menopause, neurons in the brain region of the hypothalamus as part of the (hypothalamus, pituitary, gonadal system (HPG axis)) undergo hypertrophy (enlargement) and it’s thought that the overactivation of these neurons results in rapid heat response that women experience symptomatically as a hot flush (1) (The hypothalamus also governs temperature control.)


Actual menopause is defined as not having a period for 12 months or more. Of course - we can’t say we are in menopause - until we have hit that 12-month mark. Some of the peri-menopausal symptoms can continue well into menopause.


The two main female ‘sex’ hormones aren’t the only hormones changing - there are many other changes in hormones and neurotransmitters that affect how we think, feel and even behave during this menopausal transition.


MOOD IN MENOPAUSE Studies have shown an association between the menopause transition and an increase in depressive symptoms. Although there is no clear evidence as to why exactly this may occur - there are a number of possible factors. The first one - is that the symptoms experienced above are alone enough to cause low mood and feel more stressed. Poor sleep is strongly associated with poorer mental health, decreased energy and decreased resilience. Hot flushes are exhausting and can disrupt concentration and focus impacting daily function. But there are other hormone changes which are thought to have a significant impact on our level of resilience, mood and ability to cope with stress.

STRESS INDUCING HORMONES Research has found that alongside the basic what we consider ‘female’ hormone changes - other hormonal changes happen too. Our levels of cortisol, adrenalin and nor-adrenalin levels also increase (2). These hormones are often thought of as ‘stress’ hormones, are released by our adrenal glands and can have significant impact on our physical and mental health. Hot flushes, night sweats, heart palpitations and changes in blood pressure are associated with elevated levels of cortisol. In fact, cortisol rises about 20 minutes following a hot flush. Chronically high levels of cortisol & adrenal hormones during this time of transition3 can:

  • contribute to osteoporosis

  • increase risk of diabetes

  • Increase incidence of hot flushes

  • increase abdominal fat

  • cause thinning skin

  • increase the risk of cardiovascular disease

  • contribute to mood changes; feeling irritable and anxious

  • lead to poorer memory and processing of information

  • increase the chance of infections - including viral infections

You may notice some of these similarities to the signs of ‘menopause’. Some studies suggest that it’s these changes in the hormones from the adrenal gland that may be more important than the decline in ovarian function and sex hormones. Women who suffer from more severe perimenopausal hot flushes show changes in hypothalamus, pituitary and adrenal (HPA) axis activity. Proper HPA axis function is necessary for controlling our response and recovery from stress and the release and governing of stress hormones. Poor HPA function is associated with depression. Studies have found that when treatment is given for menopausal symptoms, either through hormones, acupuncture or phytoestrogens, there is an associated decrease in cortisol levels (4,5).

MEMORY & BRAIN FUNCTION Studies suggest that our capacity to learn new things, our memory and our thinking skills are hampered by menopause transition (6). From experience, I can honestly attest to this. I just don’t pick things up as well as I used to. The good news is that after menopause, learning levels in many cases appear to improve again. One of the explanations for poor cognitive (memory and retention) health is that elevated cortisol, particularly in women, has been linked to decreases in memory and executive functioning - meaning it can be hard to focus, follow directions and carry out tasks. Brain-Derived Neurotrophic Factor (BDNF) is important for brain cell health and the growth of neurons. In postmenopausal women, lower levels of BDNF are associated with significantly worse memory performance. Lower levels of BDNF are also associated with depressed mood.

IMMUNE AND INFLAMMATION There are also changes in the immune system with an increase in pro-inflammatory serum markers and a decrease in immune-fighting cells (7). Which makes sense of your decreasing ability to fight off colds and infections and increasing achy body and joints. Inflammation is also associated with a poorer mood.

WHAT NOW? Although it’s a natural progression, our society does not always allow a smooth menopause transition. At a time that we should be easing into midlife, our children have left the nest and we can settle in to have more time on our hands and a more relaxed lifestyle, we often find that our jobs, careers and children who stay at home longer than they should - can dip into our natural reservoirs of energy and can deplete us of what little brain function we feel we have left. We also tend to have dietary and lifestyle habits that are not conducive to reducing stress and we continue to act, exercise and work as if we are still in our 20s and early 30s. We are not. And research is clear that our bodies, minds and brains aren’t what they used to be. If you are a woman going through ‘the change’ - you may have already noticed this. This may seem a little depressing all in itself - but I believe if we embrace ‘the change’, we can make the most of the benefits that are waiting on the other side of the menopause transition. With knowledge - we can understand what is happening in our brain and body and we can prepare our bodies and our minds for menopause.

So how can we make it easier for ourselves?

TOP TIPS FOR SUPPORTING THE MENOPAUSE TRANSITION

REASSESS OUR NEEDS It really is a time to adjust our lifestyle accordingly. You may need to set priorities and boundaries. It may be the time to reduce work hours, reduce commitments that no longer serve you. Looking after our HPA axis - which means reducing stress levels and adjusting our lifestyle to support HPA axis function is incredibly important. Our cortisol levels are naturally rising, as are our androgens and adrenaline. If we have a dysfunctional HPA axis going into menopause - unable to regulate our stress hormone appropriately - this transition is not going to be smooth. Research shows that Improvement in symptom levels by any means (acupuncture, hormone therapy or phytoestrogens) reduces cortisol which can have long-lasting positive effects on body and mind.

PSYCHOLOGICAL TECHNIQUES Meditation & mindfulness has been shown to be helpful in reducing menopausal symptoms and improve HPA Axis function. Meditation also has been shown to

  • Increase resilience

  • Improve sleep

  • Reduce cortisol levels (8)

  • Reduce levels of subjective stress



Other psychological interventions such as cognitive behavioural therapy and relaxation techniques (9) have also been shown to reduce perimenopausal symptoms.




DIET We know that food can have a substantial impact on mood, thinking, and behaviour. Omega threes may help with cognition in menopause therefore eating a diet high in nuts, seeds and natural fish oils can be beneficial. Soy, tofu, soy-based products and other phytoestrogen-containing foods (linseeds, sesame seeds, dried fruit and cruciferous vegetables) may help reduce menopausal symptoms. Phytoestrogens may also have positive effects in lowering low-density lipoprotein cholesterol (LDL) levels. Regular alcohol consumption raises cortisol - therefore you may wish to eliminate or significantly reduce during this time in your life (alcohol also significantly increases your rate of breast cancer).


A whole grain, Mediterranean style diet is what is most often advised for menopause, mental health, cardiovascular health and overall health and longevity - so invest a little time and knowledge into what you put on your table and in your mouth.




EXERCISE Strength-based resistance training can support healthy bones and simply walking can help reduce depression in inactive post-menopausal women (10). Yoga has been shown to be both a useful therapy to manage vasomotor (hot flushes) and psychological symptoms of menopause (11). Depending on the type of yoga - it can also involve strength and resistance training, stress reduction and breathing and relaxation techniques - all useful for the menopause transition. Avoid exercising like a 20-year-old! If you already have increased cortisol levels, over-exercising can result in more adrenaline and noradrenaline and cortisol / HPA dysfunction. Over-exercise is also associated with poor mood outcomes. A good tip is - if you struggle to recover from exercise - you are probably overdoing it. Exercise should be invigorating, improve energy, mental clarity and general well-being.

SUPPORT BRAIN HEALTH Look after your brain. Levels of BDNF can be modulated by various factors such as physical exercise, breathing exercises, circadian rhythm (a good sleep/wake cycle), and certain medications such as antidepressants (12). Increasing BDNF can be done with supplementation of zinc, curcumin and exposure to the sun, playing a musical instrument, Mediterranean diet rich in fruits and vegetables containing polyphenols (13). Reducing cortisol through diet and lifestyle changes or supplementation is likely to improve brain health and function.

ACUPUNCTURE: Acupuncture can be an effective therapy for perimenopausal symptoms, reducing cortisol (and susequent negative effects) (14) and is associated with blood pressure reduction (15).

SUPPLEMENTS WHICH HELP TO INCREASE REDUCE CORTISOL LEVELS AND OR PERIMENOPAUSAL SYMPTOMS INCLUDE;

  • Ashwagandha - research has shown Ashwagandha to support the reduction of cortisol and relieve mild to moderate climacteric symptoms during perimenopause in women (16)

  • Rhodiola rosea can support brain function, mental performance, an appropriate stress response and potentially support healthy cardiovascular health (17).

  • Schisandra appears to be effective at alleviating some symptoms of menopause including hot flashes, sweating, and heart palpitations (18).

  • L- theonine (found naturally in green and black tea) has been found to support immune health, may support cognitive function.

  • Vitamins B12, B6, B9 (folate), magnesium, zinc, D and vitamin C all have the potential to support symptoms of stress reduction, emotional resilience, and immune health or support the adrenal gland function. The best source for these is always a whole food diet and healthy lifestyle.

Last but not least - a healthy gut microbiome can help the assimilation of vitamins and minerals essential for good health. An unhealthy gut microbiome can increase inflammation in the body contributing to stress, cardiovascular disease, poor immune system function and can impact mood.

A FEW POINTS:

Allow your body to work at its best - eat well, sleep well, rest well and exercise well - but not to exhaustion. Although your brain might not be quite up to the task of what it used to be - you do have years of wisdom, intelligence and insight to refer to. I like to think of menopause as a ‘midway pause’ - a time in our lives to reflect and realign ourselves to what we want the rest of our lives to look like. Allow yourself to be drawn to creative tasks, working in the garden, being outside in nature and other activities to help you find a place of calm. These things are what I believe our body and mind truly desire at this time in our life.




Helen Duyvestyn, Mental Health Nurse, (RcN, MHSc)


Helen is a registered nurse, specialising in mental health from a holistic perspective. She is passionate about supporting people to have optimal mental health and well-being.


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REFERENCES

  1. Maki, P. M., & Thurston, R. C. (2020). Menopause and Brain Health: Hormonal Changes Are Only Part of the Story. Frontiers in neurology, 11, 562275. https://doi.org/10.3389/fneur.2020.562275

  2. McConnell, D. S., Stanczyk, F. Z., Sowers, M. R., Randolph, J. F., Jr, & Lasley, B. L. (2012). Menopausal transition stage-specific changes in circulating adrenal androgens. Menopause (New York, N.Y.), 19(6), 658–663. https://doi.org/10.1097/gme.0b013e31823fe274

  3. Woods, N. F., Carr, M. C., Tao, E. Y., Taylor, H. J., & Mitchell, E. S. (2006). Increased urinary cortisol levels during the menopausal transition. Menopause (New York, N.Y.), 13(2), 212–221. https://doi.org/10.1097/01.gme.0000198490.57242.2e

  4. Sauer, T., Tottenham, L. S., Ethier, A., & Gordon, J. L. (2020). Perimenopausal vasomotor symptoms and the cortisol awakening response. Menopause (New York, N.Y.), 27(11), 1322–1327. https://doi.org/10.1097/GME.0000000000001588

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  6. Karlamangla, A. S., Lachman, M. E., Han, W., Huang, M., & Greendale, G. A. (2017). Evidence for Cognitive Aging in Midlife Women: Study of Women's Health Across the Nation. PloS one, 12(1), e0169008. https://doi.org/10.1371/journal.pone.0169008

  7. Gameiro, C. M., Romão, F., & Castelo-Branco, C. (2010). Menopause and ageing: changes in the immune system--a review. Maturitas, 67(4), 316–320. https://doi.org/10.1016/j.maturitas.2010.08.003

  8. Koncz, A., Demetrovics, Z., & Takacs, Z. K. (2021). Meditation interventions efficiently reduce cortisol levels of at-risk samples: a meta-analysis. Health psychology review, 15(1), 56–84. https://doi.org/10.1080/17437199.2020.1760727

  9. Samami, E., Shahhosseini, Z., & Elyasi, F. (2022). The effects of psychological interventions on menopausal hot flashes: A systematic review. International journal of reproductive biomedicine, 20(4), 255–272. https://doi.org/10.18502/ijrm.v20i4.10898

  10. Bernard, P., Ninot, G., Bernard, P. L., Picot, M. C., Jaussent, A., Tallon, G., & Blain, H. (2015). Effects of a six-month walking intervention on depression in inactive post-menopausal women: a randomized controlled trial. Aging & mental health, 19(6), 485–492. https://doi.org/10.1080/13607863.2014.948806

  11. Shepherd-Banigan, M., Goldstein, K. M., Coeytaux, R. R., McDuffie, J. R., Goode, A. P., Kosinski, A. S., Van Noord, M. G., Befus, D., Adam, S., Masilamani, V., Nagi, A., & Williams, J. W., Jr (2017). Improving vasomotor symptoms; psychological symptoms; and health-related quality of life in peri- or post-menopausal women through yoga: An umbrella systematic review and meta-analysis. Complementary therapies in medicine, 34, 156–164. https://doi.org/10.1016/j.ctim.2017.08.011

  12. Konishi, K., Cherkerzian, S., Aroner, S., Jacobs, E. G., Rentz, D. M., Remington, A., Aizley, H., Hornig, M., Klibanski, A., & Goldstein, J. M. (2020). Impact of BDNF and sex on maintaining intact memory function in early midlife. Neurobiology of aging, 88, 137–149. https://doi.org/10.1016/j.neurobiolaging.2019.12.014

  13. Gravesteijn, E., Mensink, R. P., & Plat, J. (2022). Effects of nutritional interventions on BDNF concentrations in humans: a systematic review. Nutritional neuroscience, 25(7), 1425–1436. https://doi.org/10.1080/1028415X.2020.1865758

  14. Palma, F., Fontanesi, F., Facchinetti, F., & Cagnacci, A. (2019). Acupuncture or phy(F)itoestrogens vs. (E)strogen plus progestin on menopausal symptoms. A randomized study. Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology, 35(11), 995–998. https://doi.org/10.1080/09513590.2019.1621835

  15. Palma, F., Fontanesi, F., Neri, I., Xholli, A., Facchinetti, F., & Cagnacci, A. (2020). Blood pressure and cardiovascular risk factors in women treated for climacteric symptoms with acupuncture, phytoestrogens, or hormones. Menopause (New York, N.Y.), 27(9), 1060–1065. https://doi.org/10.1097/GME.0000000000001626

  16. Gopal, S., Ajgaonkar, A., Kanchi, P., Kaundinya, A., Thakare, V., Chauhan, S., & Langade, D. (2021). Effect of an ashwagandha (Withania Somnifera) root extract on climacteric symptoms in women during perimenopause: A randomized, double-blind, placebo-controlled study. The journal of obstetrics and gynaecology research, 47(12), 4414–4425. https://doi.org/10.1111/jog.15030

  17. Ivanova Stojcheva, E., & Quintela, J. C. (2022). The Effectiveness of Rhodiola rosea L. Preparations in Alleviating Various Aspects of Life-Stress Symptoms and Stress-Induced Conditions-Encouraging Clinical Evidence. Molecules (Basel, Switzerland), 27(12), 3902. https://doi.org/10.3390/molecules27123902

  18. Park, J. Y., & Kim, K. H. (2016). A randomized, double-blind, placebo-controlled trial of Schisandra chinensis for menopausal symptoms. Climacteric : the journal of the International Menopause Society, 19(6), 574–580. https://doi.org/10.1080/13697137.2016.1238453

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