Jennifer Fields
For many women, the most disruptive symptoms of perimenopause (the transition leading up to menopause) and menopause (when you’ve gone 12 months without a menstrual cycle) aren’t just the hallmark ones, such as hot flashes and night sweats. Instead, they may struggle to remember names and words or feel unusually anxious. Or, like Stephanie, who spoke on the condition that only her first name be used to discuss sensitive medical information, they may suddenly be consumed by “unbridled rage,” as she puts it.
She was in her early 40s when her life was upended by several traumatic losses. In the span of five years, both of her parents and her brother died. But when the veil of grief started to lift, she still felt unrecognisable to herself.
She was overwhelmed by a “monstrous level” of anger, she says. Even more upsetting was that its triggers were unpredictable. One day, a minor car accident that damaged her bumper was no big deal. The next, she lost it over the way a clerk bagged her groceries.
She struggled to control her fury with her children. At times, she says, she “melted them into tears” with her angry outbursts. Stephanie was so ashamed, and she tried to mask her rage. But that only left her feeling more disconnected from who she was.
Around the same time, Stephanie developed a level of forgetfulness that was so worrying she thought she might have early-onset dementia. She also noticed that the insomnia that started after her dad died had not resolved six years later. She never considered that these symptoms were related to perimenopause. After all, she hadn’t had a single hot flash, and her periods were still regular.
For the next few years, Stephanie quietly wondered if she’d ever find her way back to herself.
Her experience points to a part of the transition to menopause that some experts say is widely overlooked. Despite the fact that emotional and cognitive changes are well documented during this time, new research highlights a significant disconnect between what women are going through and what gets recorded in doctor visits.
‘Silent symptoms’ of menopause
In a July study published in JAMA Network Open, which was led by Yulin Hswen, associate professor at the University of Maryland School of Public Health, researchers compared discussions on Reddit’s all-time top posts in menopause channels to electronic health records from the University of California at San Francisco. They found that emotional and cognitive symptoms appeared 2.6 to 3.6 times as often in the online forum than they did when doctors were documenting symptoms. Clinical notes were more likely to mention hot flashes, night sweats and hormone therapy, while Reddit posts were more likely to discuss symptoms related to cognitive impairment and emotional wellbeing.
Hswen refers to these cognitive and emotional changes as silent symptoms – “the ones that women deal with alone,” she says. This includes anxiety, brain fog, anger, sadness and others that are hard to name, like “just not feeling like themselves anymore,” she says.
Why symptoms are missed
On Reddit, women frequently shared experiences of health care providers dismissing their symptoms or misdiagnosing them as mental health disorders, early-onset dementia or autoimmune issues – leading to months or years of unnecessary testing and medication, Hswen says. That may help explain why these symptoms are less visible in electronic health records.
“If a woman’s brain fog is documented as anxiety, her rage as depression or her sleeplessness as an isolated complaint, the symptom may enter the medical record but its connection to menopause does not,” Hswen says. “And when women are repeatedly dismissed, they may stop bringing these symptoms up altogether.”
One problem is that many medical providers do not receive targeted training in caring for women during perimenopause and menopause, so they assume that symptoms are mostly limited to changing periods, hot flashes and night sweats, says Karen Adams, a clinical professor of obstetrics and gynaecology at Stanford University and Farwell Family director of the Stanford Program in Menopause and Healthy Ageing.
That knowledge gap is due in part to a decades-long hesitancy to treat perimenopause symptoms after a Women’s Health Initiative trial in 2002 linked hormone therapy to an increased risk of breast cancer, heart disease and stroke. When the study came out, doctors stopped prescribing hormones, and medical schools stopped teaching menopause care, says Adams. Today, experts say hormone therapy can be beneficial for many women around the time of menopause (with caveats for those with certain contraindications), but there’s an entire generation of clinicians who are not trained in how to address menopause symptoms, she says.
The reality is that the menopausal transition is one of the times in a woman’s life (in addition to puberty, pregnancy and postpartum) when she is most vulnerable to anxiety and depressive disorders. And women with a history of major depression, generalised anxiety disorder or postpartum depression are more likely to have depression in this stage of life, Adams says. But doctors aren’t always up-to-date about the potential link.
A further complicating factor is the load that people often have to handle that happens during the same time as menopause, says Reid Mergler, assistant professor of clinical psychiatry at the University of Pennsylvania’s Perelman School of Medicine and medical director of the Penn Centre for Women’s Behavioral Wellness. Like Stephanie, many women in this age group are squeezed between caring for children and ageing or ailing parents, adding to the mental and emotional challenges and potentially keeping them from getting the care they need. In one study, 87 per cent of participants said they did not seek medical care for menopause symptoms, with most saying the reason was because they were too busy.
Treating emotional and cognitive symptoms
Any behaviours that promote overall health, such as exercise, eating a balanced diet and stress reduction, can be impactful for menopause symptoms, says Adams.
She also highlighted that when people undergoing menopause sleep better, their cognition and mood often improve. If hot flashes and night sweats are disrupting sleep, hormone therapy can help. For a drug-free approach to sleep problems, cognitive behavioral therapy for insomnia (CBT-I) is a first-line treatment. Research suggests this short-term, targeted therapy can improve sleep quality and reduce menopause-related insomnia.
Still, other women can benefit from taking medications meant to address their specific mental health concerns. For example, often for the mood and anxiety complaints, Mergler prescribes two types of antidepressant medications, SSRIs or SNRIs. For the cognitive issues, she has prescribed bupropion (which is available but not approved for treating depression in Australia) and the non-stimulant drug atomoxetine (a type of SNRI used to treat ADHD). “This is not a forever solution,” she said, “but will help them until they’re really through the thick of the perimenopause. Once they’re postmenopausal, they often are better.”
Both Mergler and Adams emphasised getting treatment from someone who has demonstrated expertise in menopause and knows how to manage it.
As for Stephanie, a casual acquaintance eventually flagged rage as a potential perimenopause symptom. A provider prescribed hormone therapy and after some trial and error, they found the right dose. Stephanie, now 50, said she is finally “back to her centre”.
“Oh, there she is,” she remembers thinking. “There I am again.”
Washington Post
Make the most of your health, relationships, fitness and nutrition with our Live Well newsletter. Get it in your inbox every Monday.
