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Menopause Triad: Depression, Anxiety & Vasomotor Symptoms

Updated: Oct 3, 2023

Entering the menopause journey, many women experience mood changes. It’s well known that hot flashes are a common symptom during menopause, however, less known is that many women are prone to anxiety and depression during this time. Women in their reproductive years often experience depression and anxiety. Mood changes during

menopause are not the same as a major depressive episode or anxiety disorder and there is some controversy about the idea of menopause-related depression and anxiety. Because this can be a difficult time in a woman’s life, other factors may be influencing mood. However, evidence does point to hormone-related mood changes. (1) So, while there are many reasons that women develop these mood disorders, one trigger is hormone changes such as fluctuating estrogen levels. There appear to be ‘windows of vulnerability’ for hormone-related mood disorders such as during postpartum, premenstrual, and during the menopause transition. (2) The research paints an alarming picture:


· Women in the menopause transition are twice as likely to become depressed than women of the same age who were premenopausal.

· Perimenopausal women have a higher risk of depressive symptoms compared to premenopausal women.

· Women in the menopause transition were 14X more likely to develop depression within 2 years of menopause than in the three decades prior.

· The greatest risk of depression during the menopause transition is a previous major depressive episode.

· Anxiety is more prevalent in women than men (30% women, 19% men) and peaks in women during the late perimenopausal phase. (1)


Depression is implicated in several other conditions. Depression impacts sexual health and libido as does the estrogen drop during menopause. Depression can also arise because of distress from body image related to changes in a during the menopause transition. Depression and anxiety are often associated with other conditions such as diabetes, incontinence, and menopause-related arthralgia (joint and muscle pain). (1) Depression is emerging as an independent risk factor for cardiovascular disease. (2)


There is a relationship between depression and vasomotor symptoms. The presence of depression is associated with a greater number of vasomotor symptoms. In addition, symptoms of anxiety include irritability, fearful for no reason, nervousness or tension and pounding/racing heart are very difficult to separate the symptoms of anxiety from vasomotor symptoms. (3)


The triad of anxiety, depression, and vasomotor symptoms together, add to women’s difficulties during the menopause transition. Sleep disturbances, particularly insomnia, are more common in women and can be associated with depression. Depression and anxiety are commonly seen together, and anxiety is the strongest predictor of poor sleep quality, compounded by sleep disturbances from vasomotor symptoms. Anxiety, depression, sleep difficulties, and VMS are associated with cognitive changes such as slower processing speed, memory, and attention.(2)


Just as fluctuations in levels of estrogen are implicated in vasomotor symptoms, so too are changes in mood. There are estrogen receptors in the brain and when estrogen levels fall, they can trigger hot flashes as well as changes in mood (depression and anxiety). (2)


Treatment of women for depression and anxiety should start with a comprehensive assessment by a qualified health care provider to determine all related factors to provide the most appropriate diagnosis and treatment. However, if it is likely that there is a hormone-related trigger for the depression and anxiety, there are treatments that offer relief for both vasomotor symptoms and depression/anxiety.


Since falling estrogen levels trigger hot flashes and likely play a part in hormone-related mood disorders, it stands to reason that estrogen therapy should help both, and it does. Estrogen for VMS has also been shown to reduce depression, although evidence in the treatment of anxiety is mixed. (1). Estrogen therapy given in perimenopause has been associated with reduced incidents of depressive episodes (1). However, it’s important to note that estrogen isn’t approved for the treatment of depression and evidence related to use of estrogen in the treatment of depression in post-menopausal women isn’t clear. (2)


Other treatments for vasomotor symptoms help alleviate depression and anxiety. Some antidepressant medications, specifically SSRIs and SNRIs are also recommended as non-hormonal treatments of vasomotor symptoms. (1,2,5). Use of estrogen along with these medications has been shown to have a synergistic effect for treatment of depression (2).


Cognitive behavioural therapy is a proven treatment for mood disorders such as anxiety and depression and is recommended in the treatment of women with hot flashes (5). Interestingly, aerobic exercise, although not indicated in the treatment of hot flashes, has had beneficial effect on depressive mood during menopause (2). As a final note, there is hope that the new category of medications for hot flashes, neurokinin 3 receptor antagonists (one medication has been approved in the US), will also provide relief for hormone-related mood changes, but more research is needed.


Menopause is a time of great change in a woman’s body, changes that greatly impact her life in many ways. The interplay between estrogen changes, menopause symptoms such as vasomotor and mood disorders, is complex and influenced by many other factors including genetic, physical, and environmental. This calls for a holistic approach in the care of women during this tumultuous time.



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References


1. Soares C. (Dec 10, 2019). Taking a Fresh Look at Mood, Hormones, and Menopause. NAMS Practice Pearl.

2. NAMS. (2019). Menopause Practice. A Clinician’s Guide. 6th Ed.

3. Jehan S, Masters-Isarilov A, Salifu I, Zizi F, Jean-Louis G, Pandi-Perumal SR, et al. Sleep Disorders in Postmenopausal Women. 2015.

4. Vigeta SMG, Hachul H, Tufik S, Sergio Tufik, de Oliveira EM. Sleep in Postmenopausal Women. Qualitative Health Research. 2012 Apr 1;22(4):466–75.

5. NAMS. (2023). NAMS Position Statement. The 2023 nonhormone therapy position statement of The North American Menopause Society https://www.menopause.org/docs/default-source/professional/2023-nonhormone-therapy-position-statement.pdf


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