The theme for World Menopause Day this year is ‘Cognition and Mood’. This includes things like brain fog, anxiety and depression, and changes in our mood, so it’s important to understand what this might include and what you can do. We were joined by Dr Clare Spencer of My Menopause Centre to find out more.
Henpicked: It’s interesting that this year’s World Menopause Day theme is cognition and mood. We’re starting to appreciate that menopause is so much more than hot flushes, aren’t we?
Dr Clare Spencer: We really are. If we look at the breadth of symptoms of the menopause they fall into categories. We have physical and vasomotor symptoms such as hot flushes, night sweats, joint aches and pains, headaches etc. Then psychological symptoms such as changes in brain function and mood. And then symptoms related to sex. It’s great they’ve chosen the cognitive and psychological symptoms to hone in on. Some women say they can cope with hot flushes. But the changes to mood and brain function can really impact how you feel, how you can go about your job, your family life. Things that are the essence of you.
Henpicked: What’s going on in our bodies that triggers these symptoms?
Dr Clare Spencer: It’s mainly to do with the drop in oestrogen and fluctuations in oestrogen. Testosterone can play a part as well. At the beginning of the menopause transition ovarian oestrogen production can start to go a bit haywire. Instead of having a nice rhythmical flow, the pattern can be more haphazard and the troughs can be deeper at the start of the perimenopause.
There are two important factors here. You can get symptoms that are triggered by the big fluctuations of hormones, known to trigger anxiety particularly and for some migraine. And the deeper troughs and overall drop in oestrogen can dampen and lower mood and affect how your brain functions.
Henpicked: How do you know the symptoms are a result of menopause or something else?
Dr Clare Spencer: In reality it can be difficult to know. Blood tests can be useful to rule out other physical conditions like changes in thyroid function. It’s worth looking at your past history. Some women’s brains are more susceptible to hormonal fluctuations and drops. You may have had premenstrual syndrome through your reproductive life, felt awful at puberty, or suffered from postnatal depression. Some women have really struggled on hormonal contraception. These are indications that, as you enter perimenopause, what you’re experiencing is a result of these hormonal changes. If you’ve got a history of depression or anxiety, we know that the menopause transition can trigger that or worsen pre-existing anxiety and depression. There is a big overlap of symptoms so it can be tricky. You may not have been sensitive to hormone changes at all, however, and still experience symptoms in the menopause transition.
Henpicked: So it’s worth understanding how your body was affected by hormonal changes before?
Dr Clare Spencer: Yes, absolutely. But it’s also really important to say you may have sailed through life without any anxiety or mood issues. Then with those profound changes you just notice you feel differently. For example, some women don’t want to drive on the motorway any more. Or find they’re sweating the small stuff, not finding enjoyment in things like holidays or events. Even subtle things can really start to chip away at your confidence and self esteem.
Once you know there’s a reason and understand what’s going on behind the scenes, it can be a relief. This allows you to consider your options.
Henpicked: What are the options to manage these symptoms?
Dr Clare Spencer: It’s not uncommon for women to feel down, depressed, hopeless, even like they don’t want to be here – suicidal. If you are feeling desperate or having dark and suicidal thoughts, please speak to your GP, call 111, speak to the Samaritans, or go to A&E. Just don’t keep these thoughts to yourself.
If you’re at the milder end of the spectrum there’s lots you can do to self help. Looking at lifestyle, there’s really good evidence that increasing exercise can help. This doesn’t need to be huge, just get active any way you can. Try things like yoga, where you’re actively switching your brain off.
Look to your diet, as having big peaks and troughs of blood sugar doesn’t help low mood. Talking therapies, too, even if it’s chatting to friends, can make a difference. Or you could try Cognitive Behavioural Therapy (CBT) or counselling.
If your symptoms are related to the menopause transition there’s evidence that hormone replacement therapy (HRT) is really effective at helping you feel better. It’s not for everybody but it can be really helpful.
Or antidepressants are another option, if you’re at the severe end of the spectrum and have been diagnosed as having clinical depression. It might be you can get part of the way with HRT but then maybe you need a low-dose antidepressant to take you to where you want to be.
Henpicked: We have heard people being refused HRT and given antidepressants instead. Where are we with this?
Dr Clare Spencer: The important thing is GP education, understanding that pyschological symptoms are a common symptom of the perimenopause and in many cases HRT is likely to be more effective than an antidepressant. We are moving forward thankfully, but it was often the case someone would automatically be given an antidepressant for these symptoms and that HRT would not be considered.
If you do try HRT don’t be disheartened if it doesn’t work first time, as it’s very common to need some tweaks to get it right for you. If you haven’t had a hysterectomy you need two hormones: oestrogen and a progestogen. Oestrogen can thicken the womb lining and increase risk of cancer there, and progestogen keeps the womb lining thin. But there’s a small percentage of women who really do not tolerate progestogens. When you swallow progestogen, for a small number of women, some of the breakdown products can affect the brain and lower your mood, so it can take some time to find a type of progestogen that you can tolerate.
Henpicked: Are there any alternatives to HRT?
Dr Clare Spencer: Yes, and these depend on the symptoms you’re addressing. All the lifestyle changes I’ve touched on will help menopause symptoms in general. If hot flushes are your main complaint, they’re keeping you awake at night, there is medication that can be prescribed by your GP or menopause specialist that can target these. There’s a blood pressure medication called clonidine which for some women will take the edge off or stop hot flushes, which then has a positive knock-on effect on sleep. There are also other prescription medications which can take the edge off hot flushes, for example gabapentin or oxybutynin. And antidepressants do have their role to play. If you’re really struggling and have been advised not to take HRT, they can help to lift mood and keep a lid on anxiety and take the edge off hot flushes.
I’d really call out CBT as a good choice, there is a lot of good evidence it helps psychological symptoms of menopause but also the cognitive and physical elements. It challenges your thoughts and your beliefs and this then impacts on behaviour. If you’ve suffered from cancer and been told not to take HRT then Maggie’s charity is amazing, this is somewhere you can access CBT, and there will be other places.
There are also supplements and alternative therapies. Just be careful with herbal remedies that they won’t interact with medication that you’re taking and that it doesn’t have oestrogen-like activity that could potentially have risks.
Henpicked: Why is testosterone not offered more, does that play a role?
Dr Clare Spencer: The issue with testosterone is that it’s not licensed for women in this country. GPs aren’t allowed to initiate it in the majority of areas. The best evidence for the benefits is around libido and sex drive. But the evidence for mood and cognitive function is quite poor when you look at the research studies, so it’s not currently recommended just for that purpose. However, we’ve heard anecdotally from some women who’ve said it does help.
Henpicked: Is there a time limit on how long you can take HRT for?
Dr Clare Spencer: I always say there is no time limit. We know that in your 50s the benefits outweigh any small risks. The risk is dependant on the type of HRT you take. As you get older you might need to change the type of HRT you take, and you may need to accept a small increase risk of breast cancer year on year. But there’s no arbitrary cut off.
Henpicked: Is there an end to menopause symptoms?
Dr Clare Spencer: On average menopause symptoms last around eight years but for some they can go on longer. If your mood dips or anxiety heightens, or you experience brain fog or memory loss during transition, it can get better as you adapt. I your symptoms do linger on, it’s worth speaking to your doctor and ruling out other medical conditions.
Always remember, the way you’re feeling is not a personal failing. Life is stressful at this time and symptoms cause added stress. If there ever is a time to switch off, step back and give your brain a break, this is it.
Watch the video here:
Henpicked Menopause in the Workplace’s Deborah Garlick was joined by Dr Clare Spencer of My Menopause Centre.
Dr Clare is a registered menopause specialist and an NHS GP. She qualified from Cambridge University and holds membership of the Royal College of Obstetricians and Gynaecologists and the Royal College of General Practitioners. She initially trained in obstetrics and gynaecology where she gained a Doctor of Medicine for research in fetomaternal medicine.
As well as her role of Clinical Director at My Menopause Centre, she currently runs an NHS menopause service and is a GP partner in a practice in Leeds. She is also a British Menopause Society menopause trainer and is involved in educating GPs about the menopause transition through talks, lectures and seminars. She wrote the menopause training module for doctors.net and has written for the Primary Care Women’s Health forum publication, Her Life Her Health, on a variety of menopause-related topics.
