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Part 3: What type of HRT do you need?
Menopause, and the perimenopause preceding it, don’t just bring on hot flushes, night sweats and other physical problems. They can also bring on a cluster of psychological symptoms too.
These can include anxiety, insomnia, brain fog or concentration problems, forgetting things, depression, loss of joy, feelings of anger, a sudden lack of confidence, low (or non-existent) sex drive, inability to orgasm, and even panic attacks.
The symptoms can make women doubt their abilities (despite their years of experience) and even quit their jobs, fall out with long standing friends, or become distant from their partner. “Menopausal women are going through a lot, but many feel it’s invisible as it’s not discussed enough,” said psychotherapist and counsellor Julia Bueno.
There’s been a flurry of high profile TV documentaries and books on menopause in the past six months, and even the formation of an All Party Parliamentary Group on Menopause. But many women still keep guard their personal menopause with privacy and struggle on. Women, said Bueno, are taught to “suck up all aspects of their reproductive lives: from painful periods that have them doubled up on the floor two days a month, to incontinence after childbirth. It’s the same with menopause.”
Feelings of being overwhelmed
The brain needs oestrogen to lubricate it and falling levels of this hormone may affect cognitive skills or your mood. But it’s also about your mid-life individual circumstances: this is a time when troubles come in multiples. Often women are juggling menopause and the end of their reproductive life alongside empty nests, or teenage children with their own issues and exams. Add to that the stress of coping with or caring for ageing parents, bereavement, and navigating changing relationships with partners. Early 50s is a peak time for divorce, and it is also when many careers either stagnate or end in redundancy.
“Women tend to have a lot going on when they hit this time in their lives,” said Bueno. “They can get totally overwhelmed when there’s so much happening. It’s crunch time for a lot of women I see: they are overwhelmed by what’s happening internally with their biology, but also with all the other external factors that the ‘sandwich’ generation are dealing with.”
Bueno said the common psychological symptoms women experience in perimenopause and post-menopause are insomnia, feelings of anxiety and panic, and mood fluctuations that they just haven’t experienced before – and it freaks them out.
“The effect of sleep deprivation in particular is really core – bad sleep or interrupted sleep can have such a profound effect on mental health, including memory and cognition, as well as mood,” said Bueno.
“Loss of sex drive can also be very damaging to relationships unless there is good communication with the partner.”
Hormonal or just overload?
Bueno said some women do need Hormone Replacement Therapy (HRT) for hormonal symptoms underlying their psychological problems, especially as it helps with sleep, low mood, and anxiety. But others might not, and it also might be the case that blaming their hormones for issues stemming from elsewhere is doing themselves a disservice.
“A lot of the women I see who end up paying for psychotherapy are high achieving, they’ve got good jobs and they’re juggling a lot and they just tend to set the bar really, really, high and expect a lot of themselves,” explained Bueno. “They’ve brought up their kids, done well at work and then the storm hits, and they just think they’ve got to cope better.”
Employ self-compassion
In these cases, Bueno encourages them to take their foot off the pedal and allow themselves to be a bit more vulnerable. “It’s about them showing themselves some self-compassion, learning to delegate and say no,” she explains.
“I’ll ask them about how they’d treat their best friend if she’d hadn’t slept in days, had a mum with early onset Alzheimer’s, a daughter with an eating disorder and was working a 50-hour week and was beating herself about being half an hour late,” said Bueno. “It’s getting women to see that they need to be kind to themselves.”
One of her clients, Bueno says, has taken to describing the menopause as a time of ‘shedding’. “I think that’s a good way to describe it. It’s okay to take your foot off the pedal.”
What treatments are available on the NHS?
- HRT: The NICE Guideline on Menopause recommends women suffering from low mood around the menopause should be offered HRT as a first line treatment, rather than trying antidepressants first. The guideline says there’s no clear evidence that antidepressants such as selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) can ease low mood in menopausal women who haven’t been diagnosed with depression. HRT can also help with low libido. See our HRT FACT SHEETS.
- Cognitive Behavioural Therapy: CBT helps you develop practical ways of managing problems by equipping you with new coping skills and useful strategies. It can help with anxiety and low mood and even give you breathing techniques for hot flushes. The focus is on developing a calmer and more accepting view of things that happen. The NICE Menopause Guideline recommends it for low moods associated with the menopause. Women’s Health Concern have a factsheet written by experts giving examples of specific situations in the menopause when CBT techniques can be useful.
- Counselling: “Counselling can be useful for situations where you are feeling overwhelmed,” advised Bueno. “Sometimes just saying it all aloud, so you can unpack it all and be heard and not be fobbed off, is an important turning point. It can help women give themselves permission to acknowledge that things aren’t right and helps them realise they are not treating themselves well or being kind enough to themselves. Women tend to put themselves at the bottom of the pecking order and it’s about raising them up and getting them to realise that they deserve as much care and attention as everyone else.”
- Mindfulness: Mindfulness is defined as learning to be fully present, aware of what we are doing, and learning how not to overreact or be overwhelmed by what’s happening around us. There is emphasis, too, on learning to sit quietly and focus on breathing. A review published in the British Journal of Obstetrics and Gynaecology found mindfulness (as well as CBT and other behaviour-based therapies) can reduce the impact of hot flushes and other menopausal symptoms.
- Testosterone gel: This can be prescribed for women who have lost their sex drive and are experiencing other menopausal problems such as brain fog, fatigue, and memory problems whose symptoms haven’t responded to HRT. This can be particularly beneficial for women who are going through a surgical menopause after hysterectomy. See our Menopause Factsheet : What types of HRT do you need?
Treating depression during menopause
The NICE Guideline on Menopause recommends treating low mood in women experiencing menopausal symptoms with HRT as a first line treatment, rather than antidepressants. “Women with low mood related to the menopause will usually have other menopausal symptoms too such as cyclical anxiety, fatigue or loss of libido,” explains Tania Adib, consultant obstetrician and gynaecologist at the private HCA Lister Hospital’s Menopause Clinic, London. “They’ll often say their life is great and they have no reason to be depressed but they just feel miserable and down.”
However, if you have not responded to HRT or behavioural therapy techniques, cannot take HRT, or have a history of depression, your GP may then consider prescribing antidepressants. This is because you may have clinical depression (where you feel persistently sad for weeks or months rather than just a few days), and this is unrelated to the hormone fluctuations of the menopause. “In those women HRT will only take the edge of their depression, but may help when combined with antidepressants,” adds Adib.
A recent review published in Nature says there’s evidence SSRI and SNRI antidepressants are effective for the treatment of depressive disorders for women during and after menopause. The authors add, however, that more long-term studies are needed to investigate the safety, efficacy, and maintenance treatment with antidepressants during menopause.
“Generally, I’m very pro my patients taking antidepressants to get them well enough to have therapy,” says Bueno. “But with women going through the menopause I tend to concentrate on getting them sleeping well first, then recommend they see a GP who knows about the menopause. I’ve heard a lot of patients say that taking HRT improved their sleep and anxiety problems.”
Next: The truth about menopause supplements