Menopause isn't only about hot flushes: here's how it may wreck your mental health.
Women are increasingly talking about the forgetfulness, worry, and suicidal thoughts they've had when their hormones alter in middle age. Why isn't more assistance available?
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Karen Arthur was on the verge of committing suicide at her lowest moment. After being fired from her teaching position due to anxiety, which she had not previously associated with menopause, the 51-year-old had planned a few days away from home to attempt to clear her thoughts. A lengthy stroll across the countryside led her to a location renowned for suicide attempts.
She had not pondered suicide at that point, she claims, but she had organized her affairs for her two children, who were away at university. "I thought it would be simpler if I wasn't here. The home would be given to the children, and the mortgage would be paid off."
This, she claims, was her watershed moment. "I recall thinking how desperate you must be... And very clearly thought, 'I don't want to die, I don't want to kill myself, that's too real for me.'" She instead went to the local tavern and ordered fries and a hot chocolate with rum. "I got out my notebook and determined I wanted to live," she says. I began writing about the things I wished to accomplish. That was both the lowest and greatest time in my life; it drew me back from the edge."
Arthur quit teaching, went to therapy, started a new career in fashion design, and six years later, in the emotionally charged aftermath of George Floyd's murder, amid the rise of the Black Lives Matter movement, created the positive ageing podcast Menopause Whilst Black, after discovering a dearth of resources catering specifically to black women. According to research, they approach menopause sooner on average than white women and are more prone to suffer certain symptoms, such as sadness. When she originally went to see her doctor about her anxiety, she described feeling hot flushes, but she wasn't prescribed hormone replacement treatment (HRT) and, at the time, felt becoming menopausal was the least of her problems. "I had no idea anxiety and despair were associated to menopause. In hindsight, I know all I know about my trip."
Midlife mood swings, wrath, and forgetfulness may be fodder for amusing Instagram memes. However, as Arthur discovered, they are anything but amusing for many women in perimenopause (the stage before the cessation of menstruation) and menopause (defined as a year without a period). According to a survey of 2,000 women conducted last year by the House of Commons women and equalities select committee inquiry into menopause at work, 75% reported problems with memory or concentration, and 69% reported feeling anxious or depressed - not necessarily to clinical levels, but frequently enough to reduce concentration and confidence at work. Those mood fluctuations might be significant in certain circumstances.
Kathy Burke, the actress, told the Observer last month that she had "very dark, suicidal ideas" in her early 50s, which she attributed to menopause. Burke stated she had battled for years since she was unable to take HRT due to other medications she was on. Meg Mathews, the menopausal activist and ex-wife of Oasis musician Noel Gallagher, has revealed comparable worry in her late 40s: "I wasn't able to leave the home for three months."
However, mental health in menopause remains remarkably unexplored, the waters muddied by the fact that it typically coincides with a period of greater change in women's lives. These are the emotionally volatile years of children leaving home, aged parents becoming ill, midlife divorces, and workplace shifts that may make it difficult to separate cause from effect. Do you suffer from mental illness as a result of the upheaval in your life? Is your life in flux due of your hormones, at least in part?
Dr. Louise Newson, a general practitioner and menopause expert, recently collaborated with the Royal College of Psychiatrists to educate its members on the mental health implications of menopause. Most of the patients she sees at her private clinic in Stratford-upon-Avon have both mental and physical menopausal symptoms, and many are desperate, she adds; some have tried everything from electric shock therapy to spending hundreds of pounds on experimental therapies. "We've seen folks on ketamine and clinics that have given ketamine - it really terrifies me," she adds. (Ketamine is a licensed anaesthetic that is sometimes taken illegally as a party drug and occasionally given "off-label" to alleviate depression.) "We see a lot of suicidal ladies."
Research on menopausal mental health is still "not as excellent as you would expect," according to Newson, but it is now well recognized that the hormones oestrogen and testosterone, which fall in midlife, play essential roles in brain function. "We know that anxiety and memory issues, poor mood and diminished motivation are particularly frequent in menopause. Whether it's the actual number of hormones or hormone swings, everything that changes in the brain has an impact." She believes that women who have previously experienced depression or postnatal depression, such as Burke, are at a higher risk of deteriorating mental health during menopause, as are women who have suffered from severe premenstrual syndrome or its more severe cousin, premenstrual dysphoric disorder (PMDD) around the time of their periods.
Newson emphasizes that not all mental health issues in middle-aged women are hormone-related, and that HRT is not a cure-all. "I often optimize hormones before assessing the patient's mental health. Antidepressants are required by certain women." However, the relationship between menopause and depression is now well accepted, and the NHS prescribing watchdog, the National Institute for Health and Care Excellence, advises HRT as a first-line therapy for menopausal women experiencing low mood or worry. Despite this, Newson says she meets women who have been prescribed antidepressants by their doctors. One of the reasons she launched Balance, a free software that helps women recognize and document menopausal symptoms, was to assist physicians and patients in connecting the links. "We've been taught for a long time that menopause is all about hot flushes and vaginal dryness. "We weren't advised it may alter your mood, energy, or focus," she explains. "Women are constantly encouraged to put up and shut up."
That resonated with Kate Duffy, a 44-year-old single mother of two children when she went to her doctor complaining of worry, sleeplessness, and significant mood swings, as well as more perplexing physical symptoms such as hair loss. Duffy's doctor diagnosed her with depression, but she was confident it was more serious. "I said to myself, 'I'm not saying I'm not depressed, but I believe it's due to menopause,'" she adds. "I kept coming back and reiterating that, but they didn't listen. It was so annoying to be bashing my head against a brick wall for a year. I'd be Googling, and there'd be a lot of ladies like me, up late trying to figure out what was wrong with them, saying things like, 'My marriage is gone, I can't perform the work I've done for 30 years, I can't think straight, I feel suicidal...'"
Her GP, who had felt she was too young to be perimenopausal, ordered the blood tests that verified her suspicions only after her first hot flush, she claims. Even then, Duffy says, she had to struggle for HRT, and it wasn't until another woman told her of a specialized menopause clinic in her hometown of Oxford that she was diagnosed with PMDD, explaining a lengthy history of extreme mood swings around her periods. "It made sense of the previous 30 years of my life, when I was up and down like a yo-yo, going in and out of doctors' offices, saying, 'I feel like killing myself... oh no, I don't, I'm great now.'" It was entirely cyclical." Duffy now volunteers as a "patient tutor", sharing her experiences with student physicians to help offset what she perceives as "the lack of knowledge, the lack of training in women's healthcare - it's an utter disaster. It's as though we're not worth the effort."
Her emotions are now much more stable at 55, but the incident has left its impact. She is unable to return to her previous office work and now earns a more flexible income by painting and upcycling furniture. Surprisingly, a poll of 4,000 women conducted for the recent Channel 4 documentary Davina McCall: Sex, Mind, and the Menopausal discovered that one in ten had abandoned their jobs due to menopause symptoms, either mental or physical, and 14% had cut their working hours. "I know of people signing non-disclosure agreements and being performance managed out of employment at quite a high level [because to menopausal symptoms]," says Kate Muir, the Channel 4 documentary's producer and author of Everything You Need to Know About the Menopause.
Muir, who had such persistent "brain fog" in her late 40s that she thought she was developing Alzheimer's, claims that her memory improved drastically within a week of beginning the proper HRT. But she is still fascinated by the link between mental health and the persistent sleeplessness that many middle-aged women endure, often without realizing it is a menopausal sign. "One of the indications for potential dementia is lack of sleep. It's really important, and it's also a sign of despair," she says. There is a particularly bitter irony for many working moms in slogging through the sleepless fog of early parenthood, only to be sideswiped professionally by interrupted nights again just as their children are fully grown up.
Lauren Chiren, 54, was in her early 40s and working as a top executive in financial services when she began having memory problems. It wasn't simply forgetting the peculiar name, she claims: one night she arrived home from work, welcomed her kid and his nanny, and then went back out to work. "I'd completely forgotten I'd gone for the day. "I was losing my mind." Her self-esteem fell, and she started to avoid speaking up in meetings for fear of disclosing her memory gaps. Chiren arranged an exit arrangement and quit, certain she had early-onset dementia and afraid of how she would survive as a single parent of a kid with lifelong medical requirements. "I quit work because I really believed I was running out of time and would have to find someone else to care for my kid," she explains. When her doctor's blood tests revealed that she had experienced early menopause, she was surprised: "I assumed it was something that occurred to elderly people, and it would be the rare hot flush."
Chiren currently operates Women of a Certain Stage, a coaching company that offers awareness training for companies to help employees deal with menopause, as well as personal counseling for women to help them stay on track in their careers. She assists her clients in recognizing and tracking their symptoms, looking for "little tweaks" at work that might help them manage, and considering lifestyle changes like as exercising and modifying their food. (As she points out, not everyone is able to use HRT, and others intentionally refuse.) Her first event in the City of London was so full that it was standing room only, but she found some of those attending had blacked out their diaries for the day "so that people didn't know they were there".
Some women in competitive workplaces, according to Chiren, still find it difficult to discuss menopause at work. "They've often worked hard to reach where they are. They don't want to be identified as weak or fragile." Women who breeze through this stage may be hesitant to publicize the prevalence of midlife worry and forgetfulness, fearing that it will become just another reason to dismiss older women.
However, as Arthur points out, the uncomfortable silence that often cloak menopausal mental health issues leaves many women poorly unable to recognize the signs. She claims she felt very alone when it occurred to her. "My current belief is that the more of us who speak out, the less alone we will feel."
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