Dr. Rebecca Brightman on how hormones can impact women’s mental health
For this installment of “In Your Business,” we spoke with Dr. Rebecca Brightman about a subject that impacts women of all ages: hormones. From puberty to pregnancy to menopause, hormones can wreak havoc on a woman’s body as well as her mood. Dr. B also took the time to answer some of the thoughtful questions submitted by our Wake-Up Call readers, and she shared the most common women’s health issues she’s been asked about during Covid.
Wake-Up Call: Let’s start off by discussing a mental health issue that’s been plaguing a number of us during this past year: Anxiety. One Wake-Up Caller writes: “I am going through the menopausal transition, and I’m experiencing a ton of mood swings, brain fog, and short-term memory loss. The brain fog brings on anxiety, especially while I’m at work meetings, and can’t remember what to say. I read that this gets better after menopause, but why is this happening, and what can I do now to help with this?”
Dr. Brightman: It’s the changes in estrogen, which is the main hormone we think about when we think about menopause, that are responsible for a lot of these symptoms. There are estrogen receptors throughout the body, and during the menopausal transition — which can last on average seven-and-a-half years — there are hormonal highs, and there are super dark hormonal lows. Many women feel like they’re on a rollercoaster ride. But everybody’s experience is different. Moms have different experiences than daughters. I’ve heard patients say, “my mom said menopause was just a non-event, whereas I’m having a really tough time.”
Mental health is hugely important, and I address it in each and every visit. Anxiety can absolutely be a symptom of the menopausal transition, and a lot of internists blow it off, and a lot of women don’t recognize what it is. I’ve had patients go to cardiologists because they’re having heart palpitations. The cardiologists will do a full workup, which I think is appropriate, but one can not be dismissive of the fact that anxiety may be triggered by hormones. There’s also some data to suggest that there are individual differences in the response of neurotransmitters in the brain to hormonal variations.
For example, you could have two patients, both of whom have the same hormonal fluxes, and one may have terrible anxiety and depression and the other one could be fine. So there’s frequently a biological basis to this. If someone is feeling anxiety and stress, that can trigger a hot flash, and the dread of the hot flashes then increases the anxiety. So it becomes a self- perpetuating process for many women.
Independent of night sweats and hot flashes, a lot of women suffer from disrupted sleep. We know that sleep is really important for mood and for cognitive function. So when you have this roller coaster of hormones and you’re not sleeping, it can really impact mood and cognitive function. The good news is, many women who have brain fog as they go through the menopausal transition eventually return to their baseline.
The same goes for anxiety, but not in every case, so I wouldn’t let it go unchecked. I’ve seen many women who are post-menopausal and they say, “Oh my gosh, I had the toughest time with anxiety and depression when I was beginning menopause, and I feel so much better now.” I think the toughest conversation I have with some of my patients is to get them to confront new anxiety if they’ve never experienced it before. Even without a prior history of anxiety, depression, or postpartum depression, women can have new onset anxiety during the menopausal transition. Women who experienced postpartum depression are at increased risk of having anxiety and depression during the menopausal transition, and these women may be more sensitive to hormonal changes.
It is on us as health care providers to be really aware of these mental health issues, especially during menopause. It’s not just night sweats, hot flashes and vaginal dryness. Hormones affect every organ system of the body.
If a woman is going through the menopausal transition and experiences a new period of depression or anxiety, is that something that you would suggest that she see a psychiatrist and potentially go on medication for?
Absolutely. I do not feel that hormones should be first-line for treating anxiety and depression, and I think most people in the menopausal realm would agree with me. I do think they help stabilize mood in many women, and if someone is having mild symptoms and they have other symptoms associated with hormonal fluctuations, you can certainly try to manage them hormonally. But for women with more significant anxiety and depressive symptoms, where they really interfere with the quality of life, these women really need to speak with a psychiatrist. I have a very low threshold when it comes to sending people to mental health professionals — I make these referrals on a daily basis.
You mentioned that the menopausal transition lasts an average of about seven-and-a-half years. One Wake-Up Caller wrote in and asked: “How long can hot flashes last? I’m 71 years old and have been experiencing them since age 50.”
Unfortunately, a small percentage of women will have continued vasomotor symptoms. The body’s thermostat and ability to regulate temperature changes with age. If you’re experiencing prolonged hot flashes, speak to your physician, because there are certainly things you can do. It’s definitely not customary to start a 70-year-old woman on hormone replacement, but there are behavioral modifications, lifestyle modifications and other pharmacologic treatments. And there is evidence that certain nutritional supplements may work. There’s some data that shows pollen extract supplements may be helpful.
Is the likelihood that women experience mood swings and irritability going to be higher during every major hormonal life shift — including puberty, pregnancy and the menopausal transition?
Yes. Hormone levels affect neurotransmitters in the brain, and some people are affected more than others. The other thing that’s really important to remember is that each of these life stages is also associated with bodily changes. For adolescents, they’re having these hormonal shifts while their bodies are changing. And for some of them, it’s a very awkward phase!
Then of course in pregnancy, the body goes through major changes. There are some positive pregnancy hormonal effects, and while some women can have new onset anxiety and depression during pregnancy, there are some happy hormones, called endorphins, that start circulating. There’s an increase in a hormone called oxytocin, and that’s responsible for feelings of love and bonding. So many women actually feel a sense of wellbeing during pregnancy, but some women really don’t. We do know that women who have postpartum depression are at greater risk of having depression and anxiety during the menopausal transition. We need to be able to flag these things, so I alway ask my patients if there’s any history of postpartum depression. And it doesn’t always follow gene lines — remember, we are not our mothers.
In terms of highs and lows, the most drastic hormonal shifts occur during the menopausal transition. A woman can have estrogen levels that look like she’s pregnant one day, and a few days later have hormone levels that are so low that it looks like she’s clearly menopausal. These big shifts can really take their toll.
Then there’s the psychological aspect to it. When you get someone who’s 46 or 47, and she’s experiencing hormonal shifts, finding out that it might be the start of menopause feels like a punch in the gut. For many women, it’s not even on their radar screen unless they have a friend who’s gone through it. It can be very upsetting for women who are having night sweats and hot flashes to be surrounded by people who are like, “I have no idea what you’re talking about.” But remember: we will all go through this.
This story was written and reported by senior producer Emily Pinto.
If you have a question for Dr. Brightman, write to us at email@example.com and we may feature it in our next installment.